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Clin Infect Dis. 2016 Jun 1;62(11):1454-1462. doi: 10.1093/cid/ciw117. Epub 2016 Mar 1.

Laboratory Monitoring of Antiretroviral Therapy for HIV Infection: Cost-Effectiveness and Budget Impact of Current and Novel Strategies.

Ouattara EN1,2,3,4, Robine M5,6, Eholié SP3,7, MacLean RL5,6, Moh R3,7, Losina E5,6,8, Gabillard D1,2, Paltiel AD9, Danel C1,2,3, Walensky RP5,6,10,11,12, Anglaret X1,2,3, Freedberg KA5,6,10,11,13,14.

Author information

1
Institut National de la Santé et de la Recherche Médicale Centre 897.
2
Institut de Santé Publique d'Epidémiologique et de Développement, University of Bordeaux, France.
3
Programme PACCI/Agence Nationale de Recherche sur le SIDA et les hépatites virales Research Site, Treichville University Hospital Center, Abidjan, Côte d'Ivoire.
4
Interdepartmental Centre of Tropical Medicine and Clinical International Health, Division of Infectious and Tropical Diseases, Department of Medicine, University Hospital Centre, Bordeaux, France.
5
Medical Practice Evaluation Center.
6
Division of General Internal Medicine, Massachusetts General Hospital, Boston.
7
Department of Infectious and Tropical Diseases, Treichville University Hospital, Abidjan, Côte d'Ivoire.
8
Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
9
Yale School of Public Health, New Haven, Connecticut.
10
Division of Infectious Diseases, Massachusetts General Hospital.
11
Harvard Medical School.
12
Division of Infectious Diseases, Brigham and Women's Hospital.
13
Department of Epidemiology, Boston University School of Public Health.
14
Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

Abstract

BACKGROUND:

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.

METHODS:

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).

RESULTS:

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.

CONCLUSIONS:

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.

KEYWORDS:

ART; HIV; cost-effectiveness; laboratory monitoring; viral load

PMID:
26936666
PMCID:
PMC4872286
DOI:
10.1093/cid/ciw117
[Indexed for MEDLINE]
Free PMC Article

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