1. Ruanne V. Barnabas1, Paul Revill2, Nicholas Tan1, Andrew Phillips3
WEAD0206LB
Cost-effectiveness of routine Viral Load Monitoring in LMICs: A Systematic Review
Ruanne V. Barnabas1, Paul Revill2, Nicholas Tan1, Andrew Phillips3
1University of Washington, Seattle, USA, 2University of York, York, UK, 3University College London, London, UK

2. Conflict of Interest
No conflicts of interest to declare

3. Outline
Background
Methods
Results
Discussion

4. Background
Routine viral load (VL) monitoring - WHO recommendation for HIV monitoring.
VL testing – substantial cost
Under what conditions are health gains from viral load monitoring at a cost such that it is cost-effective?
What can we learn from previous studies?
Hypothesis: Key features of program design and delivery costs drive the cost-effectiveness of viral load monitoring

5. Determining cost-effectiveness
Health benefits from VL monitoring should be greater than those forgone due to limited resources being unavailable for other priorities
Requires comparing the cost-per-DALY-averted from VL monitoring with a cost-effectiveness threshold

6. Methods
Systematic review of studies on the cost-effectiveness of viral load monitoring in LMICs
Broad search for VL and cost/economics
PubMed, EMBASE, conference abstracts
Inclusion criteria: CEA for VL monitoring, LMIC
Cochrane Collaboration guidelines and PRISMA reporting guidelines
Results synthesized qualitatively into themes

7. Results 1,165 unique results  23 reviewed  18 met inclusion criteria
Settings: SSA, Cameroon, Uganda, South Africa, Zambia, Zimbabwe, Cote d’Ivoire, Vietnam, Thailand between
2 RCT1,2 and 16 modeling analyses
12/18 studies concluded that VL monitoring is cost-effective
Both cost effectiveness analyses from RCTs1,2 did not find VL to be cost-effective
ICERs varied widely from $68,084/QALY gained3 to $326/DALY averted4
1Boyer et. al., LID, 2013 (Cameroon); 2Kahn et. al., BMJ, 2011 (Uganda); 3Schneider et. al, AIDS, 2011; 4Phillips, et. al., Nature, 2015

8. 1) Heterogeneity in results due to:
Variation in health care resources available/setting
Until recently, lack of consensus on appropriate cost effectiveness threshold for a given setting
Cost of VL testing ($6 - $104 per test) (variation in whether the cost was fully loaded)
Annual cost of ART ($108 - $2,071 per client)
Cost range due to agreements with manufacturers, volume of demand, advocacy, human resource costs, calendar time

9. Heterogeneity in results due to:
E.g. Keebler: Annual VL vs. VL every 36 months:
Braithwaite (20 years): $6, per DALY averted
HIV Synthesis (15 years): $3,413.8 per DALY averted
Estill (5 years): $3,760 per DALY averted
Some models did not include the benefits of decreased transmission (as a health benefit)
Due to the heterogeneity, we were not able to estimate a summary statistic

10. Discussion
We found 3 main factors that make it more likely for viral load monitoring to be cost-effective in a given setting using an appropriate CE threshold:
Use of effective but lower cost approaches
Ensuring the viral load results are acted upon
Viral suppression supports less intense clinical care (differentiated care)

11. 1) Use of effective but lower cost approaches
2014 – ceiling price for VL test - $9.40 ($20 fully loaded)
Downstream costs are important:
Second line ART – PI - $205 ppy (from $600)
Including lower cost VL monitoring and ART changes ICER
Cote d’Ivoire: ICER $4,100  <1,500/ YLS*
*Ouattara, et. al. CID, 2016

12. 2) Action based on viral load results
VL test  lab  result back to client and provider  change to 2nd line ART if needed
Protocols can support clinical next steps (adherence counseling, 2nd line ART)
Evidence is needed for criteria to switch to 2nd line ART including confirmatory viral load testing
POC VL test – real-time response
Many models assume immediate/3 month time frame for switch to second line – needed for health benefits
Caution: <5% of HIV+ people are on 2nd line therapy

13. 3) Differentiated care for HIV
Client-centered differentiated service delivery (DSD) simplifies care for HIV+ persons:
Visit spacing, replacing CD4 with VL monitoring, community-based ART, longer prescription refills, task-shifting, DBS specimens, using clinical care resources for complex cases and persons not suppressed on ART
VL testing is the key to doing this – knowing who can be seen less often - cost of VL testing is offset by clinical savings
VL testing indicates individual and program effectiveness

14. DSD for HIV in Zimbabwe
Phillips, A, et. al. Nature, 2015

15. Looking ahead
Integrase inhibitors – higher barrier to resistance – possibly decreased clinical benefits of VL testing
Alternative monitoring (TAF/TDF in urine)
Need to reassess cost effectiveness as new ART and models of care are rolled out

16. Conclusions Cost-effectiveness of VL monitoring – context dependent
DSD needs to be scaled up – cost savings support VL monitoring
Data on viral suppression and costs – standard, routine collection can support scale up of successful differentiated care strategies

17. Thank you
We are grateful to all the wonderful authors who responded to our questions as part of the systematic review
Nick Tan
Nicholas Tan
U. of Washington
Paul Revill
U. of York
Andrew Phillips
UCL
Funding: #OPP