Cost-effectiveness of point-of-care testing with task-shifting for HIV care in South Africa: a modelling study

Mudimu, Edinah; Simeon, Kate; Bershteyn, Anna; Dorward, Jienchi; Violette, Lauren R; Akullian, Adam; Karim, Salim Safurdeen. Abdool; Celum, Connie; Garrett, Nigel; Drain, Paul K.

doi:10.1016/s2352-3018(20)30279-4

Cited by 17 publications

(12 citation statements)

References 28 publications

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“…For PLHIV not on ART, risk of HIV-associated death depends on age at time of infection, with older adults progressing more rapidly toward AIDS and death. For PLHIV on ART, risk of HIV-associated death depends on age, sex, and CD4 count at time of ART initiation and level of ART adherence, with declining risk of death on ART for adherent patients who remain stable on ART [ 13 ]. For individuals who interrupt and resume ART, risk of death calculated based on CD4 count at time of interruption and re-engagement in ART [ 14 ].…”

Section: Methodsmentioning

confidence: 99%

The risks and benefits of providing HIV services during the COVID-19 pandemic

et al. 2021

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Introduction The COVID-19 pandemic has caused widespread disruptions including to health services. In the early response to the pandemic many countries restricted population movements and some health services were suspended or limited. In late 2020 and early 2021 some countries re-imposed restrictions. Health authorities need to balance the potential harms of additional SARS-CoV-2 transmission due to contacts associated with health services against the benefits of those services, including fewer new HIV infections and deaths. This paper examines these trade-offs for select HIV services. Methods We used four HIV simulation models (Goals, HIV Synthesis, Optima HIV and EMOD) to estimate the benefits of continuing HIV services in terms of fewer new HIV infections and deaths. We used three COVID-19 transmission models (Covasim, Cooper/Smith and a simple contact model) to estimate the additional deaths due to SARS-CoV-2 transmission among health workers and clients. We examined four HIV services: voluntary medical male circumcision, HIV diagnostic testing, viral load testing and programs to prevent mother-to-child transmission. We compared COVID-19 deaths in 2020 and 2021 with HIV deaths occurring now and over the next 50 years discounted to present value. The models were applied to countries with a range of HIV and COVID-19 epidemics. Results Maintaining these HIV services could lead to additional COVID-19 deaths of 0.002 to 0.15 per 10,000 clients. HIV-related deaths averted are estimated to be much larger, 19–146 discounted deaths per 10,000 clients. Discussion While there is some additional short-term risk of SARS-CoV-2 transmission associated with providing HIV services, the risk of additional COVID-19 deaths is at least 100 times less than the HIV deaths averted by those services. Ministries of Health need to take into account many factors in deciding when and how to offer essential health services during the COVID-19 pandemic. This work shows that the benefits of continuing key HIV services are far larger than the risks of additional SARS-CoV-2 transmission.

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Section: Methodsmentioning

confidence: 99%

The risks and benefits of providing HIV services during the COVID-19 pandemic

et al. 2021

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“…Although POC VL testing is more costly than centralized laboratory testing, cost savings to the health system may occur by reducing loss to follow up and increasing ART adherence. Indeed, modeling analyses show that POC testing is projected to reduce HIV-related deaths and HIV transmissions and is cost-effective for monitoring treatment in adults living with HIV in South Africa, particularly in facilities with high levels of virologic failure [9,29].…”

Section: Discussionmentioning

confidence: 99%

“…POC can enable faster identification of individuals with treatment failure for targeted adherence counseling and/or regimen switching. POC testing has been shown in randomized trials to improve viral suppression and retention in care compared to centralized laboratory testing [7], and is projected to be cost-effective in other sub-Saharan African settings [8,9].…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2021

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Background: The number of people living with HIV (PLHIV) in need of treatment monitoring in low-and-middle-income countries is rapidly expanding, straining existing laboratory capacity. Point-of-care viral load (POC VL) testing can alleviate the burden on centralized laboratories and enable faster delivery of results, improving clinical outcomes. However, implementation costs are uncertain and will depend on clinic testing volume. We sought to estimate the costs of decentralized POC VL testing compared to centralized laboratory testing for adults and children receiving HIV care in Kenya. Methods: We conducted microcosting to estimate the per-patient costs of POC VL testing compared to known costs of centralized laboratory testing. We completed time-and-motion observations and stakeholder interviews to assess personnel structures, staff time, equipment costs, and laboratory processes associated with POC VL administration. Capital costs were estimated using a 5 year lifespan and a 3% annual discount rate. Results: We estimated that POC VL testing cost USD $24.25 per test, assuming a clinic is conducting 100 VL tests per month. Test cartridge and laboratory equipment costs accounted for most of the cost (62% and 28%, respectively). Costs varied by number of VL tests conducted at the clinic, ranging from $54.93 to $18.12 per test assuming 20 to 500 VL tests per month, respectively. A VL test processed at a centralized laboratory was estimated to cost USD $25.65. Conclusion: POC VL testing for HIV treatment monitoring can be feasibly implemented in clinics within Kenya and costs declined with higher testing volumes. Our cost estimates are useful to policymakers in planning resource allocation and can inform cost-effectiveness analyses evaluating POC VL testing.

