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To assess the effect of a savings-led economic empowerment intervention on viral suppression among adolescents living with HIV. Using data from Suubi + Adherence, a longitudinal, cluster randomized trial in southern Uganda (2012–2017), we examine the effect of the intervention on HIV RNA viral load, dichotomized between undetectable (< 40 copies/ml) and detectable (≥ 40 copies/ml). Cluster-adjusted comparisons of means and proportions were used to descriptively analyze changes in viral load between study arms while multi-level modelling was used to estimate treatment efficacy after adjusting for fixed and random effects. At 24-months post intervention initiation, the proportion of virally suppressed participants in the intervention cohort increased tenfold (ΔT2−T0 = + 10.0, p = 0.001) relative to the control group (ΔT2−T0 = + 1.1, p = 0.733). In adjusted mixed models, simple main effects tests identified significantly lower odds of intervention adolescents having a detectable viral load at both 12- and 24-months. Interventions addressing economic insecurity have the potential to bolster health outcomes, such as HIV viral suppression, by improving ART adherence among vulnerable adolescents living in low-resource environments. Further research and policy dialogue on the intersections of financial security and HIV treatment are warranted.

In low-income countries, the use of laboratory monitoring of patients taking antiretroviral therapy (ART) remains controversial in view of persistent resource constraints. The Stratall trial did not show that clinical monitoring alone was non-inferior to laboratory and clinical monitoring in terms of immunological recovery. We aimed to evaluate the costs and cost-effectiveness of the ART monitoring approaches assessed in the Stratall trial. The randomised, controlled, non-inferiority Stratall trial was done in a decentralised setting in Cameroon. Between May 23, 2006, and Jan 31, 2008, ART-naive adults were randomly assigned (1:1) to clinical monitoring (CLIN) or viral load and CD4 cell count plus clinical monitoring (LAB) and followed up for 24 months. We calculated costs, number of life-years saved (LYS), and incremental cost-effectiveness ratios (ICERs) with data from patients who had been followed up for at least 6 months. We considered two cost scenarios in which viral load plus CD4 cell count tests cost either US$95 (scenario 1; Abbott RealTime HIV-1 assay) or $63 (scenario 2; generic assay). We compared ICERs with a WHO-recommended threshold of three times the per-person gross domestic product (GDP) for Cameroon ($3670–3800) and an alternative lower threshold of $2385 to determine cost-effectiveness. We assessed uncertainty with one-way sensitivity analyses and cost-effectiveness acceptability curves. 188 participants who underwent LAB and 197 who underwent CLIN were followed up for at least 6 months. In scenario 1, LAB increased costs by a mean of $489 (SD 430) per patient and saved 0·103 life-years compared with CLIN (ICER of $4768 [95% CI 3926–5613] per LYS). In scenario 2, the incremental mean cost of LAB was $343 (SD 425) —ie, an ICER of $3339 (2507–4173) per LYS. A combined strategy in which LAB would only be used in patients starting ART with a CD4 count of 200 cells per μL or fewer suggests that 0·120 life-years would be saved at an additional cost of $259 per patient in scenario 1 (ICER of $2167 [95% CI 1314–3020] per LYS) and $181 in scenario 2 (ICER of $1510 [692–2329] per LYS) when compared with CLIN. Laboratory monitoring was not cost effective in 2006–10 compared with clinical monitoring when the Abbott RealTime HIV-1 assay was used according to the $3670 cost-effectiveness threshold (three times per-person GDP in Cameroon), but it might be cost effective if a generic in-house assay is used. French National Agency for Research on AIDS and Viral Hepatitis (ANRS) and Ensemble pour une Solidarité Thérapeutique Hospitalière En Réseau (ESTHER).

The role of financial incentives in HIV care is not well studied. We conducted a single-site study of monetary incentives for viral load suppression, using each patient as his own control. The incentive size ($100/quarter) was designed to be cost-neutral, offsetting estimated downstream costs averted through reduced HIV transmission. Feasibility outcomes were clinic workflow, patient acceptability, and patient comprehension. Although the study was not powered for effectiveness, we also analyzed viral load suppression. Of 80 eligible patients, 77 consented, and 69 had 12 month follow-up. Feasibility outcomes showed minimal impact on patient workflow, near-unanimous patient acceptability, and satisfactory patient comprehension. Among individuals with detectable viral loads pre-intervention, the proportion of undetectable viral load tests increased from 57 to 69 % before versus after the intervention. It is feasible to use financial incentives to reward ART adherence, and to specify the incentive by requiring cost-neutrality and targeting biological outcomes.

