Cost-effectiveness of routine viral load monitoring in low- and middle-income countries: a systematic review.

INTRODUCTION Routine viral load monitoring for HIV-1 management of persons on antiretroviral therapy (ART) has been recommended by the World Health Organization (WHO) to identify treatment failure. However, viral load testing represents a substantial cost in resource constrained health care systems. The central challenge is whether and how viral load monitoring may be delivered such that it maximizes health gains across the population for the costs incurred. We hypothesized that key features of program design and delivery costs drive the cost-effectiveness of viral load monitoring within programs. METHODS We conducted a systematic review of studies on the cost-effectiveness of viral load monitoring in low- and middle-income countries (LMICs). We followed the Cochrane Collaboration guidelines and the PRISMA reporting guidelines. RESULTS AND DISCUSSION We identified 18 studies that evaluated the cost-effectiveness of viral load monitoring in HIV treatment programs. Overall, we identified three key factors that make it more likely for viral load monitoring to be cost-effective: 1) Use of effective, lower cost approaches to viral load monitoring (e.g. use of dried blood spots); 2) Ensuring the pathway to health improvement is established and that viral load results are acted upon; and 3) Viral load results are used to simplify HIV care in patients with viral suppression (i.e. differentiated care, with fewer clinic visits and longer prescriptions). Within the context of differentiated care, viral load monitoring has the potential to double the health gains and be cost saving compared to the current standard (CD4 monitoring). CONCLUSIONS The cost-effectiveness of viral load monitoring critically depends on how it is delivered and the program context. Viral load monitoring as part of differentiated HIV care is likely to be cost-effective. Viral load monitoring in differentiated care programs provides evidence that reduced clinical engagement, where appropriate, is not impacting health outcomes. Introducing viral load monitoring without differentiated care is unlikely to be cost-effective in most settings and results in lost opportunity for health gains through alternative uses of limited resources. As countries scale up differentiated care programs, data on viral suppression outcomes and costs should be collected to evaluate the on-going cost-effectiveness of viral load monitoring as utilized in practice.