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Sustainable HIV treatment in Africa through viral-load-informed differentiated care

Andrew Phillips (), Amir Shroufi, Lara Vojnov, Jennifer Cohn, Teri Roberts, Tom Ellman, Kimberly Bonner, Christine Rousseau, Geoff Garnett, Valentina Cambiano, Fumiyo Nakagawa, Deborah Ford, Loveleen Bansi-Matharu, Alec Miners, Jens D. Lundgren, Jeffrey W. Eaton, Rosalind Parkes-Ratanshi, Zachary Katz, David Maman, Nathan Ford, Marco Vitoria, Meg Doherty, David Dowdy, Brooke Nichols, Maurine Murtagh, Meghan Wareham, Kara M. Palamountain, Christine Chakanyuka Musanhu, Wendy Stevens, David Katzenstein, Andrea Ciaranello, Ruanne Barnabas, R. Scott Braithwaite, Eran Bendavid, Kusum J. Nathoo, David van de Vijver, David P. Wilson, Charles Holmes, Anna Bershteyn, Simon Walker, Elliot Raizes, Ilesh Jani, Lisa J. Nelson, Rosanna Peeling, Fern Terris-Prestholt, Joseph Murungu, Tsitsi Mutasa-Apollo, Timothy B. Hallett and Paul Revill
Additional contact information
Andrew Phillips: University College London
Amir Shroufi: Southern Africa Medical Unit (SAMU), Medecins sans Frontieres (MSF) SA
Lara Vojnov: Clinton Health Access Initiative
Jennifer Cohn: Médecins Sans Frontières, Access Campaign
Teri Roberts: Médecins Sans Frontières, Access Campaign
Tom Ellman: Southern Africa Medical Unit (SAMU), Medecins sans Frontieres (MSF) SA
Kimberly Bonner: Médecins Sans Frontières
Christine Rousseau: Bill and Melinda Gates Foundation
Geoff Garnett: Bill and Melinda Gates Foundation
Valentina Cambiano: University College London
Fumiyo Nakagawa: University College London
Deborah Ford: MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology
Loveleen Bansi-Matharu: University College London
Alec Miners: Health Services Research & Policy, London School of Hygiene and Tropical Medicine
Jens D. Lundgren: CHIP, Rigshospitalet, University of Copenhagen
Jeffrey W. Eaton: Imperial College London
Rosalind Parkes-Ratanshi: Infectious Diseases Institute (IDI), College of Health Sciences, Makerere University
Zachary Katz: Clinton Health Access Initiative
David Maman: Southern Africa Medical Unit (SAMU), Medecins sans Frontieres (MSF) SA
Nathan Ford: HIV/AIDS and Global Hepatitis Programme, World Health Organization
Marco Vitoria: HIV/AIDS and Global Hepatitis Programme, World Health Organization
Meg Doherty: HIV/AIDS and Global Hepatitis Programme, World Health Organization
David Dowdy: Johns Hopkins Bloomberg School of Public Health
Brooke Nichols: Erasmus Medical Center
Maurine Murtagh: International Diagnostics Centre, London School of Hygiene & Tropical, Medicine
Meghan Wareham: Clinton Health Access Initiative
Kara M. Palamountain: Kellogg School of Management, Northwestern University
Christine Chakanyuka Musanhu: WHO Country Office
Wendy Stevens: University of the Witwatersrand
David Katzenstein: Division of Infectious Disease
Andrea Ciaranello: Massachusetts General Hospital Division of Infectious Diseases
Ruanne Barnabas: Medicine, Global Health and Epidemiology, University of Washington (UW)
R. Scott Braithwaite: New York University School of Medicine
Eran Bendavid: Division of General Medical Disciplines, Department of Medicine Stanford University
Kusum J. Nathoo: University of Zimbabwe, College of Health Sciences
David van de Vijver: Erasmus Medical Center
David P. Wilson: University of New South Wales
Charles Holmes: Centre for Infectious Disease Research in Zambia
Anna Bershteyn: Institute for Disease Modeling
Elliot Raizes: Care and Treatment Branch Center for Global Health, CDC
Ilesh Jani: Instituto Nacional de Saúde (INS), Ministry of Health
Lisa J. Nelson: The Office of the US Global AIDS Coordinator and Health Diplomacy (S/GAC)
Rosanna Peeling: London School of Hygiene and Tropical Medicine
Fern Terris-Prestholt: London School of Hygiene and Tropical Medicine
Joseph Murungu: Ministry of Health and Child Care
Tsitsi Mutasa-Apollo: Ministry of Health and Child Care
Timothy B. Hallett: Imperial College London

Nature, 2015, vol. 528, issue 7580, S68-S76

Abstract: Abstract There are inefficiencies in current approaches to monitoring patients on antiretroviral therapy in sub-Saharan Africa. Patients typically attend clinics every 1 to 3 months for clinical assessment. The clinic costs are comparable with the costs of the drugs themselves and CD4 counts are measured every 6 months, but patients are rarely switched to second-line therapies. To ensure sustainability of treatment programmes, a transition to more cost-effective delivery of antiretroviral therapy is needed. In contrast to the CD4 count, measurement of the level of HIV RNA in plasma (the viral load) provides a direct measure of the current treatment effect. Viral-load-informed differentiated care is a means of tailoring care so that those with suppressed viral load visit the clinic less frequently and attention is focussed on those with unsuppressed viral load to promote adherence and timely switching to a second-line regimen. The most feasible approach to measuring viral load in many countries is to collect dried blood spot samples for testing in regional laboratories; however, there have been concerns over the sensitivity and specificity of this approach to define treatment failure and the delay in returning results to the clinic. We use modelling to synthesize evidence and evaluate the cost-effectiveness of viral-load-informed differentiated care, accounting for limitations of dried blood sample testing. We find that viral-load-informed differentiated care using dried blood sample testing is cost-effective and is a recommended strategy for patient monitoring, although further empirical evidence as the approach is rolled out would be of value. We also explore the potential benefits of point-of-care viral load tests that may become available in the future. This article has not been written or reviewed by Nature editors. Nature accepts no responsibility for the accuracy of the information provided.

Date: 2015
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DOI: 10.1038/nature16046

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