| Summary: | Background<br>
Viral load (VL) testing is recommended for monitoring people on ART. The National Health Laboratory Service (NHLS) in South Africa conducts >5million laboratory-based VL tests but faces challenges with specimen integrity and results delivery. Point-of-care (POC) VL monitoring may improve VL suppression (VLS). We assessed the cost-effectiveness of different strategies for POC testing in South Africa.
<br><br>Methods<br>
We developed a cost-outcome model utilizing NHLS data, including facility-level annual VL volumes, proportion with VLS, specimen rejection rates, turn-around-time, and the cost/test. We assessed the impact of adopting POC VL technology under 4 strategies: (1) status-quo; (2) targeted POC testing at facilities with high levels of viral failure; (3) targeted POC testing at low-performing facilities; (4) complete POC adoption. For each strategy, we determined the total cost, effectiveness (expected number of virally suppressed people) and incremental cost-effectiveness ratio (ICER) based on expected (>10%) VLS improvement.
<br><br>Findings<br>
Existing laboratory-based VL testing costs <span>$</span>126 m annually and achieves 85.2% VLS. Strategy 2 was the most cost-effective approach, with 88.5% VLS and <span>$</span>40/additional person suppressed, compared to the status-quo. Should resources allow, complete POC adoption may be cost-effective (ICER: <span>$</span>136/additional person suppressed), requiring an additional <span>$</span>49 m annually and achieving 94.5% VLS. All other strategies were dominated in the incremental analysis.
<br><br>Interpretation<br>
Assuming POC VL monitoring confers clinical benefits, the most cost-effective strategy for POC adoption in South Africa is a targeted approach with POC VL technologies placed at facilities with high level of viral failure.
<br><br>Funding<br>
Funding support from the Bill & Melinda Gates Foundation.
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