Cost-effectiveness of point-of-care testing with task-shifting for HIV care in South Africa: a modelling study

Preprint

Background: The scale-up of “HIV test and treat” has rapidly increased the number of persons on antiretroviral therapy (ART) requiring treatment monitoring in low-resource settings. Decentralized point-of-care (POC) testing for ART monitoring may alleviate burden on centralized laboratories and improve clinical outcomes, but its cost-effectiveness is unknown.

Methods: We used primary cost and effectiveness data from the STREAM trial in South Africa, which assessed the impact of POC testing for viral load, CD4 count, and creatinine, with task-shifting from professional to lower-cadre registered nurses compared to laboratory-based testing without task-shifting. We parameterized an agent-based network model, EMOD-HIV, to project the impact of implementing this intervention in South Africa. We assumed POC monitoring increased viral suppression by 9%, enrollment into community-based ART delivery by 25%, and switching to second-line ART by 1%, as reported in STREAM. We evaluated POC scale-up in varying clinic sizes (10-50 patient initiating ART/month) over a 20-year time horizon. We used a cost-effectiveness threshold of $500 USD/disability adjusted life year (DALY) averted for our main analysis.

Results:   Implementing POC testing at 70% coverage of ART patients was projected to reduce HIV infections by 4.5% and HIV-related deaths by 3.9%. In clinics with 30 ART initiations/month, the intervention was associated with an incremental cost-effectiveness ratio (ICER) of USD197/DALY averted; results remained cost-effective when varying background viral suppression, ART dropout, and intervention effectiveness within the 95% confidence bound of the trial results. Assuming POC testing did not increase enrollment into community ART delivery produced an ICER of USD1,149, exceeding the cost-effectiveness threshold. At higher clinic volumes (≥40 ART initiations/month), POC testing was cost-saving compared to standard-of-care. At lower clinic volumes (20 patients initiated on ART/month) the ICER was USD734/DALY averted.

Conclusions: POC testing for ART monitoring with task-shifting is projected to be cost-effective in moderately-sized clinics in South Africa.

Authors: Sharma, M; Mudimu, E; Simeon, K; Bershteyn, A; Dorward, J

• Publication status: Published
• Peer review status: Not peer reviewed
• Preprint server: SSRN
• Publication date: 2020-06-26
• DOI: 10.2139/ssrn.3571531
• EISSN: 1556-5068
• Server owner: Elsevier
• Language: English
• Keywords: point-of-care testing; modeling; cost-effectiveness; South Africa; sub-Saharan Africa; ART monitoring; viral load testing