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

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 $126m 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 $49m 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.