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Clin Infect Dis. 2017 Jun 15;64(12):1724-1730. doi: 10.1093/cid/cix177.

Differentiated Human Immunodeficiency Virus RNA Monitoring in Resource-Limited Settings: An Economic Analysis.

Author information

1
College of Science and Engineering, Industrial and System Engineering, University of Minnesota, Minneapolis.
2
Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel and University of Basel, Switzerland.
3
Department of Medicine, and.
4
Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University, California.

Abstract

Background.:

Viral load (VL) monitoring for patients receiving antiretroviral therapy (ART) is recommended worldwide. However, the costs of frequent monitoring are a barrier to implementation in resource-limited settings. The extent to which personalized monitoring frequencies may be cost-effective is unknown.

Methods.:

We created a simulation model parameterized using person-level longitudinal data to assess the benefits of flexible monitoring frequencies. Our data-driven model tracked human immunodeficiency virus (HIV)-infected individuals for 10 years following ART initiation. We optimized the interval between viral load tests as a function of patients' age, gender, education, duration since ART initiation, adherence behavior, and the cost-effectiveness threshold. We compared the cost-effectiveness of the personalized monitoring strategies to fixed monitoring intervals every 1, 3, 6, 12, and 24 months.

Results.:

Shorter fixed VL monitoring intervals yielded increasing benefits (6.034 to 6.221 discounted quality-adjusted life-years [QALYs] per patient with monitoring every 24 to 1 month over 10 years, respectively, standard error = 0.005 QALY), at increasing average costs: US$3445 (annual monitoring) to US$5393 (monthly monitoring) per patient, respectively (standard error = US$3.7). The adaptive policy optimized for low-income contexts achieved 6.142 average QALYs at a cost of US$3524, similar to the fixed 12-month policy (6.135 QALYs, US$3518). The adaptive policy optimized for middle-income resource settings yields 0.008 fewer QALYs per person, but saves US$204 compared to monitoring every 3 months.

Conclusions.:

The benefits from implementing adaptive vs fixed VL monitoring policies increase with the availability of resources. In low- and middle-income countries, adaptive policies achieve similar outcomes to simpler, fixed-interval policies.

KEYWORDS:

adaptive viral load monitoring.; differentiated care

PMID:
28329208
PMCID:
PMC5447887
DOI:
10.1093/cid/cix177
[Indexed for MEDLINE]
Free PMC Article

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