Diomandé Fabien V K, Bissagnéné Emmanuel, Nkengasong John N, Maurice Chantal, Monga Ben, Laga Marie, Nolan Monica L
Projet RETRO-CI, Abidjan, Côte d'Ivoire.
AIDS. 2003 Jul;17 Suppl 3:S87-93. doi: 10.1097/00002030-200317003-00012.
To describe the cost and outcome associated with the use of CD4 cell count and viral load tests as part of screening strategies to identify persons eligible for subsidized antiretroviral therapy (ART) in Côte d'Ivoire.
Empirical data from the Drug Access Initiative in Côte d'Ivoire (DAI-CI) were used to describe the laboratory cost of patient screening using sequential clinical staging, CD4 cell count, and viral load and the proportion of screened patients identified as eligible for ART. We also estimated costs modelling a parallel screening algorithm, across a range of laboratory costs and with current international recommendations to assess treatment eligibility. Benefit was defined as being found eligible for ART.
Of the 2138 HIV-positive, ART-naive, adults who presented to the DAI-CI between July 1998 and July 2000, median CD4 cell count was 172 x 10(6) cells/microl. DAI-CI criteria identified 2057 (96%) of these persons eligible for antiretroviral treatment. In a serial screening algorithm, 75% were eligible by CDC clinical stage B or C; 18% by CD4 cell count less than 500 x 10(6) cells/microl; and an estimated 3.9% by a viral load greater than 10 000 copies/ml. Use of the current US recommendations and a serial algorithm would have resulted in 1977 (92%) persons eligible for ART: 75% by CDC clinical stage B or C; 15% by CD4 cell count less than 350 x 10(6) cells/microl (including 8% < 200 x 10(6) cells/microl); and an estimated 3.6% due to viral load greater than 55 000 copies/ml. Using DAI-CI criteria and heavily subsidized laboratory test costs, the addition of CD4 cell count to clinical criteria cost US dollar 50 (serial algorithm) and US dollar 203 (parallel algorithm) to identify each additional eligible person. Modelling current recommendations with a serial algorithm, CD4 cell count cost an average US dollar 62/eligible person (US recommendations) and US dollar 109 (WHO recommendations). The addition of viral load cost between US dollar 108 (serial algorithm DAI) to US dollar 1700 (parallel algorithm DAI) to identify each additional eligible person.
In the African context of scarce resources and the huge unmet demands for voluntary HIV testing and for ART, simple screening strategies are needed to identify those most in need of ART. Health personnel should be trained to identify and refer clinically symptomatic persons. Viral load testing is of high cost and dubious benefit and should not be part of screening algorithms for initiating ART.
描述将CD4细胞计数和病毒载量检测作为筛查策略的一部分，以确定科特迪瓦符合补贴抗逆转录病毒疗法（ART）条件的人员所产生的成本和结果。
利用科特迪瓦药物获取倡议（DAI-CI）的实证数据，描述使用序贯临床分期、CD4细胞计数和病毒载量进行患者筛查的实验室成本，以及被确定符合ART条件的筛查患者比例。我们还在一系列实验室成本范围内，根据当前国际评估治疗资格的建议，对并行筛查算法进行成本估算。益处定义为被认定符合ART条件。
在1998年7月至2000年7月期间到DAI-CI就诊的2138名未接受过ART治疗的HIV阳性成年人中，CD4细胞计数中位数为172×10⁶个细胞/微升。DAI-CI标准确定其中2057人（96%）符合抗逆转录病毒治疗条件。在连续筛查算法中，75%的人根据美国疾病控制与预防中心（CDC）临床分期B或C符合条件；18%的人根据CD4细胞计数低于500×10⁶个细胞/微升符合条件；估计3.9%的人根据病毒载量大于10000拷贝/毫升符合条件。采用当前美国的建议和连续算法，将有1977人（92%）符合ART条件：75%的人根据CDC临床分期B或C符合条件；15%的人根据CD4细胞计数低于350×10⁶个细胞/微升（包括8%低于200×10⁶个细胞/微升）符合条件；估计3.6%的人由于病毒载量大于55,000拷贝/毫升符合条件。使用DAI-CI标准并大幅补贴实验室检测成本，在临床标准基础上增加CD4细胞计数，采用连续算法确定每名额外符合条件的人成本为50美元，采用并行算法为203美元。采用连续算法对当前建议进行建模，CD4细胞计数确定每名符合条件的人平均成本为62美元（美国建议）和109美元（世界卫生组织建议）。增加病毒载量检测确定每名额外符合条件的人成本在108美元（DAI连续算法）至1700美元（DAI并行算法）之间。
在非洲资源稀缺、自愿HIV检测和ART需求远未满足的情况下，需要简单的筛查策略来确定最需要ART的人群。应培训卫生人员识别并转诊有临床症状的患者。病毒载量检测成本高昂且益处存疑，不应成为启动ART筛查算法的一部分。
