title: Clinical impact and cost of monitoring for asymptomatic laboratory abnormalities among patients receiving antiretroviral therapy in a resource-poor setting.
abstract: BACKGROUND
  Laboratory monitoring for toxicity among patients receiving antiretroviral therapy (ART) in less-developed settings is technically challenging and consumes significant resources.
  
  
  METHODS
  We conducted a cohort study of the 1800 adult patients who initiated ART at the Haitian Study Group for Kaposi's Sarcoma and Opportunistic Infections (GHESKIO) in Haiti from 2003 to 2006, using baseline data to establish the prevalence and using follow-up data to establish the incidence of hepatitis, renal insufficiency, hyperglycemia, anemia, neutropenia, and thrombocytopenia. We determined how frequently routine (not symptom-driven) testing detected significant laboratory abnormalities and calculated the cost per disability-adjusted life year (DALY) averted by detection of these events in the asymptomatic stage, compared with a strategy of symptom-prompted testing only.
  
  
  RESULTS
  Forty-eight patients (3.5%) had severe anemia at baseline testing and consequently did not receive zidovudine. Fifty-three patients receiving zidovudine therapy developed severe anemia during follow-up (incidence, 2.5 cases/100 person-years). Monitoring for asymptomatic anemia with hematocrit testing was cost-saving at baseline and had a cost-effectiveness ratio of US$317/DALY averted during follow-up; with a complete blood count, costs increased to US$1182 and $10,781/DALY averted, respectively. With glucose monitoring, 11 patients were diagnosed with new-onset hyperglycemia during follow-up (incidence, 0.7 cases/100 person-years), resulting in a cost-effectiveness ratio of US$9845 per DALY averted. Monitoring for asymptomatic hepatitis and renal insufficiency was expensive and rarely affected care.
  
  
  CONCLUSIONS
  Resource-poor countries should select which laboratory tests to perform on the basis of the cost-effectiveness of each test. This will depend on the national ART drug regimen and the prevalence of other comorbidities. Routine monitoring with multitest hematological and chemistry panels is unlikely to be cost-effective.
authors.affiliation: Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA. skoenig@partners.org
authors.forename: Serena P
authors.initials: SP
authors.lastname: Koenig
authors.forename: Bruce R
authors.initials: BR
authors.lastname: Schackman
authors.forename: Cynthia
authors.initials: C
authors.lastname: Riviere
authors.forename: Paul
authors.initials: P
authors.lastname: Leger
authors.forename: Macarthur
authors.initials: M
authors.lastname: Charles
authors.forename: Patrice
authors.initials: P
authors.lastname: Severe
authors.forename: Charlene
authors.initials: C
authors.lastname: Lastimoso
authors.forename: Nicole
authors.initials: N
authors.lastname: Colucci
authors.forename: Jean W
authors.initials: JW
authors.lastname: Pape
authors.forename: Daniel W
authors.initials: DW
authors.lastname: Fitzgerald
mesh_terms: D019380:Anti-HIV Agents / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use*; D001786:Blood Glucose / Q000187:drug effects; D019411:Clinical Laboratory Techniques / Q000191:economics; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D003906:Developing Countries / Q000191:economics; D015658:HIV Infections / Q000188:drug therapy* / Q000191:economics* / Q000453:epidemiology; D006205:Haiti; D006295:Health Resources / Q000191:economics; D006801:Humans; D006943:Hyperglycemia / Q000139:chemically induced; D012959:Socioeconomic Factors; D015215:Zidovudine / Q000191:economics* / Q000627:therapeutic use*
chemical_list: D019380:Anti-HIV Agents; D001786:Blood Glucose; D015215:Zidovudine