title: Sustainable HIV treatment in Africa through viral-load-informed differentiated care.
abstract: There are inefficiencies in current approaches to monitoring patients on antiretroviral therapy in sub-Saharan Africa. Patients typically attend clinics every 1 to 3 months for clinical assessment. The clinic costs are comparable with the costs of the drugs themselves and CD4 counts are measured every 6 months, but patients are rarely switched to second-line therapies. To ensure sustainability of treatment programmes, a transition to more cost-effective delivery of antiretroviral therapy is needed. In contrast to the CD4 count, measurement of the level of HIV RNA in plasma (the viral load) provides a direct measure of the current treatment effect. Viral-load-informed differentiated care is a means of tailoring care so that those with suppressed viral load visit the clinic less frequently and attention is focussed on those with unsuppressed viral load to promote adherence and timely switching to a second-line regimen. The most feasible approach to measuring viral load in many countries is to collect dried blood spot samples for testing in regional laboratories; however, there have been concerns over the sensitivity and specificity of this approach to define treatment failure and the delay in returning results to the clinic. We use modelling to synthesize evidence and evaluate the cost-effectiveness of viral-load-informed differentiated care, accounting for limitations of dried blood sample testing. We find that viral-load-informed differentiated care using dried blood sample testing is cost-effective and is a recommended strategy for patient monitoring, although further empirical evidence as the approach is rolled out would be of value. We also explore the potential benefits of point-of-care viral load tests that may become available in the future.
authors.affiliation: Department of Infection and Population Health, University College London, Rowland Hill Street, London NW3 2PF, UK.
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authors.affiliation: Southern Africa Medical Unit (SAMU), Medecins sans Frontieres (MSF) SA, Waverley Business Park, Wyecroft Rd, Mowbray 7700, Cape Town, South Africa.
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authors.affiliation: Clinton Health Access Initiative, 383 Dorchester Avenue, Boston, Massachusetts 02127, USA.
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authors.affiliation: Médecins Sans Frontières, Access Campaign, rue du Lausanne 82, 1202 Geneva Switzerland.
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authors.affiliation: Médecins Sans Frontières, Access Campaign, rue du Lausanne 82, 1202 Geneva Switzerland.
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authors.affiliation: Southern Africa Medical Unit (SAMU), Medecins sans Frontieres (MSF) SA, Waverley Business Park, Wyecroft Rd, Mowbray 7700, Cape Town, South Africa.
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authors.affiliation: Médecins Sans Frontières, 78 rue de Lausanne, Case Postale 116, 1211 Geneva 21, Switzerland.
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authors.affiliation: Bill and Melinda Gates Foundation, PO Box 23350, Seattle, Washington 98199, USA.
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authors.affiliation: Department of Infection and Population Health, University College London, Rowland Hill Street, London NW3 2PF, UK.
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authors.affiliation: Department of Infection and Population Health, University College London, Rowland Hill Street, London NW3 2PF, UK.
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authors.affiliation: Department of Infection and Population Health, University College London, Rowland Hill Street, London NW3 2PF, UK.
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authors.affiliation: Department of Viroscience, Erasmus Medical Center, PO Box 20403000CA Rotterdam, the Netherlands.
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mesh_terms: D000293:Adolescent; D000328:Adult; D000349:Africa; D000368:Aged; D019380:Anti-HIV Agents / Q000191:economics / Q000494:pharmacology / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D015658:HIV Infections / Q000175:diagnosis / Q000188:drug therapy* / Q000191:economics / Q000821:virology*; D006801:Humans; D008875:Middle Aged; D057285:Precision Medicine / Q000191:economics / Q000379:methods*; D019562:Viral Load / Q000187:drug effects; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents