Cost analysis of centralized viral load testing for antiretroviral therapy monitoring in Nicaragua, a low-HIV prevalence, low-resource setting

Abstract

Background: HIV viral load testing as a component of antiretroviral therapy monitoring is costly. Understanding the full costs and the major sources of inefficiency associated with viral load testing is critical for optimizing the systems and technologies that support the testing process. The objective of our study was to estimate the costs associated with viral load testing performed for antiretroviral therapy monitoring to both patients and the public healthcare system in a low-HIV prevalence, low-resource country.

Methods: A detailed cost analysis was performed to understand the costs involved in each step of performing a viral load test in Nicaragua, from initial specimen collection to communication of the test results to each patient's healthcare provider. Data were compiled and cross referenced from multiple information sources: laboratory records, regional surveillance centre records, and scheduled interviews with the key healthcare providers responsible for HIV patient care in five regions of the country.

Results: The total average cost of performing a viral load test in Nicaragua varied by region, ranging from US$99.01 to US$124.58, the majority of which was at the laboratory level: $88.73 to $97.15 per specimen, depending on batch size. The average cost to clinics at which specimens were collected ranged from $3.31 to $20.92, depending on the region. The average cost per patient for transportation, food, lodging and lost income ranged from $3.70 to $14.93.

Conclusions: The quantitative viral load test remains the single most expensive component of the process. For the patient, the distance of his or her residence from the specimen collection site is a large determinant of cost. Importantly, the efficiency of results reporting has a large impact on the cost per result delivered to the clinician and utility of the result for patient monitoring. Detailed cost analysis can identify opportunities for removing barriers to effective antiretroviral therapy monitoring programmes in limited-resource countries with low HIV prevalence.

Figure 1

Summary of process for CD4 and viral load testing. The patient goes to the SCS (solid arrow) to have blood drawn. The specimen is shipped under the cold chain to the central laboratory (CNDR) for CD4 and viral load testing (double-line arrow). Results are communicated (dotted arrow) back to the originating local healthcare department (SILAIS). The SILAIS then communicates the results back to the pertinent ART multidisciplinary team. The SCS, ART multidisciplinary team and ART case management site (gray shading) may or may not reside at the same healthcare facility.

Figure 2

Relative patient, SCS and central testing facility costs to perform an HIV viral load test.

Figure 3

Relationship between costs and distance. 3A. The distance from home to the SCS for HIV patients in the Atlantic regions. Empty squares represent the direct transportation costs incurred by patients. Filled squares represent fully burdened food, lodging and opportunity costs to patients. 3B. The distance from the SCS to the central testing facility (in Managua). Empty squares represent specimen transport costs. Filled squares represent the cost per viral load test to the healthcare system.