title: Alternative antiretroviral monitoring strategies for HIV-infected patients in east Africa: opportunities to save more lives?
abstract: BACKGROUND
  Updated World Health Organization guidelines have amplified debate about how resource constraints should impact monitoring strategies for HIV-infected persons on combination antiretroviral therapy (cART). We estimated the incremental benefit and cost effectiveness of alternative monitoring strategies for east Africans with known HIV infection.
  
  
  METHODS
  Using a validated HIV computer simulation based on resource-limited data (USAID and AMPATH) and circumstances (east Africa), we compared alternative monitoring strategies for HIV-infected persons newly started on cART. We evaluated clinical, immunologic and virologic monitoring strategies, including combinations and conditional logic (e.g., only perform virologic testing if immunologic testing is positive). We calculated incremental cost-effectiveness ratios (ICER) in units of cost per quality-adjusted life year (QALY), using a societal perspective and a lifetime horizon. Costs were measured in 2008 US dollars, and costs and benefits were discounted at 3%. We compared the ICER of monitoring strategies with those of other resource-constrained decisions, in particular earlier cART initiation (at CD4 counts of 350 cells/mm3 rather than 200 cells/mm3).
  
  
  RESULTS
  Monitoring strategies employing routine CD4 testing without virologic testing never maximized health benefits, regardless of budget or societal willingness to pay for additional health benefits. Monitoring strategies employing virologic testing conditional upon particular CD4 results delivered the most benefit at willingness-to-pay levels similar to the cost of earlier cART initiation (approximately $2600/QALY). Monitoring strategies employing routine virologic testing alone only maximized health benefits at willingness-to-pay levels (> $4400/QALY) that greatly exceeded the ICER of earlier cART initiation.
  
  
  CONCLUSIONS
  CD4 testing alone never maximized health benefits regardless of resource limitations. Programmes routinely performing virologic testing but deferring cART initiation may increase health benefits by reallocating monitoring resources towards earlier cART initiation.
authors.affiliation: Section on Value and Comparative Effectiveness, Department of Medicine, New York University School of Medicine, USA. scott.braithwaite@nyumc.org
authors.forename: R Scott
authors.initials: RS
authors.lastname: Braithwaite
authors.forename: Kimberly A
authors.initials: KA
authors.lastname: Nucifora
authors.forename: Constantin T
authors.initials: CT
authors.lastname: Yiannoutsos
authors.forename: Beverly
authors.initials: B
authors.lastname: Musick
authors.forename: Sylvester
authors.initials: S
authors.lastname: Kimaiyo
authors.forename: Lameck
authors.initials: L
authors.lastname: Diero
authors.forename: Melanie C
authors.initials: MC
authors.lastname: Bacon
authors.forename: Kara
authors.initials: K
authors.lastname: Wools-Kaloustian
mesh_terms: D000351:Africa, Eastern; D019380:Anti-HIV Agents / Q000008:administration & dosage*; D018791:CD4 Lymphocyte Count; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D016903:Drug Monitoring / Q000191:economics / Q000379:methods*; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology / Q000473:pathology / Q000821:virology; D006801:Humans; D016896:Treatment Outcome; D019562:Viral Load
chemical_list: D019380:Anti-HIV Agents