The Cost-effectiveness of Routine Tuberculosis Screening with Xpert MTB/RIF Prior to Initiation of Antiretroviral Therapy: a Model-based Analysis

Overview

Journal AIDS

Specialty Infectious Diseases

Date 2012 Feb 16

PMID 22333751

Citations 51

Authors

Jason R Andrews

Stephen D Lawn

Corina Rusu

Robin Wood

Farzad Noubary

Melissa A Bender

C Robert Horsburgh

Elena Losina

Kenneth A Freedberg

Rochelle P Walensky

Affiliations

Soon will be listed here.

Abstract

Background: In settings with high tuberculosis (TB) prevalence, 15-30% of HIV-infected individuals initiating antiretroviral therapy (ART) have undiagnosed TB. Such patients are usually screened by symptoms and sputum smear, which have poor sensitivity.

Objective: To project the clinical and economic outcomes of using Xpert MTB/RIF(Xpert), a rapid TB/rifampicin-resistance diagnostic, to screen individuals initiating ART.

Design: We used a microsimulation model to evaluate the clinical impact and cost-effectiveness of alternative TB screening modalities - in all patients or only symptomatic patients - for hypothetical cohorts of individuals initiating ART in South Africa (mean CD4 cell count = 171 cells/μl; TB prevalence 22%). We simulated no active screening and four diagnostic strategies, smear microscopy (sensitivity 23%); smear and culture (sensitivity, 100%); one Xpert sample (sensitivity in smear-negative TB: 43%); two Xpert samples (sensitivity in smear-negative TB: 62%). Outcomes included projected life expectancy, lifetime costs (2010 US$), and incremental cost-effectiveness ratios (ICERs). Strategies with ICERs less than $7100 (South African gross domestic product per capita) were considered very cost-effective.

Results: Compared with no screening, life expectancy in TB-infected patients increased by 1.6 months using smear in symptomatic patients and by 6.6 months with two Xpert samples in all patients. At 22% TB prevalence, the ICER of smear for all patients was $2800 per year of life saved (YLS), and of Xpert (two samples) for all patients was $5100/YLS. Strategies involving one Xpert sample or symptom screening were less efficient.

Conclusion: Model-based analysis suggests that screening all individuals initiating ART in South Africa with two Xpert samples is very cost-effective.

Citing Articles

Comparing the cost-effectiveness of the MPT64-antigen detection test to Xpert MTB/RIF and ZN-microscopy for the diagnosis of Extrapulmonary Tuberculosis: An economic evaluation modelling study.

Hassan S, Mustafa T, Muller W, Torres L, Marijani M, Ngadaya E PLOS Glob Public Health. 2024; 4(8):e0003414.

PMID: 39116052 PMC: 11309377. DOI: 10.1371/journal.pgph.0003414.

The Value-of-Information and Value-of-Implementation from Clinical Trials of Diagnostic Tests for HIV-Associated Tuberculosis: A Modeling Analysis.

Pei P, Fitzmaurice K, Le M, Panella C, Jones M, Pandya A MDM Policy Pract. 2023; 8(2):23814683231198873.

PMID: 37743931 PMC: 10517616. DOI: 10.1177/23814683231198873.

Costs and cost-effectiveness of Gene Xpert compared to smear microscopy for the diagnosis of pulmonary tuberculosis using real-world data from Arsi zone, Ethiopia.

Kaso A, Hailu A PLoS One. 2021; 16(10):e0259056.

PMID: 34695153 PMC: 8544827. DOI: 10.1371/journal.pone.0259056.

Tuberculosis screening costs and cost-effectiveness in high-risk groups: a systematic review.

Alsdurf H, Empringham B, Miller C, Zwerling A BMC Infect Dis. 2021; 21(1):935.

PMID: 34496804 PMC: 8425319. DOI: 10.1186/s12879-021-06633-3.

Cost-Effectiveness Analysis of High-Risk Groups Tuberculosis Screening in Malaysia.

Mohd Hassan N, Razali A, Shahari M, Mohd Nor Sham Kunusagaran M, Halili J, Zaimi N Front Public Health. 2021; 9:699735.

PMID: 34322473 PMC: 8310930. DOI: 10.3389/fpubh.2021.699735.

References

Lawn S, Kranzer K, Wood R . Antiretroviral therapy for control of the HIV-associated tuberculosis epidemic in resource-limited settings. Clin Chest Med. 2009; 30(4):685-99, viii. PMC: 2887494. DOI: 10.1016/j.ccm.2009.08.010. View

Boehme C, Nabeta P, Hillemann D, Nicol M, Shenai S, Krapp F . Rapid molecular detection of tuberculosis and rifampin resistance. N Engl J Med. 2010; 363(11):1005-15. PMC: 2947799. DOI: 10.1056/NEJMoa0907847. View

Banada P, Sivasubramani S, Blakemore R, Boehme C, Perkins M, Fennelly K . Containment of bioaerosol infection risk by the Xpert MTB/RIF assay and its applicability to point-of-care settings. J Clin Microbiol. 2010; 48(10):3551-7. PMC: 2953088. DOI: 10.1128/JCM.01053-10. View

