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Background: Updated World Health Organization guidelines have amplified debate about how resource constraints should impact monitoring strategies for HIV‐infected persons on combination antiretroviral therapy (cART). We estimated the incremental benefit and cost effectiveness of alternative monitoring strategies for east Africans with known HIV infection. Methods: Using a validated HIV computer simulation based on resource‐limited data (USAID and AMPATH) and circumstances (east Africa), we compared alternative monitoring strategies for HIV‐infected persons newly started on cART. We evaluated clinical, immunologic and virologic monitoring strategies, including combinations and conditional logic (e.g., only perform virologic testing if immunologic testing is positive). We calculated incremental cost‐effectiveness ratios (ICER) in units of cost per quality‐adjusted life year (QALY), using a societal perspective and a lifetime horizon. Costs were measured in 2008 US dollars, and costs and benefits were discounted at 3%. We compared the ICER of monitoring strategies with those of other resource‐constrained decisions, in particular earlier cART initiation (at CD4 counts of 350 cells/mm[sup.3] rather than 200 cells/mm[sup.3]). Results: Monitoring strategies employing routine CD4 testing without virologic testing never maximized health benefits, regardless of budget or societal willingness to pay for additional health benefits. Monitoring strategies employing virologic testing conditional upon particular CD4 results delivered the most benefit at willingness‐to‐pay levels similar to the cost of earlier cART initiation (approximately $2600/QALY). Monitoring strategies employing routine virologic testing alone only maximized health benefits at willingness‐to‐pay levels (> $4400/QALY) that greatly exceeded the ICER of earlier cART initiation. Conclusions: CD4 testing alone never maximized health benefits regardless of resource limitations. Programmes routinely performing virologic testing but deferring cART initiation may increase health benefits by reallocating monitoring resources towards earlier cART initiation., Background Considerable debate exists about how resource constraints should impact laboratory monitoring for HIV‐infected patients on combination antiretroviral therapy (cART) [1‐6]. This lack of consensus is reflected in the equivocal [...]

Introduction Health plans, employers, and policymakers are looking for more effective approaches to control health expenditures. Reductions in health expenditures can arise from lowering either the costs or the quantities [...], Background: Evidence suggests that cost sharing (i.e., copayments and deductibles) decreases health expenditures but also reduces essential care. Value-based insurance design (VBID) has been proposed to encourage essential care while controlling health expenditures. Our objective was to estimate the impact of broader diffusion of VBID on US health care benefits and costs. Methods and Findings: We used a published computer simulation of costs and life expectancy gains from US health care to estimate the impact of broader diffusion of VBID. Two scenarios were analyzed: (1) applying VBID solely to pharmacy benefits and (2) applying VBID to both pharmacy benefits and other health care services (e.g., devices). We assumed that cost sharing would be eliminated for high-value services ( Conclusion: Broader diffusion of VBID may amplify benefits from US health care without increasing health expenditures. Please see later in the article for the Editors' Summary.