Cost-effectiveness of Point-Of-Care Viral Load Monitoring of Antiretroviral Therapy in Resource-Limited Settings: Mathematical Modelling Study

AIDS. 2013 Jun 1;27(9):1483-92. doi: 10.1097/QAD.0b013e328360a4e5.

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.

Design: 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.

Conclusion: 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.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Africa South of the Sahara
  • Anti-HIV Agents / economics*
  • Anti-HIV Agents / therapeutic use
  • Cohort Studies
  • Cost-Benefit Analysis / economics
  • Female
  • HIV Infections / drug therapy
  • HIV Infections / economics*
  • Humans
  • Male
  • Models, Theoretical
  • Patient Compliance
  • Point-of-Care Systems / economics*
  • Quality-Adjusted Life Years
  • Randomized Controlled Trials as Topic
  • Viral Load / drug effects

Substances

  • Anti-HIV Agents