Work

Cost-Effectiveness of the World Health Organization-Recommended Algorithms for Tuberculosis Case Finding at Ethiopian Human Immunodeficiency Virus (HIV) Clinics

Year: 2016

Type: article

Abstract: Background. The World Health Organization (WHO) recommends active tuberculosis (TB) case finding and the use of 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 implementation in resource-limited settings. Methods. We conducted a model-based cost-effectiveness analysis comparing two algorithms for TB screening and diagnosis at HIV clinics in Ethiopia: (1) a WHO-recommended symptom screen combined with Xpert for PLHIV with positive symptom screen; and (2) current recommended practice algorithm (CRPA), which includes sequential (a) WHO-recommended symptom screen, (b) smear microscopy for those with a positive symptom screen, and (c) clinical diagnosis and empiric treatment for selected patients with negative smear microscopy. Our primary outcome was US$ per disability-adjusted life year (DALY) averted. Secondary outcomes were additional true positive diagnoses with symptom screen/Xpert, and false-negative and false-positive diagnoses averted. Results. Compared to CRPA, combining two WHO-recommendations—a WHO symptom screen with Xpert for those with a positive symptom screen—was highly cost effective for TB diagnosis among PLHIV (incremental cost of $21 per DALY averted). Among a cohort of 15,000 PLHIV with TB prevalence of 6%, this algorithm detected 54 more true-positive cases than CRPA, and averted 2059 false positive and 54 false-negative diagnoses. Per 15,000 patients, the WHO-recommended algorithm was modestly more costly ($252,000) than CRPA ($225,000). Cost-effectiveness of the symptom screen/Xpert algorithm was largely robust to sensitivity analyses. Conclusion. In this model-based analysis, combining a WHO-recommended symptom screen with Xpert for TB diagnosis among PLHIV was highly cost-effective ($21 per DALY averted) and more sensitive and specific than CRPA in a high-burden, resource-limited setting. The high number of false positive diagnoses in CRPA was due to low specificity of both the WHO-recommended symptom screen and clinical diagnosis. High cost of symptom screen and Xpert will require additional resources for widespread scale up and implementation. Disclosures. All authors: No reported disclosures.

Source: Open Forum Infectious Diseases

DOI: 10.1093/ofid/ofw172.412

Authors: Max Adelman, Deborah Mcfarland, Mulugeta Tsegaye, Russell Kempker, Abraham Aseffa, Henry Blumberg