Objective To examine the cost and cost effectiveness of quarterly CD4 cell count and viral load monitoring among patients taking antiretroviral therapy (ART).Design Cost effectiveness study.Setting A randomised trial in a home based ART programme in Tororo, Uganda.Participants People with HIV who were members of the AIDS Support Organisation and had CD4 cell counts <250 ×106 cells/L or World Health Organization stage 3 or 4 disease. Main outcome measures Outcomes calculated for the study period and projected 15 years into the future included costs, disability adjusted life years (DALYs), and incremental cost effectiveness ratios (ICER; $ per DALY averted). Cost inputs were based on the trial and other sources. Clinical inputs derived from the trial; in the base case, we assumed that point estimates reflected true differences even if non-significant. We conducted univariate and multivariate sensitivity analyses.Interventions Three monitoring strategies: clinical monitoring with quarterly CD4 cell counts and viral load measurement (clinical/CD4/viral load); clinical monitoring and quarterly CD4 counts (clinical/CD4); and clinical monitoring alone.Results With the intention to treat (ITT) results per 100 individuals starting ART, we found that clinical/CD4 monitoring compared with clinical monitoring alone increases costs by $20 458 (£12 780, €14 707) and averts 117.3 DALYs (ICER=$174 per DALY). Clinical/CD4/viral load monitoring compared with clinical/CD4 monitoring adds $142 458, and averts 27.5 DALYs ($5181 per DALY). The superior ICER for clinical/CD4 monitoring is robust to uncertainties in input values, and that strategy is dominant (less expensive and more effective) compared with clinical/CD4/viral load monitoring in one quarter of simulations. If clinical inputs are based on the as treated analysis starting at 90 days (after laboratory monitoring was initiated), then clinical/CD4/viral load monitoring is dominated by other strategies.Conclusions Based on this trial, compared with clinical monitoring alone, monitoring of routine CD4 cell count is considerably more cost effective than additionally including routine viral load testing in the monitoring strategy and is more cost effective than ART.

Despite immense progress in antiretroviral therapy (ART) scale-up, many people still lack access to basic standards of care, with our ability to meet the Joint United Nations Programme on HIV/AIDS 90-90-90 treatment targets for HIV/AIDS dependent on dramatic improvements in diagnostics. The World Health Organization recommends routine monitoring of ART effectiveness using viral load (VL) testing at 6 months and every 12 months, to monitor treatment adherence and minimize failure, and will publish its VL toolkit later this year. However, the cost and complexity of VL is preventing scale-up beyond developed contries and there is a lack of awareness among clinicians as to the long-term patient benefits and its role in prolonging the longevity of treatment programs. With developments in this diagnostic field rapidly evolving—including the recent improvements for accurately using dried blood spots and the imminent appearance to the market of point-of-care technologies offering decentralized diagnosis—we describe current barriers to VL testing in resource-limited settings. Effective scale-up can be achieved through health system and laboratory system strengthening and test price reductions, as well as tackling multiple programmatic and funding challenges.

