TY - JOUR

T1 - Sustainable HIV treatment in Africa through viral-load-informed differentiated care

AU - Phillips, Andrew

AU - Shroufi, Amir

AU - Vojnov, Lara

AU - Cohn, Jennifer

AU - Roberts, Teri

AU - Ellman, Tom

AU - Bonner, Kimberly

AU - Rousseau, Christine

AU - Garnett, Geoff

AU - Cambiano, Valentina

AU - Nakagawa, Fumiyo

AU - Ford, Deborah

AU - Bansi-Matharu, Loveleen

AU - Miners, Alec

AU - Lundgren, Jens D

AU - Eaton, Jeffrey W

AU - Parkes-Ratanshi, Rosalind

AU - Katz, Zachary

AU - Maman, David

AU - Ford, Nathan

AU - Vitoria, Marco

AU - Doherty, Meg

AU - Dowdy, David

AU - Nichols, Brooke

AU - Murtagh, Maurine

AU - Wareham, Meghan

AU - Palamountain, Kara M

AU - Chakanyuka Musanhu, Christine

AU - Stevens, Wendy

AU - Katzenstein, David

AU - Ciaranello, Andrea

AU - Barnabas, Ruanne

AU - Braithwaite, R Scott

AU - Bendavid, Eran

AU - Nathoo, Kusum J

AU - van de Vijver, David

AU - Wilson, David P

AU - Holmes, Charles

AU - Bershteyn, Anna

AU - Walker, Simon

AU - Raizes, Elliot

AU - Jani, Ilesh

AU - Nelson, Lisa J

AU - Peeling, Rosanna

AU - Terris-Prestholt, Fern

AU - Murungu, Joseph

AU - Mutasa-Apollo, Tsitsi

AU - Hallett, Timothy B

AU - Revill, Paul

AU - Working Group on Modelling of Antiretroviral Therapy Monitoring Strategies in Sub-Saharan Africa

PY - 2015/12/3

Y1 - 2015/12/3

N2 - 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.

AB - 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.

KW - Adolescent

KW - Adult

KW - Africa

KW - Aged

KW - Anti-HIV Agents

KW - Cost-Benefit Analysis

KW - HIV Infections

KW - Humans

KW - Middle Aged

KW - Precision Medicine

KW - Viral Load

KW - Young Adult

U2 - 10.1038/nature16046

DO - 10.1038/nature16046

M3 - Journal article

C2 - 26633768

VL - 528 Suppl.

SP - S68-S76

JO - Nature

JF - Nature

SN - 0028-0836

IS - 7580

ER -