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Publication Details
AFRICAN RESEARCH NEXUS
SHINING A SPOTLIGHT ON AFRICAN RESEARCH
Cost-effectiveness of different strategies to monitor adults on antiretroviral treatment: A combined analysis of three mathematical models
The Lancet Global Health, Volume 2, No. 1, Year 2014
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Description
Background: WHO's 2013 revisions to its Consolidated Guidelines on antiretroviral drugs recommend routine viral load monitoring, 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 in view of other competing priorities such as expansion of antiretroviral therapy coverage. We assessed the cost-effectiveness of alternative patient monitoring strategies. Methods: We evaluated a range of monitoring strategies, including clinical, CD4 cell count, and viral load monitoring, alone and together, at different frequencies and with different criteria for switching to second-line therapies. We used three independently constructed and validated models simultaneously. We estimated costs on the basis of resource use projected in the models and associated unit costs; we quantified impact as disability-adjusted life years (DALYs) averted. We compared alternatives using incremental cost-effectiveness analysis. Findings: All models show that clinical monitoring delivers significant benefit compared with 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 viral load monitoring, which is currently more expensive. Viral load monitoring without CD4 cell count every 6-12 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 antiretroviral therapy coverage or expanding antiretroviral therapy eligibility. Interpretation: The priority for HIV programmes should be to expand antiretroviral therapy coverage, firstly at CD4 cell count lower than 350 cells per μL, and then at a CD4 cell count lower than 500 cells per μL, using lower-cost clinical or CD4 monitoring. At current costs, viral load monitoring should be considered only after high antiretroviral therapy coverage has been achieved. Point-of-care technologies and other factors reducing costs might make viral load monitoring more affordable in future. Funding: Bill & Melinda Gates Foundation, WHO. © 2014 Keebler et al.
Authors & Co-Authors
Keebler, Daniel
South Africa, Stellenbosch
Stellenbosch University
Revill, Paul A.
United Kingdom, York
University of York
Braithwaite, Scott R.
United States, New York
New York University
Phillips, Andrew N.
United Kingdom, London
University College London
Blaser, Nello
Switzerland, Bern
Institute of Social and Preventive Medicine
Bórquez, Annick B.
United Kingdom, London
Imperial College London
Cambiano, Valentina
United Kingdom, London
University College London
Ciaranello, Andrea L.
United States, Boston
Massachusetts General Hospital
Estill, Janne Anton Markus
Switzerland, Bern
Institute of Social and Preventive Medicine
Gray, Richard Thomas
Australia, Kensington
The Kirby Institute
Hill, Andrew M.
United Kingdom, Liverpool
University of Liverpool
Keiser, Olivia
Switzerland, Bern
Institute of Social and Preventive Medicine
Kessler, Jason
United States, New York
New York University
Menzies, Nicolas A.
United States, Boston
Harvard T.h. Chan School of Public Health
Nucifora, Kimberly A.
United States, New York
New York University
Salazar-Vizcaya, Luisa
Switzerland, Bern
Institute of Social and Preventive Medicine
Walker, Simon A.
United Kingdom, York
University of York
Welte, Alex
South Africa, Stellenbosch
Stellenbosch University
Easterbrook, Philippa Jane
Switzerland, Geneva
Organisation Mondiale de la Santé
Doherty, Meg C.
Switzerland, Geneva
Organisation Mondiale de la Santé
Hirnschall, Gottfried O.
Switzerland, Geneva
Organisation Mondiale de la Santé
Hallett, Timothy B.
United Kingdom, London
Imperial College London
Statistics
Citations: 53
Authors: 22
Affiliations: 11
Identifiers
Doi:
10.1016/S2214-109X(13)70048-2
e-ISSN:
2214109X
Research Areas
Disability
Health System And Policy
Infectious Diseases