title: Cost-effectiveness of point-of-care viral load monitoring of antiretroviral therapy in resource-limited settings: mathematical modelling study.
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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors: Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland. jestill@ispm.unibe.ch
authors: Janne
authors: J
authors: Estill
authors: Matthias
authors: M
authors: Egger
authors: Nello
authors: N
authors: Blaser
authors: Luisa Salazar
authors: LS
authors: Vizcaya
authors: Daniela
authors: D
authors: Garone
authors: Robin
authors: R
authors: Wood
authors: Jennifer
authors: J
authors: Campbell
authors: Timothy B
authors: TB
authors: Hallett
authors: Olivia
authors: O
authors: Keiser
mesh_terms: D000328:Adult; D017954:Africa South of the Sahara; D019380:Anti-HIV Agents / Q000191:economics* / Q000627:therapeutic use; D015331:Cohort Studies; D003362:Cost-Benefit Analysis / Q000191:economics; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000191:economics*; D006801:Humans; D008297:Male; D008962:Models, Theoretical; D010349:Patient Compliance; D019095:Point-of-Care Systems / Q000191:economics*; D019057:Quality-Adjusted Life Years; D016032:Randomized Controlled Trials as Topic; D019562:Viral Load / Q000187:drug effects
chemical_list: D019380:Anti-HIV Agents