title: Monitoring of highly active antiretroviral therapy in HIV infection.
abstract: OBJECTIVE
  Patients on antiretroviral therapy (ART) in high-income countries have routine laboratory tests to monitor ART efficacy/toxicity. We review studies describing the outcomes and costs of different monitoring approaches, predominantly in low-income countries.
  
  
  RESULTS
  CD4 cell counts, HIV RNA viral load and clinical events are frequently discordant; viral load suppression occurs with WHO-defined CD4 failure and, as expected, viral load failure often occurs before CD4 failure. Routine CD4 monitoring provides small but significant mortality/morbidity benefits over clinical monitoring, but, at current prices, is not yet cost-effective in many sub-Saharan African countries. Viral load monitoring is less cost-effective with modelling studies reporting variable results. More research into point-of-care tests, methods for targeting monitoring and thresholds for defining failure is needed. Most laboratory monitoring for toxicity is neither effective nor cost-effective. In terms of models for delivery of care, task-shifting with nurse-led and decentralized care appear as effective as doctor-led or centralized care.
  
  
  CONCLUSIONS
  Recent studies have improved the evidence base for monitoring on ART. Future research to increase cost-effectiveness by better targeting of monitoring and/or evaluating implementation of less costly point-of-care tests will contribute to long-term success of ART while continuing to increase ART coverage.
authors.affiliation: MRC Clinical Trials Unit, London, UK. sarah.walker@ctu.mrc.ac.uk
authors.forename: A Sarah
authors.initials: AS
authors.lastname: Walker
authors.forename: Diana M
authors.initials: DM
authors.lastname: Gibb
mesh_terms: D019380:Anti-HIV Agents / Q000008:administration & dosage* / Q000009:adverse effects; D023241:Antiretroviral Therapy, Highly Active / Q000009:adverse effects / Q000379:methods*; D018791:CD4 Lymphocyte Count; D016903:Drug Monitoring / Q000191:economics* / Q000379:methods*; D006678:HIV / Q000302:isolation & purification*; D015658:HIV Infections / Q000188:drug therapy* / Q000821:virology*; D006801:Humans; D012367:RNA, Viral / Q000097:blood; D017211:Treatment Failure; D016896:Treatment Outcome; D019562:Viral Load
chemical_list: D019380:Anti-HIV Agents; D012367:RNA, Viral