Cost-effectiveness of laboratory monitoring for management of HIV treatment in sub-Saharan Africa: a model-based analysis

Raph L. Hamers, A. W. Sawyer, Martin Tuohy, Wendy S. Stevens, Tobias F. Rinke de Wit, Andrew M. Hill

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Objective: To compare the cost-effectiveness of three different strategies for long-term monitoring of antiretroviral therapy (ART) failure and regimen switching in sub-Saharan Africa: a symptom-based approach, or monitoring of either CD4 cell counts or plasma viral load (pVL). Design: Markov model. Setting and participants: Hypothetical HIV-infected adult population who began first-line ART and subsequently had up to 6 years of follow-up. Main outcome measures: Total cost, life expectancy and incremental cost-effectiveness ratio (ICER). Results: A symptom-based approach yielded a life expectancy of 64.0 months at a total cost of US$ 4028 per person. All laboratory-based strategies, at testing intervals of 6 or 12 months, were cost-saving and improved life expectancy, compared with a symptom-based approach. The life-expectancy gain was larger for pVL than for CD4 strategies at 6-monthly (2.3 and 0.9 months, respectively) and 12-monthly testing (2.0 and 0.8 months, respectively). Cost-savings of 6-monthly pVL or CD4 testing were similar (US$ 630 and 621, respectively), whereas 12-monthly CD4 cell counts were more cost-saving than 12-monthly pVL (US$ 1132 and 880, respectively). Testing every 12 months - rather than every 6 months - decreased the ICER by 102% for CD4 cell count and 67% for pVL. These findings were robust to a wide range of deterministic sensitivity analyses, but were sensitive to the specificity and costs of diagnostic tests. Conclusion: Additional diagnostic costs are balanced by cost-savings from avoiding unnecessary switching due to misdiagnosis of ART failure. Routine pVL monitoring may be preferred as a replacement for CD4 cell counts because of its additional public-health advantages in preventing drug-resistance, supporting adherence and reducing HIV transmission. (C) 2012 Wolters Kluwer Health vertical bar Lippincott Williams & Wilkins
Original languageEnglish
Pages (from-to)1663-1672
JournalAIDS (London, England)
Issue number13
Publication statusPublished - 2012

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