{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T11:06:31Z","timestamp":1790766391453,"version":"4.1.0"},"reference-count":17,"publisher":"Wiley","issue":"9","license":[{"start":{"date-parts":[[2019,9,12]],"date-time":"2019-09-12T00:00:00Z","timestamp":1568246400000},"content-version":"vor","delay-in-days":11,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000200","name":"United States Agency for International Development","doi-asserted-by":"publisher","award":["AID\u2010OAA\u2010A\u201015\u201000070"],"award-info":[{"award-number":["AID\u2010OAA\u2010A\u201015\u201000070"]}],"id":[{"id":"10.13039\/100000200","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["J Intern AIDS Soc"],"published-print":{"date-parts":[[2019,9]]},"abstract":"Abstract<\/jats:title>\n \n Introduction<\/jats:title>\n \n Routine viral load testing is the\n WHO<\/jats:styled-content>\n \u2010recommended method for monitoring\n HIV<\/jats:styled-content>\n \u2010infected patients on\n ART<\/jats:styled-content>\n , and many countries are rapidly scaling up testing capacity at centralized laboratories. Providing testing access to the most remote populations and facilities (the \u201clast mile\u201d) is especially challenging. Using a geospatial optimization model, we\u00a0estimated the incremental costs of accessing the most remote 20% of patients in Zambia by expanding the transportation network required to bring blood samples from\n ART<\/jats:styled-content>\n clinics to centralized laboratories and return results to clinics.\n <\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n \n The model first optimized a sample transportation network (\n STN<\/jats:styled-content>\n ) that can transport 80% of anticipated sample volumes to centralized viral load testing laboratories on a daily or weekly basis, in line with Zambia's 2020 targets. Data incorporated into the model included the location and infrastructure of all health facilities providing\n ART<\/jats:styled-content>\n , location of laboratories, measured distances and drive times between the two, expected future viral load demand by health facility, and local cost estimates. We then continued to expand the modelled\n STN<\/jats:styled-content>\n in 5% increments until 100% of all samples could be collected.\n <\/jats:p>\n <\/jats:sec>\n \n Results and Discussion<\/jats:title>\n \n The cost per viral load test when reaching 80% patient volumes using centralized viral load testing was a median of $18.99. With an expanded\n STN<\/jats:styled-content>\n , the incremental cost per test rose to $20.29 for 80% to 85% and $20.52 for 85% to 90%. Above 90% coverage, the incremental cost per test increased substantially to $31.57 for 90% to 95% and $51.95 for 95% to 100%. The high numbers of kilometres driven per sample transported and large number of vehicles needed increase costs dramatically for reaching the clinics that serve the last 5% of patients.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n Providing sample transport services to the most remote clinics in low\u2010 and middle\u2010income countries is likely to be cost\u2010prohibitive. Other strategies are needed to reduce the cost and increase the feasibility of making viral load monitoring available to the last 10% of patients. The cost of alternative methods, such as optimal point\u2010of\u2010care viral load equipment placement and usage, dried blood\/plasma spot specimen utilization, or use of drones in geographically remote facilities, should be evaluated.<\/jats:p>\n <\/jats:sec>","DOI":"10.1002\/jia2.25337","type":"journal-article","created":{"date-parts":[[2019,9,13]],"date-time":"2019-09-13T02:13:11Z","timestamp":1568340791000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":36,"title":["Monitoring viral load for the last mile: what will it cost?"],"prefix":"10.1002","volume":"22","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4682-4999","authenticated-orcid":false,"given":"Brooke E","family":"Nichols","sequence":"first","affiliation":[{"name":"Department of Global Health School of Public Health Boston University Boston MA USA"},{"name":"Health Economics and Epidemiology Research Office Department of Internal Medicine School of Clinical Medicine Faculty of Health Sciences University of the Witwatersrand Johannesburg