4 years ago

The value of point-of-care CD4+ and laboratory viral load in tailoring antiretroviral therapy monitoring strategies to resource limitations

Walensky, Rochelle P., Maggiore, Paolo, Hyle, Emily P., Jani, Ilesh V., Freedberg, Kenneth A., Rosettie, Katherine L., Parker, Robert A., Pei, Pamela P., Resch, Stephen, Peter, Trevor, Osher, Benjamin, Wood, Robin
imageObjective: To examine the clinical and economic value of point-of-care CD4+ (POC-CD4+) or viral load monitoring compared with current practices in Mozambique, a country representative of the diverse resource limitations encountered by HIV treatment programs in sub-Saharan Africa. Design/methods: We use the Cost-Effectiveness of Preventing AIDS Complications-International model to examine the clinical impact, cost (2014 US$), and incremental cost-effectiveness ratio [$/year of life saved (YLS)] of ART monitoring strategies in Mozambique. We compare: monitoring for clinical disease progression [clinical ART monitoring strategy (CLIN)] vs. annual POC-CD4+ in rural settings without laboratory services and biannual laboratory CD4+ (LAB-CD4+), biannual POC-CD4+, and annual viral load in urban settings with laboratory services. We examine the impact of a range of values in sensitivity analyses, using Mozambique's 2014 per capita gross domestic product ($620) as a benchmark cost-effectiveness threshold. Results: In rural settings, annual POC-CD4+ compared to CLIN improves life expectancy by 2.8 years, reduces time on failed ART by 0.6 years, and yields an incremental cost-effectiveness ratio of $480/YLS. In urban settings, biannual POC-CD4+ is more expensive and less effective than viral load. Compared to biannual LAB-CD4+, viral load improves life expectancy by 0.6 years, reduces time on failed ART by 1.0 year, and is cost-effective ($440/YLS). Conclusion: In rural settings, annual POC-CD4+ improves clinical outcomes and is cost-effective compared to CLIN. In urban settings, viral load has the greatest clinical benefit and is cost-effective compared to biannual POC-CD4+ or LAB-CD4+. Tailoring ART monitoring strategies to specific settings with different available resources can improve clinical outcomes while remaining economically efficient.
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