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Cost-effectiveness of different strategies to monitor adults on antiretroviral treatment : a combined analysis of three mathematical models

dc.contributor.authorKeebler, Danielen_ZA
dc.contributor.authorRevill, Paulen_ZA
dc.contributor.authorBraithwaite, Scotten_ZA
dc.contributor.authorPhillips, Andrewen_ZA
dc.contributor.authorBlaser, Nelloen_ZA
dc.contributor.authorBorquez, Annicken_ZA
dc.contributor.authorCambiano, Valentinaen_ZA
dc.contributor.authorCiaranello, Andreaen_ZA
dc.contributor.authorEstill, Janneen_ZA
dc.contributor.authorGray, Richarden_ZA
dc.contributor.authorHill, Andrewen_ZA
dc.contributor.authorKeiser, Oliviaen_ZA
dc.contributor.authorKessler, Jasonen_ZA
dc.contributor.authorMenzies, Nicolas A.en_ZA
dc.contributor.authorNucifora, Kimberly A.en_ZA
dc.contributor.authorVizcaya, Luisa Salazaren_ZA
dc.contributor.authorWalker, Simonen_ZA
dc.contributor.authorWelte, Alexen_ZA
dc.contributor.authorEasterbrook, Philippaen_ZA
dc.contributor.authorDoherty, Megen_ZA
dc.contributor.authorHirnschall, Gottfrieden_ZA
dc.contributor.authorHallett, Timothy B.en_ZA
dc.date.accessioned2017-09-07T13:44:55Z
dc.date.available2017-09-07T13:44:55Z
dc.date.issued2014-01
dc.identifier.citationKeebler, D. et al. 2014. Cost-effectiveness of different strategies to monitor adults on antiretroviral treatment : a combined analysis of three mathematical models. Lancet Global Health, 2:e35–43, doi:10.1016/S2214-109X(13)70048-2.
dc.identifier.issn2214-109X (online)
dc.identifier.otherdoi:10.1016/S2214-109X(13)70048-2
dc.identifier.urihttp://hdl.handle.net/10019.1/102206
dc.descriptionCITATION: Keebler, D. et al. 2014. Cost-effectiveness of different strategies to monitor adults on antiretroviral treatment : a combined analysis of three mathematical models. Lancet Global Health, 2:e35–43, doi:10.1016/S2214-109X(13)70048-2.
dc.descriptionThe original publication is available at http://www.thelancet.com/journals/langlo
dc.description.abstractBackground WHO's 2013 revisions to its Consolidated Guidelines on antiretroviral drugs recommend routine viral load monitoring, rather than clinical or immunological monitoring, as the preferred monitoring approach on the basis of clinical evidence. However, HIV programmes in resource-limited settings require guidance on the most cost-effective use of resources in view of other competing priorities such as expansion of antiretroviral therapy coverage. We assessed the cost-effectiveness of alternative patient monitoring strategies. Methods We evaluated a range of monitoring strategies, including clinical, CD4 cell count, and viral load monitoring, alone and together, at different frequencies and with different criteria for switching to second-line therapies. We used three independently constructed and validated models simultaneously. We estimated costs on the basis of resource use projected in the models and associated unit costs; we quantified impact as disability-adjusted life years (DALYs) averted. We compared alternatives using incremental cost-effectiveness analysis. Findings All models show that clinical monitoring delivers significant benefit compared with a hypothetical baseline scenario with no monitoring or switching. Regular CD4 cell count monitoring confers a benefit over clinical monitoring alone, at an incremental cost that makes it affordable in more settings than viral load monitoring, which is currently more expensive. Viral load monitoring without CD4 cell count every 6–12 months provides the greatest reductions in morbidity and mortality, but incurs a high cost per DALY averted, resulting in lost opportunities to generate health gains if implemented instead of increasing antiretroviral therapy coverage or expanding antiretroviral therapy eligibility. Interpretation The priority for HIV programmes should be to expand antiretroviral therapy coverage, firstly at CD4 cell count lower than 350 cells per μL, and then at a CD4 cell count lower than 500 cells per μL, using lower-cost clinical or CD4 monitoring. At current costs, viral load monitoring should be considered only after high antiretroviral therapy coverage has been achieved. Point-of-care technologies and other factors reducing costs might make viral load monitoring more affordable in future.en_ZA
dc.description.sponsorshipBill & Melinda Gates Foundation, WHO
dc.description.urihttp://www.thelancet.com/journals/langlo/article/PIIS2214-109X(13)70048-2/fulltext
dc.format.extent9 pages
dc.language.isoen_ZAen_ZA
dc.publisherElsevier
dc.subjectAntiretroviral therapy -- Cost effectivenessen_ZA
dc.subjectHIV-positive persons -- Care -- Cost effectivenessen_ZA
dc.subjectHIV infections -- Economic aspectsen_ZA
dc.subjectViral load monitoringen_ZA
dc.titleCost-effectiveness of different strategies to monitor adults on antiretroviral treatment : a combined analysis of three mathematical modelsen_ZA
dc.typeArticleen_ZA
dc.description.versionPublisher's version
dc.rights.holderAuthors retain copyright


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