World Health Organization (WHO)-recommended strategies for diagnosing tuberculosis would prevent more deaths than the standard approach now used in most parts of sub-Saharan Africa, according to results of a cost-effectiveness analysis of people starting antiretroviral therapy (ART) by the US Centers for Disease Control and Prevention (CDC). One of the WHO strategies cost less than the current approach.
Because many people in sub-Saharan Africa do not get diagnosed with HIV until they have advanced disease, antiretroviral therapy often starts at low CD4 counts, and early on-treatment mortality can be high. In many parts of Africa, TB usually causes these early deaths.
To compare two WHO-recommended TB-diagnostic strategies with the current standard of care in many parts of Africa, CDC researchers planned this cost-effectiveness analysis. Current standard practice involves symptom screening, sputum smear, and chest x-ray. The first WHO strategy also uses sputum mycobacterial culture for TB diagnosis when sputum smear does not yield a diagnosis. The second WHO strategy uses the Xpert Mycobacterium tuberculosis and resistance to rifampicin test.
The CDC team considered medical costs from a health system perspective through the first 6 months of antiretroviral therapy.
Cost per patient was $850 with current practice, which identified 70 TB cases per 1000 patients starting ART. The Xpert diagnostic approach identified 78 TB cases per 1000 patients at a cost of $806 per patient. The culture-based approach identified 86 TB cases per 1000 patients at a cost of $879 per patient. The WHO culture-based approach diagnosed 23% more TB cases than current practice and 10% more TB cases than the Xpert approach.
The WHO culture-based algorithm averted 2 deaths per 100 prevalent TB cases compared with the current approach, whereas the Xpert-based algorithm averted 1 death per 100 prevalent TB cases compared with current practice.
Diagnosis using the Xpert test proved least costly in reducing early mortality among patients starting ART when compared with current practice. Compared with current practice, the culture-based approach cost $29 more per patient starting ART, while the Xpert approach cost $41 less per patient starting ART.
The CDC investigators believe their findings “provide support for ongoing efforts to expand TB diagnostic capacity.”
Source: Taiwo O. Abimbola, Barbara J. Marston, Anand A. Date, John M. Blandford, Nalinee Sangrujee, Stefan Z. Wiktor. Cost-effectiveness of tuberculosis diagnostic strategies to reduce early mortality among persons with advanced HIV infection initiating antiretroviral therapy. JAIDS. 2012; 60: e1-e7.
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