Abstract
Background: Viral load (VL) testing is recommended for monitoring people living with HIV on antiretroviral therapy (ART). The National Health Laboratory Service (NHLS) in South Africa conducted >5 million VL tests at 16 laboratories in 2018 but faced challenges with specimen integrity and results delivery. Point-of-care (POC) VL monitoring may improve results delivery and viral suppression. We assessed the cost-effectiveness of different adoption strategies for POC testing in South Africa. Methods: We developed a cost-outcome model utilizing NHLS data, including facility-level annual VL volume, suppression rates (<1000 copies/ml), specimen rejection rates, turn-around time, and the cost/test. We assessed the health and economic impact of adopting two validated POC VL technologies (Cepheid GeneXpert and Abbott m-PIMATM) under 4 scenarios: 1) status-quo; 2) targeted POC testing at facilities with high levels of viral failure; 3) targeted POC testing at low-performing facilities; and 4) complete POC adoption. For each scenario, we determined the total cost, effectiveness (expected number of people with suppressed VL) and incremental cost-effectiveness ratio (ICER) based on expected improvement in suppression rates. Finding: The existing centralized network of laboratory based VL testing costs $126m annually and achieves a VL suppression rate of 85.2%. Targeted testing using the GeneXpert, was the most cost-effective approach, with 88.5% VL suppression and $40 per additional person suppressed, compared to the centralized network. Should resources allow, complete POC VL adoption may be cost-effective (ICER: $136/additional person suppressed), requiring an additional $49m annually and achieving VL 94.5% suppression. All other scenarios were dominated in the incremental analysis. Interpretation: Assuming POC HIV viral load monitoring confers clinical benefits consistent with trial results, the most cost-effective strategy for POC adoption in South Africa is likely a targeted approach with POC VL technologies placed at facilities with high rates of viral failure.
Highlights
The World Health Organization (WHO) recommends viral load testing for monitoring persons living with HIV (PLHIV) on ART [1]
Whilst the National Health Laboratory Service (NHLS) currently uses 4, 16 or 80 module Xpert instruments for tuberculosis diagnosis, these instruments are located at laboratories and have not been used in a POC setting, nor have they been used for HIV viral load testing in South Africa
Given clinical benefits from improved viral suppression rates due to POC viral load testing, we find that the most cost-effective strategy for viral load POC adoption in South Africa is likely a targeted approach, with POC instruments placed at larger facilities with high numbers of patients experiencing viral failure
Summary
The World Health Organization (WHO) recommends viral load testing for monitoring persons living with HIV (PLHIV) on ART [1]. To our knowledge, this is the first paper to assess the feasibility of different adoption strategies for POC viral load monitoring on a national scale. This is the first paper to assess the feasibility of different adoption strategies for POC viral load monitoring on a national scale This analysis is novel in that it incorporates both costs and outcomes and uses facility-level data to match viral load demand to equipment capacity in order to minimize costs. Interpretation: Assuming POC VL monitoring confers clinical benefits, the most cost-effective strategy for POC adoption in South Africa is a targeted approach with POC VL technologies placed at facilities with high level of viral failure.
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