Journal Article

Sustainable HIV treatment in Africa through viral-load-informed differentiated care

Terris-Prestholt, Fern, Murungu, Joseph, Revill, Paul, Murtagh, Maurine, Rousseau, Christine, Ford, Nathan, Parkes-Ratanshi, Rosalind, Nakagawa, Fumiyo, Lundgren, Jens D., Peeling, Rosanna, Shroufi, Amir, Braithwaite, R. Scott, Vojnov, Lara, Eaton, Jeffrey W., Cambiano, Valentina, Barnabas, Ruanne, Holmes, Charles, van de Vijver, David, Cohn, Jennifer, Doherty, Meg, Mutasa-Apollo, Tsitsi, Bonner, Kimberly, Palamountain, Kara M., Roberts, Teri, Dowdy, David, Nathoo, Kusum J., Phillips, Andrew, Bershteyn, Anna, Chakanyuka Musanhu, Christine, Jani, Ilesh, Hallett, Timothy B., Raizes, Elliot, Bansi-Matharu, Loveleen, Wareham, Meghan, Ford, Deborah, Katz, Zachary, Maman, David, Stevens, Wendy, Wilson, David P., Ellman, Tom, Miners, Alec, Vitoria, Marco, Nichols, Brooke, Walker, Simon, Katzenstein, David, Bendavid, Eran, Garnett, Geoff, Ciaranello, Andrea, Nelson, Lisa J.

2015

Overview

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. This article has not been written or reviewed by Nature editors. Nature accepts no responsibility for the accuracy of the information provided.

• Publisher: Nature Publishing Group UK,Nature Publishing Group
• Subject: 631/154/140 / 692/699/255 / 692/699/255/1629 / Adolescent / Adult / Africa / Aged / Analysis / Anti-HIV Agents - economics / Anti-HIV Agents - pharmacology / Anti-HIV Agents - therapeutic use / Antiretroviral agents / Antiretroviral drugs / Blood / Care and treatment / Complications and side effects / Cost assessments / Cost reduction / Cost-Benefit Analysis / Drug resistance / Drug therapy / Health aspects / Highly active antiretroviral therapy / HIV / HIV infection / HIV Infections - diagnosis / HIV Infections - drug therapy / HIV Infections - economics / HIV Infections - virology / Human immunodeficiency virus / Humanities and Social Sciences / Humans / Middle Aged / multidisciplinary / Patients / Precision Medicine - economics / Precision Medicine - methods / Science / Sensitivity analysis / supplement / Trends / Viral Load - drug effects / Young Adult