Background : Very few studies have evaluated the cost of highly active antiretroviral therapy (HAART) per successful treatment in HIV-infected patients. Objectives : To evaluate the cost of achieving undetectable plasma HIV-RNA levels in highly treatment-experienced, HIV-1-infected adults receiving darunavir/ritonavir (DRV/r 600 mg/100mg twice a day) or control protease inhibitor (PI)-based HAART. Methods : The mean annual per-patient cost of DRV/r and control PI-based HAART was determined from the proportional use of antiretroviral agents in the DRV/r and control PI arms of the pooled POWER 1 and 2 trials, applying drug acquisition costs for 13 healthcare settings. The mean annual cost per patient of achieving undetectable plasma HIV-RNA levels (<50 copies/mL) was calculated by dividing the cost of each treatment by the proportion of patients with undetectable plasma HIV-RNA levels after 48 weeks in the DRV/r (45%) and control PI (10%) arms of the POWER trials. Results : Whereas absolute costs of treatment were 1–19% higher with DRV/r versus control PI-based HAART depending on the healthcare setting, the mean annual per-patient cost of achieving undetectable plasma HIV-RNA levels was 73–78%lower. These cost savings were maintained in the sensitivity analyses, adjusting for control PI and enfuvirtide use, and the number of active drugs in the background regimen. The incremental annual cost per additional patient achieving undetectable plasma HIV-RNA levels with DRV/r versus control PI-based HAART in POWER 1 and 2 (d4148) compared favourably with that determined for enfuvirtide (d137 740; TORO trials) and tipranavir/ritonavir (d32 176; RESIST) versus control therapy. Conclusions : DRV/r-based HAART provided consistent reductions in the cost of achieving undetectable plasma HIV-RNA levels compared with control PI-based therapy in highly treatment-experienced patients across various healthcare settings. The incremental cost per additional patient achieving undetectable plasma HIV-RNA levels with DRV/r versus control PI-based HAART was also lower than that calculated for other treatment options in this population. These results suggest that DRV/r is an economically viable option for highly treatment-experienced patients.

Viral load (VL) monitoring programs have been scaled up rapidly, but are now facing the challenge of providing access to the most remote facilities (the \"last mile\"). For the hardest-to-reach facilities in Zambia, we compared the cost of placing point of care (POC) viral load instruments at or near facilities to the cost of an expanded sample transportation network (STN) to deliver samples to centralized laboratories. We extended a previously described geospatial model for Zambia that first optimized a STN for centralized laboratories for 90% of estimated viral load volumes. Amongst the remaining 10% of volumes, facilities were identified as candidates for POC placement, and then instrument placement was optimized such that access and instrument utilization is maximized. We evaluated the full cost per test under three scenarios: 1) POC placement at all facilities identified for POC; 2)an optimized combination of both on-site POC placement and placement at facilities acting as POC hubs; and 3) integration into the centralized STN to allow use of centralized laboratories. For the hardest-to-reach facilities, optimal POC placement covered a quarter of HIV-treating facilities. Scenario 2 resulted in a cost per test of $39.58, 6% less than the cost per test of scenario 1, $41.81. This is due to increased POC instrument utilization in scenario 2 where facilities can act as POC hubs. Scenario 3 was the most costly at $53.40 per test, due to high transport costs under the centralized model ($36 per test compared to $12 per test in scenario 2). POC VL testing may reduce the costs of expanding access to the hardest-to-reach populations, despite the cost of equipment and low patient volumes. An optimal combination of both on-site placement and the use of POC hubs can reduce the cost per test by 6-35% by reducing transport costs and increasing instrument utilization.

Background and Objectives There is growing international concern that food insecurity may negatively impact antiretroviral (ARV) treatment outcomes, but no studies have directly evaluated the effect of food insecurity on viral load suppression and antiretroviral adherence. We hypothesized that food insecurity would be associated with poor virologic response among homeless and marginally housed HIV-positive ARV-treated patients. Design This is a cross-sectional study. Participants and Setting Participants were ARV-treated homeless and marginally housed persons receiving adherence monitoring with unannounced pill counts in the Research on Access to Care in the Homeless (REACH) Cohort. Measurements Food insecurity was measured by the Household Food Insecurity Access Scale (HFIAS). The primary outcome was suppression of HIV viral RNA to <50 copies/ml. We used multivariate logistic regression to assess whether food insecurity was associated with viral suppression. Results Among 104 participants, 51% were food secure, 24% were mildly or moderately food insecure and 25% were severely food insecure. Severely food insecure participants were less likely to have adherence >=80%. In adjusted analyses, severe food insecurity was associated with a 77% lower odds of viral suppression (95% CI = 0.06–0.82) when controlling for all covariates. In analyses stratified by adherence level, severe food insecurity was associated with an 85% lower odds of viral suppression (95% CI = 0.02–0.99) among those with <=80% adherence and a 66% lower odds among those with >80% adherence (95% CI = 0.06–1.81). Conclusions Food insecurity is present in half of the HIV-positive urban poor in San Francisco, one of the best resourced settings for HIV-positive individuals in the United States, and is associated with incomplete viral suppression. These findings suggest that ensuring access to food should be an integral component of public health HIV programs serving impoverished populations.

