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

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

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

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 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 Point-Of-Care Technologies Must Be Considered Against Conventional Laboratory- Based technologies

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 Cost is an Important Factor to Consider When Placing Point-Of-Care Devices

Conventional CD4 testing Costs Vary Significantly But Point-Of-Care CD4 Counting Costs Are Relatively Stable Across Countries Cost ComponentPrice Range Reagents$ $10.89 $5.95 plus distributor margin Other Consumables$ $1.61$1.00 Controls$ $0.52$100 per year Price per Instrument$27,000 (FACSCount)$5,000 (PIMA) Maintenance$4,000 per year$1,200 per year Freight10% of costs Lab Overhead$ $0.46$ $0.60 Sample Transport~$1.25 per sample 1 None Human Resources$ $2.10$ $1.15 Source: 1 Machinga District, Malawi

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

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

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

CD4 Tests Demanded/Year Higher Volume Sites Comprise a Large Proportion of Point-Of-Care Test Demand 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!

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.

Kanimambo! Obrigado! Grazie! Thank You!