South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8492-028X","authenticated-orcid":false,"given":"Sarah J","family":"Girdwood","sequence":"additional","affiliation":[{"name":"Health Economics and Epidemiology Research Office Department of Internal Medicine School of Clinical Medicine Faculty of Health Sciences University of the Witwatersrand Johannesburg South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas","family":"Crompton","sequence":"additional","affiliation":[{"name":"GIS Mapping Department Right to Care Johannesburg South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lynsey","family":"Stewart\u2010Isherwood","sequence":"additional","affiliation":[{"name":"National Health Laboratory Service Johannesburg South Africa"},{"name":"Department of Molecular Medicine and Haematology Faculty of Health Sciences University of the Witwatersrand Johannesburg South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Leigh","family":"Berrie","sequence":"additional","affiliation":[{"name":"National Health Laboratory Service Johannesburg South Africa"},{"name":"Department of Molecular Medicine and Haematology Faculty of Health Sciences University of the Witwatersrand Johannesburg South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dorman","family":"Chimhamhiwa","sequence":"additional","affiliation":[{"name":"GIS Mapping Department Right to Care Johannesburg South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Crispin","family":"Moyo","sequence":"additional","affiliation":[{"name":"EQUIP Zambia Lusaka Zambia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John","family":"Kuehnle","sequence":"additional","affiliation":[{"name":"United States Agency for International Development Lusaka Zambia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wendy","family":"Stevens","sequence":"additional","affiliation":[{"name":"National Health Laboratory Service Johannesburg South Africa"},{"name":"Department of Molecular Medicine and Haematology Faculty of Health Sciences University of the Witwatersrand Johannesburg South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sydney","family":"Rosen","sequence":"additional","affiliation":[{"name":"Department of Global Health School of Public Health Boston University Boston MA USA"},{"name":"Health Economics and Epidemiology Research Office Department of Internal Medicine School of Clinical Medicine Faculty of Health Sciences University of the Witwatersrand Johannesburg South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"EQUIP Health","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2019,9,12]]},"reference":[{"key":"e_1_2_9_2_1","volume-title":"Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection; Recommendations for a public health approach","author":"World Health Organization","year":"2016"},{"key":"e_1_2_9_3_1","doi-asserted-by":"publisher","DOI":"10.15585\/mmwr.mm6547a2"},{"key":"e_1_2_9_4_1","unstructured":"UNAIDS.Panel\u00a0on People living with HIV receiving ART (#) \u2010 up to 30 June 2017. Zambia2018[cited 2018 Jan 16]. Available from:http:\/\/aidsinfo.unaids.org\/"},{"key":"e_1_2_9_5_1","volume-title":"Viral Load and Early Infant Diagnosis Testing Scale\u2010up Implementation Plan 2016\u20132020","author":"Republic of Zambia Ministry of Health","year":"2016"},{"key":"e_1_2_9_6_1","unstructured":"Ministry of Health Zambia.District Health Information System 2 (DHIS2). Ministry of Health Zambia editor. Lusaka;2017."},{"key":"e_1_2_9_7_1","doi-asserted-by":"publisher","DOI":"10.1002\/jia2.25206"},{"key":"e_1_2_9_8_1","doi-asserted-by":"publisher","DOI":"10.1097\/01.aids.0000327620.47103.1d"},{"key":"e_1_2_9_9_1","doi-asserted-by":"publisher","DOI":"10.1097\/QAD.0000000000001322"},{"key":"e_1_2_9_10_1","unstructured":"ESRI.ArcGIS Desktop Network Analyst tool. Release 10.5. Redlands California: Environment Systems Research Institute (ESRI);2018."},{"key":"e_1_2_9_11_1","doi-asserted-by":"publisher","DOI":"10.1177\/0734242X16649679"},{"key":"e_1_2_9_12_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12913-018-3006-0"},{"key":"e_1_2_9_13_1","unstructured":"GuthrieT MoyoC KinghornA KuehnleJ SinyangweG vanRensbergC et\u00a0al.Cost and outcomes of ART scale\u2010up in Zambia. Johannesburg:2016."},{"issue":"10","key":"e_1_2_9_14_1","first-page":"747","article-title":"Does scale matter? 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