Cost-effectiveness of adoption strategies for point of care HIV viral load monitoring in South Africa

Sarah J Girdwood,Paul K Drain,Jienchi Dorward,Wendy Stevens,Monisha Sharma,Thomas Crompton,Nigel Garrett,Brooke E Nichols

doi:10.1016/j.eclinm.2020.100607

Abstract

BackgroundViral load (VL) testing is recommended for monitoring people on ART. The National Health Laboratory Service (NHLS) in South Africa conducts >5million laboratory-based VL tests but faces challenges with specimen integrity and results delivery. Point-of-care (POC) VL monitoring may improve VL suppression (VLS). We assessed the cost-effectiveness of different strategies for POC testing in South Africa.MethodsWe developed a cost-outcome model utilizing NHLS data, including facility-level annual VL volumes, proportion with VLS, specimen rejection rates, turn-around-time, and the cost/test. We assessed the impact of adopting POC VL technology under 4 strategies: (1) status-quo; (2) targeted POC testing at facilities with high levels of viral failure; (3) targeted POC testing at low-performing facilities; (4) complete POC adoption. For each strategy, we determined the total cost, effectiveness (expected number of virally suppressed people) and incremental cost-effectiveness ratio (ICER) based on expected (>10%) VLS improvement.FindingsExisting laboratory-based VL testing costs $126 m annually and achieves 85.2% VLS. Strategy 2 was the most cost-effective approach, with 88.5% VLS and $40/additional person suppressed, compared to the status-quo. Should resources allow, complete POC adoption may be cost-effective (ICER: $136/additional person suppressed), requiring an additional $49 m annually and achieving 94.5% VLS. All other strategies were dominated in the incremental analysis.InterpretationAssuming 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.FundingFunding support from the Bill & Melinda Gates Foundation.

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

Introduction

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.

Methods

Results

Conclusion