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“…We will use an individual-based, stochastic HIV model we developed for KwaZulu-Natal that incorporates sexual behaviour, concurrency, migration, sexually transmitted coinfections and the HIV treatment cascade. 8 Model outcomes will include HIV incidence, HIV-related deaths and disability-adjusted life-years (DALYs) in the intervention compared with standard-of-care scenario over a 20-year time horizon. We will assess the cost-effectiveness of the intervention by calculating the incremental cost-effectiveness ratios as the difference in costs (US dollars) divided by the difference in effects (DALYs) for the intervention arm compared with the control arm over 20 years.…”

Section: Methodsmentioning

confidence: 99%

“…5 Point-of-care (POC) VL monitoring has been shown to be cost-effective and effective in improving viral suppression and retention in care among PLHIV as compared with standard-of-care laboratory-based VL monitoring and may be a scalable strategy for routine care. [6][7][8] Although VL testing is considered a gold standard for monitoring ART adherence, the WHO recommends implementing other approaches to differentiate whether virologic failure is more likely resulting from nonadherence or HIV drug resistance. 4 Early identification of poor adherence, particularly before a client's first VL test when clients are most likely to be lost to follow-up, could be crucial for implementing timely adherence support interventions.…”

Section: Introductionmentioning

confidence: 99%

Simplifying TREAtment and Monitoring for HIV (STREAM HIV): protocol for a randomised controlled trial of point-of-care urine tenofovir and viral load testing to improve HIV outcomes

et al. 2021

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IntroductionSubstantial improvements in viral suppression among people living with HIV (PLHIV) are needed to end the HIV epidemic, requiring extensive scale-up of low-cost HIV monitoring services. Point-of-care (POC) tests for monitoring antiretroviral therapy (ART) adherence and viral load (VL) may be efficient and effective tools for real-time clinical decision making. We aim to evaluate the effects of a combined intervention of POC ART adherence and VL testing compared with standard-of-care on ART adherence, viral suppression and retention at 6 and 18 months post-ART initiation among PLHIV.Methods and analysisSimplifying TREAtment and Monitoring for HIV (STREAM HIV) is a two-arm, open-label, randomised controlled superiority trial of POC urine tenofovir (POC TFV) and VL monitoring in PLHIV. We aim to enrol 540 PLHIV initiating a first-line ART regimen at a public HIV clinic in South Africa. Participants will be randomised 1:1 to the intervention or control arm. Intervention arm participants will receive monthly POC TFV testing for the first 5 months and POC VL testing at months 6 and 12. Intervention arm participants will also receive reflex POC TFV testing if viraemic and reflex HIV drug resistance testing for those with viraemia and detectable TFV. Control arm participants will receive standard-of-care, including laboratory-based VL testing at months 6 and 12. Primary outcomes include ART adherence (TFV-diphosphate concentration) at 6 months and viral suppression and retention at 18 months. Secondary outcomes include viral suppression and retention at 6 months, TFV-diphosphate concentration at 18 months, cost and cost-effectiveness of the intervention and acceptability of the intervention among PLHIV and healthcare workers.Ethics and disseminationSTREAM HIV has received ethical approval from the University of Washington Institutional Review Board (STUDY00007544), University of KwaZulu-Natal Biomedical Research Ethics Committee (BREC/00000833/2019) and Division of AIDS Regulatory Support Center (38509). Findings will be disseminated at international conferences and in peer-reviewed journals.Trial registration numberNCT04341779.

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Cost-effectiveness of point-of-care testing with task-shifting for HIV care in South Africa: a modelling study

Cited by 17 publications

References 28 publications

The risks and benefits of providing HIV services during the COVID-19 pandemic

The risks and benefits of providing HIV services during the COVID-19 pandemic

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

Simplifying TREAtment and Monitoring for HIV (STREAM HIV): protocol for a randomised controlled trial of point-of-care urine tenofovir and viral load testing to improve HIV outcomes

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