The potential for quality assurance systems to save costs and lives: the case of early infant diagnosis of HIV

Objectives
Scaling up of point‐of‐care testing (POCT) for early infant diagnosis of HIV (EID) could reduce the large gap in infant testing. However, suboptimal POCT EID could have limited impact and potentially high avoidable costs. This study models the cost‐effectiveness of a quality assurance system to address testing performance and screening interruptions, due to e.g. supply stockouts, in Kenya, Senegal, South Africa, Uganda, Zimbabwe, with varying HIV epidemics and different health systems.

Methods
We modelled a quality assurance system‐raised EID quality from suboptimal levels: i.e. from misdiagnosis rates of 5%, 10% and 20% and EID testing interruptions in months, to uninterrupted optimal performance (98.5% sensitivity, 99.9% specificity). For each country, we estimated the 1‐year impact and cost‐effectiveness (US$/DALY averted) of improved scenarios in averting missed HIV infections and unneeded HIV treatment costs for false positive diagnoses.

Results
The modelled 1‐year costs of a national POCT quality assurance system range from US$ 69,359 in South Africa to US$ 334,341 in Zimbabwe. At the country‐level, quality assurance systems could potentially avert between 36 and 711 missed infections (i.e. false negatives) per year and unneeded treatment costs between US$ 5,808 and US$ 739,030.

Conclusions
The model estimates adding effective quality assurance systems is cost‐saving in four of the five countries within the first year. Starting EQA requires an initial investment but will provide a positive return on investment within five years by averting the costs of misdiagnoses and would be even more efficient if implemented across multiple applications of POCT.