There are inefficiencies in
current approaches to monitoring patients on antiretroviral therapy in
sub-Saharan Africa. Patients typically attend clinics every 1 to 3 months for
clinical assessment. The clinic costs are comparable with the costs of the drugs themselves
and CD4 counts are measured every 6 months, but patients are rarely switched to
second-line therapies. To ensure sustainability of treatment programmes, a
transition to more cost-effective delivery of antiretroviral therapy is needed.
In contrast to the CD4 count, measurement of the level of HIV RNA in plasma
(the viral load) provides a direct measure of the current treatment effect.
Viral-load-informed differentiated care is a means of tailoring care so that
those with suppressed viral load visit the clinic less frequently and attention
is focussed on those with unsuppressed viral load to promote adherence and
timely switching to a second-line regimen.
The most feasible approach to
measuring viral load in many countries is to collect dried blood spot samples
for testing in regional laboratories; however, there have been concerns over
the sensitivity and specificity of this approach to define treatment failure
and the delay in returning results to the clinic.
We use modelling to
synthesize evidence and evaluate the cost-effectiveness of viral-load-informed
differentiated care, accounting for limitations of dried blood sample testing.
We find that viral-load-informed differentiated care using dried blood sample
testing is cost-effective and is a recommended strategy for patient monitoring,
although further empirical evidence as the approach is rolled out would be of
value. We also explore the potential benefits of point-of-care viral load tests
that may become available in the future.
Below: Costs in US$m per 3 months, according to monitoring strategy (mean 2015–2034, discounted at 3% per annum from 2015). ART, antiretroviral therapy; VL, viral load; WHO, World Health Organization
Full article at: http://goo.gl/l72y8p
By:
1Department of Infection and Population Health,
University College London, Rowland Hill Street, London NW3 2PF, UK.
2Southern Africa Medical Unit (SAMU), Medecins sans
Frontieres (MSF) SA, Waverley Business Park, Wyecroft Rd, Mowbray 7700, Cape
Town, South Africa.
3Clinton Health Access Initiative, 383 Dorchester
Avenue, Boston, Massachusetts 02127, USA.
4Médecins Sans Frontières, Access Campaign, rue du
Lausanne 82, 1202 Geneva Switzerland.
5Médecins Sans Frontières, 78 rue de Lausanne, Case
Postale 116, 1211 Geneva 21, Switzerland.
6Bill and Melinda Gates Foundation, PO Box 23350,
Seattle, Washington 98199, USA.
7MRC Clinical Trials Unit at UCL, Institute of Clinical
Trials &Methodology, Aviation House, 125 Kingsway, London WC2B 6NH, UK.
8Health Services Research &Policy, London School of
Hygiene and Tropical Medicine, Room 134, 15-17 Tavistock Place, London WC1H
9SY, UK.
9CHIP, Department of infectious diseases,
Rigshospitalet, University of Copenhagen, Blegdamsvej 92100 Copenhagen,
Denmark.
10Department of Infectious Disease Epidemiology,
Imperial College London, St Mary's Campus, Norfolk Place, London W2 1PG, UK.
11Infectious Diseases Institute (IDI), College of Health
Sciences, Makerere University, PO Box 22418, Kampala, Uganda.
12HIV/AIDS and Global Hepatitis Programme, World Health
Organization, 20 Ave Appia 1211, Geneva, Switzerland.
13Department of Epidemiology, Johns Hopkins Bloomberg
School of Public Health, 615 N. Wolfe Street E6531, Baltimore, Maryland 21205,
USA.
14Department of Viroscience, Erasmus Medical Center, PO
Box 20403000CA Rotterdam, the Netherlands.
15International Diagnostics Centre, London School of
Hygiene &Tropical, Medicine, Keppel Street, London WC1E 7HT, UK.
16Kellogg School of Management, Northwestern University,
2001 Sheridan Road Evanston, Illinois 60208, USA.
17WHO Country Office 86 Enterprise Road Cnr,
Glenara PO Box CY 348, Causeway Harare, Zimbabwe.
18Department of Molecular Medicine and Haematology,
University of the Witwatersrand, South Africa.
19Division of Infectious Disease, Laboratory Grant
Building S-146, Office Lane 154, Stanford University Medical Center, 300
Pasteur Drive, Stanford, California 94305-5107, USA.
20Massachusetts General Hospital Division of Infectious
Diseases, 50 Staniford Street, 936 Boston, Massachusetts 02114, USA.
21Medicine, Global Health and Epidemiology, University
of Washington (UW), 325 9th Avenue, Seattle, Washington 98104, USA.
22Department of Population Health, New York University
School of Medicine, 227 East 30th Street Office 615, New York, New York 10016,
USA.
23Division of General Medical Disciplines, Department of
Medicine Stanford University, MSOB 1265 Welch Road x332 Stanford, California
94305, USA.
24University of Zimbabwe, College of Health Sciences,
Department of Paediatrics and Child Health, PO Box A178, Avondale, Harare,
Zimbabwe.
25University of New South Wales, Level 6, Wallace Wurth
Building, UNSW Campus, Sydney, New South Wales 2052, Australia.
26Centre for Infectious Disease Research in Zambia, 5032
Great North Road, Lusaka, Zambia.
27Institute for Disease Modeling, 3150 139th Avenue SE,
Bellevue, Washington 98005, USA.
28Centre for Health Economics, University of York,
Heslington, York YO10 5DD, UK.
29Care and Treatment Branch Center for Global Health,
Division of Global HIV/AIDS (GAP), CDC, MS-E04, 1600 Clifton Road NE, Atlanta,
Georgia 30333, USA.
30Instituto Nacional de Saúde (INS), Ministry of Health,
PO Box 264, Maputo, Mozambique.
31The Office of the US Global AIDS Coordinator and
Health Diplomacy (S/GAC), U.S. Department of State, SA-22, Suite 10300, 2201 C
Street, Washington DC 20520, USA.
32Clinical Research Department, London School of Hygiene
and Tropical Medicine, Keppel St, London WC1E 7HT, UK.
33Department of Global Health and Development, London
School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H
9SH, UK.
34Ministry of Health and Child Care, P. O CY 1122,
Causeway, Harare, Zimbabwe.
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