Comparative cost analysis of point-of-care versus laboratory-based testing to initiate and monitor HIV treatment in South Africa

Abstract

BackgroundThe number of people living with HIV (PLHIV) in need of treatment monitoring in low-and-middle-income countries has been rapidly expanding, placing an increasing burden on laboratories. Promising new point-of-care (POC) test have the potential to reduce laboratory workloads, but the implementation cost is uncertain. We sought to estimate the costs of decentralized POC testing compared to centralized laboratory testing for PLHIV initiating treatment in South Africa.MethodsWe conducted a microcosting analyses comparing clinic-based POC testing to centralized laboratory testing for HIV viral load, creatinine, and CD4 count monitoring. We completed time-and-motion studies to assess staff time for sample collection and processing. Instrument costs were estimated assuming five-year lifespans and we applied a 3% annual discount rate. Total costs and cost per patient were estimated over a five-year period: the first year of ART initiation and four years of routine HIV monitoring, following World Health Organization ART monitoring guidelines.ResultsWe estimated that per-patient costs of POC HIV viral load, CD4, and creatinine tests were USD $25, $11, and $9, respectively, assuming a clinic volume of 50 patients initiated per month. At centralized laboratories, per-patient costs of POC HIV viral load, CD4, and creatinine tests were USD $26, $6, $3. Total monitoring costs of all testing over a 5-year period was $45 higher for POC testing compared to centralized laboratory testing ($210 vs $166).ConclusionsPOC testing for HIV care and treatment can be feasibly implemented within clinics in South Africa, particularly those with larger patient volumes. POC HIV viral load costs are similar to lab-based testing while CD4 count and creatinine testing are more costly as POC tests. Our cost estimates are useful to policymakers in planning resource allocation and can inform cost-effectiveness analyses of POC testing.

Costs of Point-of-Care Viral Load Testing for Adults and Children Living with HIV in Kenya

“…Our findings are similar to previous costing studies, which estimated the cost per POC VL test to be between $25 and $30 [ 8 , 13 ]. One study in South Africa found that staff time to collect a sample and conduct the POC VL test contributed $8 to the per-test cost, which is substantially higher than our staff costs [ 23 ].…”

“…In Kenya, children with HIV are more likely to have elevated viral loads than adults [ 12 ]. Implementing nation-wide POC VL testing platforms to complement existing centralized laboratory testing can alleviate the burden on centralized laboratories and reduce delays by enabling the rapid return of VL results and counseling within the same clinical visit [ 13 ]. The cost of implementing POC VL testing in Kenya is uncertain.…”

Point of Care Diagnostics in Resource-Limited Settings: A Review of the Present and Future of PoC in Its Most Needed Environment

“…In Kenya, 51% of healthcare expenses are payed out of pocket, healthcare costs are often covered through “harambees“ fundraising events in the community; 46% of the population only has USD 1 or less to spend each day [ 28 ]. HCTs platforms have high fixed costs for the PoC device itself and, therefore, the cost per test is strongly dependent on the use case and the workload of the device to be economically justifiable [ 71 ]; therefore, those diagnostic devices, with their high implementation cost, are considered as too expensive for widespread use [ 70 ]. A good example for this is HIV diagnosis and monitoring.…”

“…However, assuming only 10 patients per month, this would increase to a USD 183 additional cost over the same timeframe. Price is also dependent on which biomarker is analyzed, as viral load was, in the 50 patients per month case, just as cost effective as in the laboratory, while CD4+ count and creatinine test were more expensive [ 71 ]. The notion of cost effective PoC ART monitoring is supported by several mathematical simulations from South Africa, Zimbabwe and Mozambique, especially when all the costs are taken into account.…”

HIV screening in the dental setting in New York State

“…Still further research seems beneficial on the cost-effectiveness analysis of routine HIV screening in dental setting. There are only a small number of published articles [34][35][36][37][38][39][40] on the cost-effectiveness of HIV screening in primary care setting. Our findings corroborate one of their suggestions: Routine HIV screening is more cost-effective in high-prevalence regions.…”