Cost-Effectiveness of Laboratory Monitoring in Sub-Saharan Africa: A Review of the Current Literature

Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
Clinical Infectious Diseases (Impact Factor: 8.89). 07/2010; 51(1):85-92. DOI: 10.1086/653119
Source: PubMed


As the global community evaluates the unprecedented investment in the scale-up of human immunodeficiency virus (HIV) therapy
and considers future investments in HIV care, it is crucial to identify those HIV interventions that maximize the benefit
realized from each dollar spent. The use of laboratory monitoring assays—CD4 cell count and HIV RNA level—in decisions about
when to initiate and switch antiretroviral therapy may offer substantial clinical benefit, but their economic value remains
controversial. Cost-effectiveness analysis can be used to evaluate the value for money of strategies for HIV care, including
alternative approaches to laboratory monitoring. Five published cost-effectiveness analyses address the question of CD4 cell
count and HIV RNA level monitoring for HIV-infected patients in Africa, with differing conclusions.We describe the use of
cost-effectiveness analysis in resource-limited settings and review the cost-effectiveness literature with regard to monitoring
the CD4 cell count and HIV RNA level in Africa, highlighting some of the most critical issues in this debate.

Download full-text


Available from: Ji Eun Park, Mar 10, 2015
  • Source
    • "Monitoring of CD4 T cell count is cost-effective and may be cost-saving when compared to clinical monitoring alone for determining the timing of ART initiation, way before the development of life-threatening symptoms [43-45]. The issue of whether the monitoring of patients on ART with a mobile unit is a valid economic option remains unresolved. "
    [Show abstract] [Hide abstract]
    ABSTRACT: A mobile health unit may be useful to follow up adult and pediatric patients on antiretroviral treatment and living in remote areas devoid of laboratory facilities. The study evaluated the use of the simplified, robust, single-plateform, volumetric, pan-leucogating Auto40 flow cytometer (Apogee Flow Systems Ltd, Hemel Hempstead, UK) for CD4 T cell numeration in a mobile unit, compared against a reference flow cytometry method. The therapeutic mobile unit of the Laboratoire National de Santé Hygiène Mobile, Yaoundé, Cameroon, was equipped with the Auto40. A FACSCalibur flow cytometer (Becton Dickinson Immuno-cytometry System, San Jose, CA, USA) was used as reference method. EDTA-blood samples from volunteers were first subjected to CD4 T cell count in the mobile unit, and an aliquot was sent within 4 hours to Centre International de Référence Chantal Biya, Yaoundé, for FACSCalibur assay. Two HIV screening campaigns with the mobile unit were organised in December 2009 and January 2010. The campaign in the suburb of Yaoundé which was 20 km from the reference laboratory included 188 volunteers comprising 93 children less than 5 years old. The campaign in Ambang Bikok (53 km far from Yaoundé) included 69 adult volunteers. In Yaoundé suburb, mean ± standard deviation (SD) CD4 T cell count was 996 ± 874 cells/μl by Auto40, and 989 ± 883 cells/μl by FACSCalibur; in Ambang Bikok, mean ± SD CD4 T cell count was 1041 ± 317 cells/μl by Auto40, and 1032 ± 294 cells/μl by FACSCalibur. Results by Auto40 and FACSCalibur were highly correlated in Yaoundé (r(2) = 0.982) as in Ambang Bikok (r(2) = 0.921). Bland-Altman analysis showed a close agreement between Auto40 and FACSCalibur results expressed in absolute count as in percentage in Yaoundé and Ambang Bikok. When pooling the 257 CD4 T cell count measurements, the Auto40 yielded a mean difference of +7.6 CD4 T cells/μl higher than by reference flow cytometry; and the sensitivity and specificity of Auto40 in enumerating absolute CD4 T cell counts of less than 200 cells/μl were 87% and 99%, respectively, and in enumerating absolute CD4 T cell counts of less than 350 cells/μl were 87% and 98%, respectively. The intrarun and interun precisions of the Auto40 assay assessed in the mobile unit were 5.5% and 7.9%, respectively. The Auto40 flow cytometer installed in a therapeutic mobile unit and operated far from its reference laboratory gave a perfect correlation with the reference method, and could be useful in carrying out immunological monitoring of HIV-infected patients living in areas without access to laboratory facilities.
    Full-text · Article · Feb 2012 · Journal of Translational Medicine
  • Source
    • "Cost-effectiveness studies are fairly concordant on the added value of CD4 testing versus symptom-based management of patients on ART [1-4]. Less clear is the cost effectiveness of viral load testing for management of patients on ART [2,3,5,6]. Compared with CD4 testing, viral load testing is more expensive and technically complex. Yet there is increasing awareness of the benefit of viral load testing both for patient management and for public health in terms of early and accurate detection of failure to respond to ART, thus mitigating drug resistance and averting new infections [7-10]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: HIV viral load testing as a component of antiretroviral therapy monitoring is costly. Understanding the full costs and the major sources of inefficiency associated with viral load testing is critical for optimizing the systems and technologies that support the testing process. The objective of our study was to estimate the costs associated with viral load testing performed for antiretroviral therapy monitoring to both patients and the public healthcare system in a low-HIV prevalence, low-resource country. A detailed cost analysis was performed to understand the costs involved in each step of performing a viral load test in Nicaragua, from initial specimen collection to communication of the test results to each patient's healthcare provider. Data were compiled and cross referenced from multiple information sources: laboratory records, regional surveillance centre records, and scheduled interviews with the key healthcare providers responsible for HIV patient care in five regions of the country. The total average cost of performing a viral load test in Nicaragua varied by region, ranging from US$99.01 to US$124.58, the majority of which was at the laboratory level: $88.73 to $97.15 per specimen, depending on batch size. The average cost to clinics at which specimens were collected ranged from $3.31 to $20.92, depending on the region. The average cost per patient for transportation, food, lodging and lost income ranged from $3.70 to $14.93. The quantitative viral load test remains the single most expensive component of the process. For the patient, the distance of his or her residence from the specimen collection site is a large determinant of cost. Importantly, the efficiency of results reporting has a large impact on the cost per result delivered to the clinician and utility of the result for patient monitoring. Detailed cost analysis can identify opportunities for removing barriers to effective antiretroviral therapy monitoring programmes in limited-resource countries with low HIV prevalence.
    Full-text · Article · Nov 2010 · Journal of the International AIDS Society
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Updates on the Thai clinical vaccine trial, the discovery of additional neutralizing antibodies, and several new, nonhuman primate vaccine studies were presented at the 17th Conference on Retroviruses and Opportunistic Infections this year. Interestingly, the vaccine effect observed in the Thai trial diminished with time and was most effective in individuals who reported low-risk behavior. Two new neutralizing monoclonal antibodies were reported that were more potent and broadly reactive than the previously described monoclonal antibodies, giving the neutralization field an important boost. New studies were presented in macaques showing that a DNA prime modified vaccinia virus Ankara boost regimen can reduce acquisition of infection after a low-dose mucosal challenge with a heterologous pathogenic simian immunodeficiency virus (SIV) strain. Data suggesting that attenuated SIV vaccines can induce cellular immune responses that control viral replication were also discussed. Finally, and perhaps most encouragingly, vaccination with cytomegalovirus-expressing SIV antigens provided robust levels of protection against the highly pathogenic SIVmac239 viral isolate. All of these promising results should serve to energize the HIV vaccine field.
    Preview · Article · Jan 2011 · Topics in HIV medicine: a publication of the International AIDS Society, USA
Show more