This brief considers evidence on the effectiveness, cost-effectiveness and opportunity costs of the WHO recommendations for monitoring people on ART. It draws on modelling and cost-effectiveness work carried out by the HIV Modelling Consortium, commissioned by WHO for the guidelines, as well as randomised controlled trials looking into this question.
In summary, the key points made by the authors are:
1.budget constraints mean that not all the recommendations can be adopted at once without threatening the roll-out of ART to those most in need;
2. moving to routine viral load monitoring is important for improving health care and limiting drug resistance, but should only be a priority once ART coverage for those eligible for treatment is close to full;
3. where large coverage gaps remain more lives will be saved if increasing access to ART is prioritised over moving to viral load monitoring;
4. strategies such as clinical monitoring, targeted ‘tiebreaker’ CD4 tests, or CD4 monitoring will allow more people to access ART than routine viral load testing;
5. reducing the costs of second line regimens and viral load tests may improve the cost-effectiveness of viral load monitoring.
South, A.; Cambiano, V.; Cataldo, F.; Ford, D.; Gibb, D. M.; Gilks, C.; Phillips, A.; Revill, P. MRC CTU Briefing Paper, December 2013, Issue 9. MRC Clinical Trials Unit, (2013)