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

By  Sarah Girdwood  Thomas Crompton, Monisha Sharma, Jienchi Dorward, Nigel Garrette, Paul K Drain, Wendy Stevens  Brooke Nichols  |  | 

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.

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