4.4 Article

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

Journal

OPEN FORUM INFECTIOUS DISEASES
Volume 5, Issue 1, Pages -

Publisher

OXFORD UNIV PRESS INC
DOI: 10.1093/ofid/ofx269

Keywords

cost-effectiveness; developing countries; Ethiopia; modeling; TB/HIV co-infection

Funding

  1. National Institutes of Health (NIH) National Center for Advancing Translational Sciences [UL1TR000454, UL1TR002378, TL1TR000456]
  2. Fogarty International Center at the NIH [D43TW009127]
  3. NIH National Institute of Allergy and Infectious Diseases [K23AI103044]
  4. Emory Global Health Institute
  5. Infectious Diseases Society of America
  6. American Medical Association Foundation

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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.

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