Costs and Consequences of Additional Chest X-Ray in a Tuberculosis Prevention Program in Botswana

Rationale: Isoniazid preventive therapy is effective in reducing the risk of tuberculosis (TB) in persons living with HIV (PLWH); however, screening must exclude TB disease before initiating therapy. Symptom screening alone may be insufficient to exclude TB disease in PLWH because some PLWH with TB disease have no symptoms. The addition of chest radiography (CXR) may improve disease detection. Objectives: The objective of the present analysis was to compare the costs and effects of the addition of CXR to the symptom screening process against the costs and effects of symptom screening alone. Methods: Using data from Botswana, a decision analytic model was used to compare a Symptomonly'' policy against a Symptom+CXR'' policy. The outcomes of interest were cost, death, and isoniazid-and multidrug-resistant TB in a hypothetical cohort of 10,000 PLWH. Measurements and Main Results: The Symptom+CXR policy prevented 16 isoniazid-and 0.3 multidrug-resistant TB cases; however, because of attrition from the screening process, there were 98 excess cases of TB, 15 excess deaths, and an additional cost of U. S. $127,100. The Symptom+CXR policy reduced deaths only if attrition was close to zero; however, to eliminate attrition the cost would be U. S. $2.8 million per death averted. These findings did not change in best-and worst-case scenario analyses. Conclusions: In Botswana, a policy with symptom screening only preceding isoniazid-preventive therapy initiation prevents more TB and TB-related deaths, and uses fewer resources, than a policy that uses both CXR and symptom screening.