Abstract:
Background:
Updated World Health Organization guidelines have amplified debate about how resource
constraints should impact monitoring strategies for HIV-infected persons on combination antiretroviral therapy
(cART). We estimated the incremental benefit and cost effectiveness of alternative monitoring strategies for east
Africans with known HIV infection.
Methods:
Using a validated HIV computer simulation based on resource-limited data (USAID and AMPATH) and
circumstances (east Africa), we compared alternative monitoring strategies for HIV-infected persons newly started
on cART. We evaluated clinical, immunologic and virologic monitoring strategies, including combinations and
conditional logic (e.g., only perform virologic testing if immunologic testing is positive). We calculated incremental
cost-effectiveness ratios (ICER) in units of cost per quality-adjusted life year (QALY), using a societal perspective and
a lifetime horizon. Costs were measured in 2008 US dollars, and costs and benefits were discounted at 3%. We
compared the ICER of monitoring strategies with those of other resource-constrained decisions, in particular earlier
cART initiation (at CD4 counts of 350 cells/mm
3
rather than 200 cells/mm
3
).
Results:
Monitoring strategies employing routine CD4 testing without virologic testing never maximized health
benefits, regardless of budget or societal willingness to pay for additional health benefits. Monitoring strategies
employing virologic testing conditional upon particular CD4 results delivered the most benefit at willingness-to-pay
levels similar to the cost of earlier cART initiation (approximately $2600/QALY). Monitoring strategies employing
routine virologic testing alone only maximized health benefits at willingness-to-pay levels (> $4400/QALY) that
greatly exceeded the ICER of earlier cART initiation.
Conclusions:
CD4 testing alone never maximized health benefits regardless of resource limitations. Programmes
routinely performing virologic testing but deferring cART initiation may increase health benefits by reallocating
monitoring resources towards earlier cART initiation.
