title: Laboratory Monitoring of Antiretroviral Therapy for HIV Infection: Cost-Effectiveness and Budget Impact of Current and Novel Strategies.
abstract: Optimal laboratory monitoring of antiretroviral therapy (ART) for human immunodeficiency virus (HIV) remains controversial. We evaluated current and novel monitoring strategies in Côte d'Ivoire, West Africa.
  
  
  
  We used the Cost-Effectiveness of Preventing AIDS Complications -International model to compare clinical outcomes, cost-effectiveness, and budget impact of 11 ART monitoring strategies varying by type (CD4 and/or viral load [VL]) and frequency. We included "adaptive" strategies (biannual then annual monitoring for patients on ART/suppressed). Mean CD4 count at ART initiation was 154/μL. Laboratory test costs were CD4=$11 and VL=$33. The standard of care (SOC; biannual CD4) was the comparator. We assessed cost-effectiveness relative to Côte d'Ivoire's 2013 per capita GDP ($1500).
  
  
  
  Discounted life expectancy was 16.69 years for SOC, 16.97 years with VL confirmation of immunologic failure, and 17.25 years for adaptive VL. Mean time on failed first-line ART was 3.7 years for SOC and <0.9 years for all routine/adaptive VL strategies. VL failure confirmation was cost-saving compared with SOC. Adaptive VL had an incremental cost-effectiveness ratio (ICER) of $4100/year of life saved compared with VL confirmation and increased the 5-year budget by $310/patient compared with SOC. Adaptive VL achieved an ICER <1× GDP if second-line ART and VL costs simultaneously decreased to $156 and $13, respectively.
  
  
  
  VL confirmation of immunologic failure is more effective and less costly than CD4 monitoring in Côte d'Ivoire. Adaptive VL monitoring reduces time on failing ART, is cost-effective, and should become standard in Côte d'Ivoire and similar settings.
authors.affiliation: Institut National de la Santé et de la Recherche Médicale Centre 897.|Institut de Santé Publique d'Epidémiologique et de Développement, University of Bordeaux, France.|Programme PACCI/Agence Nationale de Recherche sur le SIDA et les hépatites virales Research Site, Treichville University Hospital Center, Abidjan, Côte d'Ivoire.|Interdepartmental Centre of Tropical Medicine and Clinical International Health, Division of Infectious and Tropical Diseases, Department of Medicine, University Hospital Centre, Bordeaux, France.
authors.forename: Eric N
authors.initials: EN
authors.lastname: Ouattara
authors.affiliation: Medical Practice Evaluation Center.|Division of General Internal Medicine, Massachusetts General Hospital, Boston.
authors.forename: Marion
authors.initials: M
authors.lastname: Robine
authors.affiliation: Programme PACCI/Agence Nationale de Recherche sur le SIDA et les hépatites virales Research Site, Treichville University Hospital Center, Abidjan, Côte d'Ivoire.|Department of Infectious and Tropical Diseases, Treichville University Hospital, Abidjan, Côte d'Ivoire.
authors.forename: Serge P
authors.initials: SP
authors.lastname: Eholié
authors.affiliation: Medical Practice Evaluation Center.|Division of General Internal Medicine, Massachusetts General Hospital, Boston.
authors.forename: Rachel L
authors.initials: RL
authors.lastname: MacLean
authors.affiliation: Programme PACCI/Agence Nationale de Recherche sur le SIDA et les hépatites virales Research Site, Treichville University Hospital Center, Abidjan, Côte d'Ivoire.|Department of Infectious and Tropical Diseases, Treichville University Hospital, Abidjan, Côte d'Ivoire.
authors.forename: Raoul
authors.initials: R
authors.lastname: Moh
authors.affiliation: Medical Practice Evaluation Center.|Division of General Internal Medicine, Massachusetts General Hospital, Boston.|Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Elena
authors.initials: E
authors.lastname: Losina
authors.affiliation: Institut National de la Santé et de la Recherche Médicale Centre 897.|Institut de Santé Publique d'Epidémiologique et de Développement, University of Bordeaux, France.
authors.forename: Delphine
authors.initials: D
authors.lastname: Gabillard
authors.affiliation: Yale School of Public Health, New Haven, Connecticut.
authors.forename: A David
authors.initials: AD
authors.lastname: Paltiel
authors.affiliation: Institut National de la Santé et de la Recherche Médicale Centre 897.|Institut de Santé Publique d'Epidémiologique et de Développement, University of Bordeaux, France.|Programme PACCI/Agence Nationale de Recherche sur le SIDA et les hépatites virales Research Site, Treichville University Hospital Center, Abidjan, Côte d'Ivoire.
authors.forename: Christine
authors.initials: C
authors.lastname: Danel
authors.affiliation: Medical Practice Evaluation Center.|Division of General Internal Medicine, Massachusetts General Hospital, Boston.|Division of Infectious Diseases, Massachusetts General Hospital.|Harvard Medical School.|Division of Infectious Diseases, Brigham and Women's Hospital.
authors.forename: Rochelle P
authors.initials: RP
authors.lastname: Walensky
authors.affiliation: Institut National de la Santé et de la Recherche Médicale Centre 897.|Institut de Santé Publique d'Epidémiologique et de Développement, University of Bordeaux, France.|Programme PACCI/Agence Nationale de Recherche sur le SIDA et les hépatites virales Research Site, Treichville University Hospital Center, Abidjan, Côte d'Ivoire.
authors.forename: Xavier
authors.initials: X
authors.lastname: Anglaret
authors.affiliation: Medical Practice Evaluation Center.|Division of General Internal Medicine, Massachusetts General Hospital, Boston.|Division of Infectious Diseases, Massachusetts General Hospital.|Harvard Medical School.|Department of Epidemiology, Boston University School of Public Health.|Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Freedberg
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000191:economics* / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D016903:Drug Monitoring; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000191:economics* / Q000453:epidemiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D019562:Viral Load
chemical_list: D019380:Anti-HIV Agents
keywords: ART; HIV; cost-effectiveness; laboratory monitoring; viral load