Cost-effectiveness of different strategies to monitor adults on antiretroviral treatment: a combined analysis of three mathematical models

Abstract

Background The WHO’s 2013 revisions to its Consolidated Guidelines on ARVs will recommend routine viral load monitoring (VLM), rather than clinical or immunological monitoring, as the preferred monitoring approach on the basis of clinical evidence. However, HIV programmes in resource-limited settings require guidance on the most cost-effective use of resources given other competing priorities, including expansion of ART coverage. Here we assess the cost-effectiveness of alternative patient monitoring strategies. Methods A range of monitoring strategies was evaluated, including clinical, CD4 and viral load monitoring alone and together at different frequencies and with different criteria for switching to second-line therapies. Three independently-constructed and validated models were analysed simultaneously. Costs were estimated based on resource use projected in the models and associated unit costs; impact was quantified as disability-adjusted life years (DALYs) averted. Alternatives were compared using incremental cost-effectiveness analysis. Results All models show that clinical monitoring delivers significant benefit compared to a hypothetical baseline scenario with no monitoring or switching. Regular CD4 cell count monitoring confers a benefit over clinical monitoring alone, at an incremental cost that makes it affordable in more settings than VLM, which is currently more expensive. VLM without CD4 every six to 12 months provides the greatest reductions in morbidity and mortality, but incurs a high cost per DALY averted, resulting in lost opportunities to generate health gains if implemented instead of increasing ART coverage or expanding ART eligibility. Interpretation The priority for HIV programmes should be to expand ART coverage, firstly at CD4 <350 cells and then at CD4 <500, using lower-cost clinical or CD4 monitoring. At current costs, VLM should be considered only after high ART coverage has been achieved. Point-of-care technologies and other factors reducing costs may make VLM more affordable in future. Funding The HIV Modelling Consortium is funded by the Bill and Melinda Gates Foundation. Funding for this work was also provided by the World Health Organization.

Incidence and Predictors of Anti-Retroviral Treatment (ART) Failure among Adults Receiving HIV Care at Zewditu Memorial Hospital, Addis Ababa, Ethiopia

“…Global ART scale-up has been made possible by the use of standardized and simplified treatment protocols and decentralized service delivery, with limited reliance on laboratory monitoring [3,4]. In order to enhance treatment monitoring, WHO recommended by 2013 that viral load measurements among people receiving ART be performed 6 months after initiating ART and every 12 months thereafter [5,6].…”

HIV patients' decision of switching to second-line antiretroviral therapy in India

“…Recent costing studies have concluded that when the benefits of guided regimen switches are considered, viral load monitoring is found to be cost effective and life-saving (Ajose et al, 2012;Kahn et al, 2011). Improving the feasibility and reducing the cost of viral load monitoring are important policy objectives (Keebler et al, 2014).…”

“…Even though WHO (2013WHO ( , 2014 guidelines recommend routine viral load monitoring, India is not currently recommending routine viral load monitoring (Medecins Sans Frontieres, 2014). The priority for HIV programs should be to expand ART coverage using lower cost clinical or CD4 monitoring (Keebler et al, 2014). Further, as second-line ART has a greater role in the management of HIV infection, the need for evidence to establish the criteria for switching to second-line ART is critical.…”

Using modeling to inform international guidelines for antiretroviral treatment

“…Summary results have been presented elsewhere by Eaton and Menzies et al [5] and Keebler and Revill et al [6]. In brief, we estimated that, in programmes with high ART coverage, expanding treatment eligibility to HIV-positive adults with CD4 þ cell counts up to 500 cells/ml or even higher appears to be cost-effective, but this will need to be accompanied by large expansions in HIV testing and a enrolment in care in order to maximize the potential reductions in HIV incidence [5].…”

“…In brief, we estimated that, in programmes with high ART coverage, expanding treatment eligibility to HIV-positive adults with CD4 þ cell counts up to 500 cells/ml or even higher appears to be cost-effective, but this will need to be accompanied by large expansions in HIV testing and a enrolment in care in order to maximize the potential reductions in HIV incidence [5]. Moreover, although more sophisticated forms of patient monitoring-such as frequent viral load measurement-are expected to confer benefits, expanding ART coverage would be expected to generate greater population health benefits from limited resources [6].…”