Laboratory Monitoring to Guide Switching Antiretroviral Therapy in Resource-Limited Settings: Clinical Benefits and Cost-Effectiveness

Background: As second-line antiretroviral therapy (ART) availability increases in resource-limited settings, questions about the value of laboratory monitoring remain. We assessed the outcomes and cost-effectiveness (CE) of laboratory monitoring to guide switching ART. Methods: We used a computer model to project life expectancy and costs of different strategies to guide ART switching in patients in Cote d'Ivoire. Strategies included clinical assessment, CD4 count, and HIV RNA testing. Data were from clinical trials and cohort studies from Cote d'Ivoire and the literature. Outcomes were compared using the incremental CE ratio. We conducted multiple sensitivity analyses to assess uncertainty in model parameters. Results: Compared with first-line ART only, second-line ART increased life expectancy by 24% with clinical monitoring only, 46% with CD4 monitoring, and 61% with HIV RNA monitoring. The incremental CE ratio of switching based on clinical monitoring was $1670 per year of life gained (YLS) compared with first-line ART only; biannual CD4 monitoring was $2120 per YLS. The CE ratio of biannual HIV RNA testing ranged from $2920 ($87/test) to $1990 per YLS ($25/test). If second-line ART costs were reduced, the CE of HIV RNA monitoring improved. Conclusions: In resource-limited settings, CD4 count and HIV RNA monitoring to guide switching to second-line ART improve survival and, under most conditions, are cost-effective.