Introduction Routine viral load testing is the WHO‐recommended method for monitoring HIV‐infected patients on ART, and many countries are rapidly scaling up testing capacity at centralized laboratories. Providing testing access to the most remote populations and facilities (the “last mile”) is especially challenging. Using a geospatial optimization model, we estimated the incremental costs of accessing the most remote 20% of patients in Zambia by expanding the transportation network required to bring blood samples from ART clinics to centralized laboratories and return results to clinics. Methods The model first optimized a sample transportation network (STN) that can transport 80% of anticipated sample volumes to centralized viral load testing laboratories on a daily or weekly basis, in line with Zambia's 2020 targets. Data incorporated into the model included the location and infrastructure of all health facilities providing ART, location of laboratories, measured distances and drive times between the two, expected future viral load demand by health facility, and local cost estimates. We then continued to expand the modelled STN in 5% increments until 100% of all samples could be collected. Results and Discussion The cost per viral load test when reaching 80% patient volumes using centralized viral load testing was a median of$18.99. With an expanded STN, the incremental cost per test rose to $ 20.29 for 80% to 85% and$20.52 for 85% to 90%. Above 90% coverage, the incremental cost per test increased substantially to $ 31.57 for 90% to 95% and $51.95 for 95% to 100%. The high numbers of kilometres driven per sample transported and large number of vehicles needed increase costs dramatically for reaching the clinics that serve the last 5% of patients. Conclusions Providing sample transport services to the most remote clinics in low‐ and middle‐income countries is likely to be cost‐prohibitive. Other strategies are needed to reduce the cost and increase the feasibility of making viral load monitoring available to the last 10% of patients. The cost of alternative methods, such as optimal point‐of‐care viral load equipment placement and usage, dried blood/plasma spot specimen utilization, or use of drones in geographically remote facilities, should be evaluated.

Background Hepatitis B virus (HBV) is a leading cause of liver infections, which can lead to chronic illness and, in some cases, liver cancer. It affects millions of people worldwide, with a particularly high burden in Africa, especially Ethiopia. Despite its prevalence, access to HBV viral load testing is limited, and its affordability has not been well documented, particularly in Ethiopia, making it challenging to diagnose and treat the disease effectively. Therefore, this study aimed to quantify the HBV viral load, assess affordability, knowledge, attitudes, and practices related to the disease, and identify various determinants associated with these parameters.” study aimed to quantify the HBV viral load, affordability, knowledge, attitudes, and practices related to this disease among HBV-infected patients at St. Paul Hospital Millennium Medical College, Addis Ababa, Ethiopia, in 2024. Methods A cross-sectional study was conducted from January to April 2024 using quantitative and qualitative data from 256 participants. Affordability was assessed using household income and expenditure on HBV viral load (VL) tests, with VL quantification performed using the Cobas ® 6800. Knowledge, attitudes, and practices (KAPs) were measured using a Likert scale. Data management and analysis were conducted using SPSS version 25, with a significance level set at p  < 0.05. Results A total of 256 participants were included in this study, 53.1% of whom were females. Compared with female participants, male participants demonstrated a significantly greater likelihood of having a high viral load (AOR = 2.49, 95% CI: 1.26–4.92, p  = 0.01). Individuals with co-infections exhibited a substantially increased likelihood of having a high viral load (AOR = 8.38, 95% CI: 3.76–12.29, p  < 0.01). Regarding KAP concerning HBV infection, 50% of the participants demonstrated good knowledge, and 38.3% exhibited a positive attitude, and 57.8% reported good practices. Urban residents (AOR = 0.11, 95% CI: 0.02–0.60, p  = 0.01), higher-income earners (AOR = 0.14, 95% CI: 0.05–0.43, p  < 0.01), and individuals who had undergone viral load testing within the previous month (AOR = 0.01, 95% CI: 0.09–0.17, p  < 0.03) all demonstrated significantly lower odds of experiencing catastrophic expenditures. Conclusion This study highlights the importance of tailored HBV management strategies, including targeted interventions and comprehensive infection prevention and control. Enhancing public health education and reducing financial barriers to HBV diagnosis and care, especially for vulnerable populations, remain crucial. Clinical trial number Not applicable.