Cost Comparison of Point-Of-Care and Conventional CD4 Testing in Resource-Limited Settings

1. Cost Comparison of Point-Of-Care and Conventional CD4 Testing in Resource-Limited Settings Ilesh V. Jani Instituto Nacional de Saúde Maputo, Mozambique

2. Nurses in Primary Health Clinics Can Accurately Perform CD4 counts Using Point-Of-Care Devices Alere PIMA (Lab Techs) vs. BD FACSCalibur Alere PIMA (Nurses) vs. BD FACSCalibur Limits of Agreement -249 to +148 Limits of Agreement -314 to +257 Jani et al. (2011); AIDS

3. Point-Of-Care CD4 Counting Reduces Pre-Treatment Loss-To-Follow-Up Percent Of Patients Receiving CD4 Test Results Percent Of Patients Returning After Initial CD4

4. Point-Of-Care Technologies Must Be Considered Against Conventional Laboratory-Based technologies • Point-Of-Care CD4 (Alere Pima) • Lower throughput (5-20 tests/day) • New technology without large installed base • Does not require significant infrastructure • Performed by non-specialised personnel • May be more expensive in certain settings • Significant patient benefits • Conventional CD4 (BD FACSCount) • Higher throughput (50-75 tests/day) • Large installed base (>1000 instruments across Africa) • Takes advantage of existing infrastructure • Performed by trained laboratory technicians • May be more efficient and cheaper due to economies of scale

5. Cost is an Important Factor to Consider When Placing Point-Of-Care Devices • Methods • Data were gathered from health facilities across • 13 countries in sub-Saharan Africa: • Reagent, control, and consumable costs • Equipment and maintenance costs • Lab infrastructure and overhead costs • Sample transport costs • Human resource salaries • Site patient volumes • Total cost per test for a site with known testing • volume was calculated to determine if it would be less costly to refer samples to an existing CD4 laboratory or to implement Point-Of-Care CD4 testing on-site

6. Conventional CD4 testing Costs Vary Significantly But Point-Of-Care CD4 Counting Costs Are Relatively Stable Across Countries Source: 1Machinga District, Malawi

7. At Average Volumes of ~1,400 Tests/Yr Point-Of-Care CD4 Cost/Test is Comparable to Conventional CD4 Averages obscure higher reagent prices for laboratory based CD4 in some countries

8. For a Single ART Site Referring Samples, Conventional CD4 Cost/Test Drops Slightly as Volumes Rise CD4 Cost per Test CD4 Volume per Year per Site

9. For a Single ART Site with Point-Of-Care CD4, Cost/Test Drops Dramatically as Volumes Rise Above 5,000 tests/year, a 2nd device is required CD4 Cost per Test CD4 Volume per Year per Site

10. As Testing Volumes Rise, Point-Of-Care CD4 Testing Becomes More Cost-Competitive At 1,400 tests/yr per site (avg. CD4 demand at a health center in Africa), POC all-in costs are higher CD4 Cost per Test Cost is equal at ~2,900 tests per year at one site CD4 Volume per Year per Site

11. Higher Volume Sites Comprise a Large Proportion of Point-Of-Care Test Demand CD4 Tests Demanded/Year Sites above >2,900 tests per year comprise >90% of CD4 test demand But it is more intuitive that POC would belong at small, remote sites!

12. Deploying Device Based Point-Of-Care CD4 at a (relatively) Modest Number of Higher Volume Sites Seems to Be Less Costly - But Site Selection Depends on Many Factors • Other factors to consider: • Universal access • Equity • Distance to laboratories • Patient loss-to-follow-up • Size of catchment area • ART coverage • HIV prevalence • PMTCT services • Etc.

13. Kanimambo!Obrigado!Grazie!Thank You!