Cost-effectiveness of adoption strategies for point of care HIV viral load monitoring in South Africa
Girdwood SJ., Crompton T., Sharma M., Dorward J., Garrett N., Drain PK., Stevens W., Nichols BE.
Background: Viral 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. Methods: We 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. Findings: Existing 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. 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. Funding: Funding support from the Bill & Melinda Gates Foundation.