UNAIDS estimates there were 160 000 incident paediatric HIV infections globally in 2021.1UNAIDSGlobal HIV & AIDS statistics—fact sheet.https://www.unaids.org/en/resources/fact-sheetDate accessed: March 3, 2023Google Scholar HIV is associated with high neonatal and infant morbidity and mortality. More than half of untreated HIV-positive children die before their second birthday.2Newell ML Coovadia H Cortina-Borja M et al.Mortality of infected and uninfected infants born to HIV-infected mothers in Africa: a pooled analysis.Lancet. 2004; 364: 1236-1243Summary Full Text Full Text PDF PubMed Scopus (916) Google Scholar Early infant diagnosis (EID) and prompt initiation of antiretroviral therapy (ART) dramatically improves infant survival, reducing mortality by 76%.3Iyun V Technau KG Eley B et al.Earlier antiretroviral therapy initiation and decreasing mortality among HIV-infected infants initiating antiretroviral therapy within 3 months of age in South Africa, 2006–2017.Pediatr Infect Dis J. 2020; 39: 127-133Crossref PubMed Scopus (13) Google Scholar, 4Violari A Cotton MF Gibb DM et al.Early antiretroviral therapy and mortality among HIV-infected infants.N Engl J Med. 2008; 359: 2233-2244Crossref PubMed Scopus (1089) Google Scholar Consequently, WHO recommends EID for HIV-exposed infants within the first 6 weeks of life.5WHOConsolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach. World Health Organization, Geneva2021Google Scholar Current EID standard-of-care (SOC) models rely on a complex cascade of steps that include clinical presentation, sample collection, sample transport (frequently to central laboratories) for the highly sensitive and specific HIV nucleic acid tests (NAT), notification of results, and coordination of patient and caregivers to facilitate entry into HIV care. At each step of this diagnostic cascade, there is substantial attrition, which programme managers have tried to mitigate through several interventions including improved specimen handling and electronic return of results.6Bianchi F Cohn J Sacks E et al.Evaluation of a routine point-of-care intervention for early infant diagnosis of HIV: an observational study in eight African countries.Lancet HIV. 2019; 6: e373-e381Summary Full Text Full Text PDF PubMed Scopus (45) Google Scholar Delays in time-to-result has led to increasing interest in point-of-care NAT (POC-NAT) to decrease attrition in linkage to paediatric HIV care.5WHOConsolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach. World Health Organization, Geneva2021Google Scholar, 7Carlucci JG Liu Y Friedman H et al.Attrition of HIV-exposed infants from early infant diagnosis services in low- and middle-income countries: a systematic review and meta-analysis.J Int AIDS Soc. 2018; 21e25209Crossref PubMed Scopus (20) Google Scholar In The Lancet HIV, Stanzi M Le Roux and colleagues8le Roux SM Odayar J Sutcliffe CG et al.Cost-effectiveness of point-of-care versus centralized, laboratory-based nucleic acid testing for diagnosis of HIV in infants: a systematic review of modelling studies.Lancet HIV. 2023; 10: e320-e331Summary Full Text Full Text PDF Scopus (1) Google Scholar add to the growing evidence supporting the use of POC-NAT in EID. Their analysis focuses on the results of two mathematical models, the Cost-Effectiveness of Preventing AIDS Complications-paediatric model and the Johns Hopkins University model. They examine the cost-effectiveness and survival outcomes in children with HIV tested under POC-NAT versus those tested under SOC.8le Roux SM Odayar J Sutcliffe CG et al.Cost-effectiveness of point-of-care versus centralized, laboratory-based nucleic acid testing for diagnosis of HIV in infants: a systematic review of modelling studies.Lancet HIV. 2023; 10: e320-e331Summary Full Text Full Text PDF Scopus (1) Google Scholar Although there is heterogeneity in the reviewed studies, including different time horizons, choice of denominators, and selection of cost categories, POC-NAT was consistently more cost-effective than was SOC. The authors report that POC-NAT increases the probability of ART initiation within 60 days of testing from 19% to 82%, with stable results under sensitivity analyses. POC-NAT also leads to earlier diagnosis, faster treatment initiation, better treatment coverage, and increased survival.8le Roux SM Odayar J Sutcliffe CG et al.Cost-effectiveness of point-of-care versus centralized, laboratory-based nucleic acid testing for diagnosis of HIV in infants: a systematic review of modelling studies.Lancet HIV. 2023; 10: e320-e331Summary Full Text Full Text PDF Scopus (1) Google Scholar The incremental cost-effectiveness ratios (ICERs) in the systematic review fell within the acceptable ranges of cost-effectiveness thresholds and mirrored those found in other reviews.9Elsbernd K Emmert-Fees KMF Erbe A et al.Costs and cost-effectiveness of HIV early infant diagnosis in low- and middle-income countries: a scoping review.Infect Dis Poverty. 