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AIDS:
doi: 10.1097/QAD.0b013e328360a4e5
Epidemiology and Social

Cost-effectiveness of point-of-care viral load monitoring of antiretroviral therapy in resource-limited settings: mathematical modelling study

Estill, Jannea; Egger, Matthiasa; Blaser, Nelloa; Vizcaya, Luisa Salazara; Garone, Danielab; Wood, Robinc; Campbell, Jenniferd; Hallett, Timothy B.e; Keiser, Oliviaa

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Abstract

Background:

Monitoring of HIV viral load in patients on combination antiretroviral therapy (ART) is not generally available in resource-limited settings. We examined the cost-effectiveness of qualitative point-of-care viral load tests (POC-VL) in sub-Saharan Africa.

Design:

Mathematical model based on longitudinal data from the Gugulethu and Khayelitsha township ART programmes in Cape Town, South Africa.

Methods:

Cohorts of patients on ART monitored by POC-VL, CD4 cell count or clinically were simulated. Scenario A considered the more accurate detection of treatment failure with POC-VL only, and scenario B also considered the effect on HIV transmission. Scenario C further assumed that the risk of virologic failure is halved with POC-VL due to improved adherence. We estimated the change in costs per quality-adjusted life-year gained (incremental cost-effectiveness ratios, ICERs) of POC-VL compared with CD4 and clinical monitoring.

Results:

POC-VL tests with detection limits less than 1000 copies/ml increased costs due to unnecessary switches to second-line ART, without improving survival. Assuming POC-VL unit costs between US$5 and US$20 and detection limits between 1000 and 10 000 copies/ml, the ICER of POC-VL was US$4010–US$9230 compared with clinical and US$5960–US$25540 compared with CD4 cell count monitoring. In Scenario B, the corresponding ICERs were US$2450–US$5830 and US$2230–US$10380. In Scenario C, the ICER ranged between US$960 and US$2500 compared with clinical monitoring and between cost-saving and US$2460 compared with CD4 monitoring.

Conclusion:

The cost-effectiveness of POC-VL for monitoring ART is improved by a higher detection limit, by taking the reduction in new HIV infections into account and assuming that failure of first-line ART is reduced due to targeted adherence counselling.

© 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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