Jones-Lopez E, Ayakaka I, Levin J, Reilly N, Mumbowa F, Dryden-Peterson S . Effectiveness of the standard WHO recommended retreatment regimen (category II) for tuberculosis in Kampala, Uganda: a prospective cohort study. PLoS Med. 2011; 8(3):e1000427. PMC: 3058098. DOI: 10.1371/journal.pmed.1000427. View

Brust J, Lygizos M, Chaiyachati K, Scott M, van der Merwe T, Moll A . Culture conversion among HIV co-infected multidrug-resistant tuberculosis patients in Tugela Ferry, South Africa. PLoS One. 2011; 6(1):e15841. PMC: 3017058. DOI: 10.1371/journal.pone.0015841. View

Heller T, Lessells R, Wallrauch C, Barnighausen T, Cooke G, Mhlongo L . Community-based treatment for multidrug-resistant tuberculosis in rural KwaZulu-Natal, South Africa. Int J Tuberc Lung Dis. 2010; 14(4):420-6. View

Getahun H, Kittikraisak W, Heilig C, Corbett E, Ayles H, Cain K . Development of a standardized screening rule for tuberculosis in people living with HIV in resource-constrained settings: individual participant data meta-analysis of observational studies. PLoS Med. 2011; 8(1):e1000391. PMC: 3022524. DOI: 10.1371/journal.pmed.1000391. View

Cox H, McDermid C, Azevedo V, Muller O, Coetzee D, Simpson J . Epidemic levels of drug resistant tuberculosis (MDR and XDR-TB) in a high HIV prevalence setting in Khayelitsha, South Africa. PLoS One. 2010; 5(11):e13901. PMC: 2981525. DOI: 10.1371/journal.pone.0013901. View

Pablos-Mendez A, Sterling T, Frieden T . The relationship between delayed or incomplete treatment and all-cause mortality in patients with tuberculosis. JAMA. 1996; 276(15):1223-8. DOI: 10.1001/jama.1996.03540150025026. View

10.

Badri M, Cleary S, Maartens G, Pitt J, Bekker L, Orrell C . When to initiate highly active antiretroviral therapy in sub-Saharan Africa? A South African cost-effectiveness study. Antivir Ther. 2006; 11(1):63-72. View

11.

Holmes C, Wood R, Badri M, Zilber S, Wang B, Maartens G . CD4 decline and incidence of opportunistic infections in Cape Town, South Africa: implications for prophylaxis and treatment. J Acquir Immune Defic Syndr. 2006; 42(4):464-9. DOI: 10.1097/01.qai.0000225729.79610.b7. View

12.

Walensky R, Wood R, Ciaranello A, Paltiel A, Lorenzana S, Anglaret X . Scaling up the 2010 World Health Organization HIV Treatment Guidelines in resource-limited settings: a model-based analysis. PLoS Med. 2011; 7(12):e1000382. PMC: 3014084. DOI: 10.1371/journal.pmed.1000382. View

13.

Dimairo M, MacPherson P, Bandason T, Zezai A, Munyati S, Butterworth A . The risk and timing of tuberculosis diagnosed in smear-negative TB suspects: a 12 month cohort study in Harare, Zimbabwe. PLoS One. 2010; 5(7):e11849. PMC: 2911383. DOI: 10.1371/journal.pone.0011849. View

14.

Lawn S, Kranzer K, Edwards D, McNally M, Bekker L, Wood R . Tuberculosis during the first year of antiretroviral therapy in a South African cohort using an intensive pretreatment screening strategy. AIDS. 2010; 24(9):1323-8. PMC: 3772277. DOI: 10.1097/QAD.0b013e3283390dd1. View

15.

Hammond R, Harry T . Efficacy of antiretroviral therapy in Africa: effect on immunological and virological outcome measures -- a meta-analysis. Int J STD AIDS. 2008; 19(5):291-6. DOI: 10.1258/ijsa.2007.007248. View

16.

Kramer F, Modilevsky T, Waliany A, LEEDOM J, Barnes P . Delayed diagnosis of tuberculosis in patients with human immunodeficiency virus infection. Am J Med. 1990; 89(4):451-6. DOI: 10.1016/0002-9343(90)90375-n. View

17.

Golub J, Durovni B, King B, Cavalacante S, Pacheco A, Moulton L . Recurrent tuberculosis in HIV-infected patients in Rio de Janeiro, Brazil. AIDS. 2008; 22(18):2527-33. PMC: 2603140. DOI: 10.1097/QAD.0b013e328311ac4e. View

18.

Sinanovic E, Kumaranayake L . Financing and cost-effectiveness analysis of public-private partnerships: provision of tuberculosis treatment in South Africa. Cost Eff Resour Alloc. 2006; 4:11. PMC: 1534060. DOI: 10.1186/1478-7547-4-11. View

19.

Seung K, Omatayo D, Keshavjee S, Furin J, Farmer P, Satti H . Early outcomes of MDR-TB treatment in a high HIV-prevalence setting in Southern Africa. PLoS One. 2009; 4(9):e7186. PMC: 2746313. DOI: 10.1371/journal.pone.0007186. View

20.

Tostmann A, Kik S, Kalisvaart N, Sebek M, Verver S, Boeree M . Tuberculosis transmission by patients with smear-negative pulmonary tuberculosis in a large cohort in the Netherlands. Clin Infect Dis. 2008; 47(9):1135-42. DOI: 10.1086/591974. View