2022; 11: 82Crossref PubMed Scopus (3) Google Scholar The ICERS in the reviewed studies were high, similar to those of other diagnostic interventions, and should be viewed within this context. To aid policymakers, the authors provide summary results from budget impact analyses, which suggest that incorporating a POC-NAT approach would result in an increase in HIV programme budgets of less than 1%.8le Roux SM Odayar J Sutcliffe CG et al.Cost-effectiveness of point-of-care versus centralized, laboratory-based nucleic acid testing for diagnosis of HIV in infants: a systematic review of modelling studies.Lancet HIV. 2023; 10: e320-e331Summary Full Text Full Text PDF Scopus (1) Google Scholar The reviewed mathematical models did not capture the potential economies of scope arising from existing POC-NAT investments. For example, many health systems have adapted these platforms for SARS-CoV-2 testing. These platforms can also be used to detect multiple pathogens, which would increase their benefits beyond HIV programmes. Many POC sites do not generate sufficient clinical volumes, with some sites having one or two EID clients daily.6Bianchi F Cohn J Sacks E et al.Evaluation of a routine point-of-care intervention for early infant diagnosis of HIV: an observational study in eight African countries.Lancet HIV. 2019; 6: e373-e381Summary Full Text Full Text PDF PubMed Scopus (45) Google Scholar The low throughput and associated equipment downtime would be difficult to justify from a budgeting perspective. The studies included in the review also focused on the two approved POC-NAT systems, but other potentially less expensive alternatives are in development, including p24 assays.10Sutcliffe CG Mutanga J Moyo N et al.Point-of-care p24 antigen detection for early infant diagnosis of HIV infection: cross-sectional and longitudinal studies in Zambia.BMC Infect Dis. 2021; 21: 118Crossref PubMed Scopus (4) Google Scholar These systems could alter cost calculations in the future. The technical nature of laboratory diagnosis, including sample preparation, quality control, and result interpretation, and high initial capital costs of NAT platforms necessitate the use of qualified laboratorians. This might make task-shifting of POC-NAT tests to non-laboratory personnel, as suggested by some of the cited studies, untenable. For robust services, a hybrid system will most likely be required, with quality control and some confirmatory testing at central laboratories. The cost-effectiveness analyses included in the systematic review relied on average population values and were not designed to capture the equity impacts of POC-NAT. Scaling-up of POC-NAT could be the first step in increasing access to crucial diagnostic services for underprivileged people who face barriers in accessing and navigating care. However, this potential can only be realised and sustained if improvements are also made to antenatal care and prevention of vertical transmission programmes and the immediate initiation of ART. These promising results are an additional piece of evidence justifying the role of POC-NAT in strengthening HIV programmes. I declare no competing interests. The findings and conclusions in this paper are those of the author and do not necessarily represent the official position of the US Centers for Disease Control and Prevention. Cost-effectiveness of point-of-care versus centralised, laboratory-based nucleic acid testing for diagnosis of HIV in infants: a systematic review of modelling studiesFour reports from two different models suggest that POC is a cost-effective and potentially cost-saving strategy for upscaling of early infant testing compared with SOC. Full-Text PDF Open Access