Cost-effectiveness of WHO-Recommended Algorithms for TB Case Finding at Ethiopian HIV Clinics

• Type of Material: Article
• Authors: Max W. Adelman, Massachusetts General Hospital; Deborah A McFarland, Emory University; Mulugeta Tsegaye, ALERT Hospital; Abraham Aseffa, Armauer Hansen Research Institute; Russell Ryan Kempker, Emory University; Henry Michael Blumberg, Emory University
• Language: English
• Date: 2018-01-01
• Publisher: Oxford University Press (OUP)
• Publication Version: Final Published Version
• Copyright Statement: © The Author(s) 2017. Published by Oxford University Press on behalf of Infectious Diseases Society of America.
• License: Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1093/ofid/ofx269
• Title of Journal or Parent Work: Open Forum Infectious Diseases
• ISSN: 2328-8957
• Volume: 5
• Issue: 1
• Start Page: ofx269
• End Page: ofx269
• Grant/Funding Information: This work was supported in part by the National Institutes of Health (NIH) National Center for Advancing Translational Sciences (grant numbers UL1TR000454, UL1TR002378 and TL1TR000456); Fogarty International Center at the NIH (grant number D43TW009127); the NIH National Institute of Allergy and Infectious Diseases (grant number K23AI103044); the Emory Global Health Institute; the Infectious Diseases Society of America; and the American Medical Association Foundation.
• Keywords: ACCURACY; Infectious Diseases; developing countries; RESISTANCE; cost-effectiveness; THERAPY; CARE; AFRICA; ADDIS-ABABA; TUBERCULOSIS; DIAGNOSIS; Ethiopia; TB/HIV co-infection; Science & Technology; INFECTED PERSONS; Life Sciences & Biomedicine; XPERT MTB/RIF ASSAY; modeling
• Research Categories: Health Sciences, Epidemiology; Health Sciences, Public Health

Abstract

Background: The World Health Organization (WHO) recommends active tuberculosis (TB) case finding and a rapid molecular diagnostic test (Xpert MTB/RIF) to detect TB among people living with HIV (PLHIV) in high-burden settings. Information on the cost-effectiveness of these recommended strategies is crucial for their implementation. Methods: We conducted a model-based cost-effectiveness analysis comparing 2 algorithms for TB screening and diagnosis at Ethiopian HIV clinics: (1) WHO-recommended symptom screen combined with Xpert for PLHIV with a positive symptom screen and (2) current recommended practice algorithm (CRPA; based on symptom screening, smear microscopy, and clinical TB diagnosis). Our primary outcome was US$ per disability-adjusted life-year (DALY) averted. Secondary outcomes were additional true-positive diagnoses, and false-negative and false-positive diagnoses averted. Results: Compared with CRPA, combining a WHO-recommended symptom screen with Xpert was highly cost-effective (incremental cost of $5 per DALY averted). Among a cohort of 15 000 PLHIV with a TB prevalence of 6% (900 TB cases), this algorithm detected 8 more true-positive cases than CRPA, and averted 2045 false-positive and 8 false-negative diagnoses compared with CRPA. The WHO-recommended algorithm was marginally costlier ($240 000) than CRPA ($239 000). In sensitivity analysis, the symptom screen/Xpert algorithm was dominated at low Xpert sensitivity (66%). Conclusions: In this model-based analysis, combining a WHO-recommended symptom screen with Xpert for TB diagnosis among PLHIV was highly cost-effective ($5 per DALY averted) and more sensitive than CRPA in a high-burden, resource-limited setting.