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CD4 cell count and viral load monitoring in patients undergoing antiretroviral therapy in Uganda: cost effectiveness study

BMJ 2011; 343 doi: (Published 09 November 2011) Cite this as: BMJ 2011;343:d6884
  1. James G Kahn, professor1,
  2. Elliot Marseille, principal2,
  3. David Moore, research scientist3,
  4. Rebecca Bunnell, acting director, division of community health45,
  5. Willy Were, medical epidemiologist4,
  6. Richard Degerman, data management adviser4,
  7. Jordan W Tappero, director, health systems reconstruction office45,
  8. Paul Ekwaru, statistician4,
  9. Frank Kaharuza, chief, epidemiology branch4,
  10. Jonathan Mermin, director, division of HIV/AIDS prevention45
  1. 1Philip R Lee Institute for Health Policy Studies and Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
  2. 2Health Strategies International, Oakland, CA
  3. 3Department of Medicine, Faculty of Medicine, University of British Columbia and British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
  4. 4CDC-Uganda, National Center for HIV, Viral Hepatitis, STD and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention, Entebbe, Uganda
  5. 5Centers for Disease Control and Prevention, Atlanta, GA, USA
  1. Correspondence to: J G Kahn, University of California, 3333 California Street, Suite 265, San Francisco CA, US 94118 jgkahn{at}
  • Accepted 21 September 2011


Objective To examine the cost and cost effectiveness of quarterly CD4 cell count and viral load monitoring among patients taking antiretroviral therapy (ART).

Design Cost effectiveness study.

Setting A randomised trial in a home based ART programme in Tororo, Uganda.

Participants People with HIV who were members of the AIDS Support Organisation and had CD4 cell counts <250 ×106 cells/L or World Health Organization stage 3 or 4 disease.

Main outcome measures Outcomes calculated for the study period and projected 15 years into the future included costs, disability adjusted life years (DALYs), and incremental cost effectiveness ratios (ICER; $ per DALY averted). Cost inputs were based on the trial and other sources. Clinical inputs derived from the trial; in the base case, we assumed that point estimates reflected true differences even if non-significant. We conducted univariate and multivariate sensitivity analyses.

Interventions Three monitoring strategies: clinical monitoring with quarterly CD4 cell counts and viral load measurement (clinical/CD4/viral load); clinical monitoring and quarterly CD4 counts (clinical/CD4); and clinical monitoring alone.

Results With the intention to treat (ITT) results per 100 individuals starting ART, we found that clinical/CD4 monitoring compared with clinical monitoring alone increases costs by $20 458 (£12 780, €14 707) and averts 117.3 DALYs (ICER=$174 per DALY). Clinical/CD4/viral load monitoring compared with clinical/CD4 monitoring adds $142 458, and averts 27.5 DALYs ($5181 per DALY). The superior ICER for clinical/CD4 monitoring is robust to uncertainties in input values, and that strategy is dominant (less expensive and more effective) compared with clinical/CD4/viral load monitoring in one quarter of simulations. If clinical inputs are based on the as treated analysis starting at 90 days (after laboratory monitoring was initiated), then clinical/CD4/viral load monitoring is dominated by other strategies.

Conclusions Based on this trial, compared with clinical monitoring alone, monitoring of routine CD4 cell count is considerably more cost effective than additionally including routine viral load testing in the monitoring strategy and is more cost effective than ART.


  • Contributors: JGK and EM designed the analysis, constructed the cost effectiveness model, and wrote the manuscript. DM, RD, and JM provided data and interpretation for the clinical trial results. RD and PE provided healthcare use and cost data from the trial. DM, RB, WW, JWT, PE, FK, and JM reviewed and edited the manuscript to assure accurate interpretation and representation of the trial context, clinical practices, and economic findings. JGK is guarantor.

  • Funding: This study was funded by US Centers for Disease Control and Prevention, Kenya, and US National Institute of Drug Abuse (R01 DA15612). The findings and conclusions in this manuscript are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: This study was approved by the science and ethics committee of the Uganda Virus Research Institute, the Uganda National Council of Science and Technology; CDC Institutional Review Board; UCSF CHR 04024782.

  • Data sharing: Detailed costing data available on request.

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