Screening for Tuberculosis Among Adults Newly Diagnosed With HIV in Sub-Saharan Africa

Zwerling, Alice; Sahu, Maitreyi; Ngwira, Lucky G.; Khundi, McEwen; Harawa, Tina; Corbett, Elizabeth L.; Chaisson, Richard E.; Dowdy, David W.

doi:10.1097/qai.0000000000000712

Cited by 19 publications

(21 citation statements)

References 21 publications

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“…Our scenario analysis result also revealed that the cost of both diagnostic algorithms was reduced from the base case estimate by increasing the volume of tests per day. This cost estimate is in line with nding from sub-Sahara Africa [29] and Uganda [30] on the cost and cost-effectiveness of the GeneXpert diagnostic test. The cost of the test method was high in health facilities where their testing volume was low.…”

Section: Discussionsupporting

confidence: 82%

Cost-effectiveness of GeneXpert Compared to Smear Microscopy for Diagnosis of Tuberculosis in Ethiopia

Kaso¹,

Hailu²

2020

Preprint

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Background Early diagnosis is one of the pillars of the TB (TB) control, and there are strong efforts to detect and treat cases in Ethiopia. Smear microscopy testing has been a routine test for the diagnosis of pulmonary TB in resource-constrained settings for a long time. Recently, many countries, including Ethiopia, are scaling up the use of GeneXpert without a precise evaluation of the cost and cost-effectiveness of this technology. Therefore, this study aimed to evaluate the cost-effectiveness of GeneXpert compared to smear microscopy tests for the diagnosis of TB patients in Ethiopia. Methods We develop a decision tree model using TreeAge Pro 2020 software. The model accounts for the prevalence and incidence of TB in the study area. The costs were estimated from the health providers' perspective in one year (in 2017/18). We applied an ingredients-based costing approach to identify, measure, and evaluate the smear microscopy cost and GeneXpert. We employed the 'proportion of cases detected' as an outcome measure of effectiveness. The incremental cost-effectiveness ratio (ICER) was calculated by dividing the changes in cost and change effectiveness. One way and probabilistic sensitivity analysis were done by varying different input parameters. All costs and ICER are reported in 2018 US$. Results The unit cost per test for GeneXpert and smear microscopy testing was US$12.9 and $3.1, respectively. The average cost of testing using GeneXpert was $113.0 and $3.3 for smear microscopy. The cost of the cartridge ($10.7) was the primary (83%) parameter influencing the overall cost of GeneXpert, while it was the cost of reagent and consumables $1.28 (41%) for the smear microscopy. The ICER for GeneXpert strategy was $729.8 per new TB cases detected compared to smear microscopy. The sensitivity analysis indicates that TB prevalence was the most influential parameter on the ICER. Conclusion The present study indicates that testing all individuals with suspected TB using GeneXpert is a very cost-effective strategy compared to smear microscopy, and therefore, it can be part of the routine diagnostic testing strategy in Ethiopia.

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Section: Discussionsupporting

confidence: 82%

Cost-effectiveness of GeneXpert Compared to Smear Microscopy for Diagnosis of Tuberculosis in Ethiopia

Kaso¹,

Hailu²

2020

Preprint

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“…Few studies have estimated the economic effect of implementing Xpert at the point of care 22,25,26 and all have used modelling analyses rather than prospectively obtained trial data to assess cost-effectiveness. 19,20,24,25,35 In most of these modelling studies, Xpert was cost-effective either as a full replacement 19,24,25,35 or in conjunction with other diagnostic tests 20,21 compared with the standard of care (smearmicroscopy). However, some of these studies did not incorporate empirical treatment and thus might have overestimated the effectiveness of Xpert.…”

Section: Discussionmentioning

confidence: 99%

“…However, some of these studies did not incorporate empirical treatment and thus might have overestimated the effectiveness of Xpert. 24,25 Our estimates of cost-effectiveness account for levels of empirical treatment observed in the TB-NEAT trial and require fewer modelling assumptions than these previous analyses but might, there fore, underestimate the effectiveness of point-of-care Xpert by not explicitly accounting for effects on secondary transmission. Conversely, clinical trials can provide direct and real-world data on patient important outcomes related to Xpert implementation.…”

Section: Discussionmentioning

confidence: 99%

“…9,17,18 Thus, crucial questions for policy makers, and of prime importance to resource allocation planning, are (1) how does the cost of Xpert performed by a minimally trained nurse at point of care compare with when performed by a trained technician at a centralised laboratory; and (2) is point-ofcare placement of Xpert cost-effective? Although multiple studies 17,[19][20][21][22][23][24][25][26] have examined the economic implications of using Xpert in endemic settings, few have focused on the costs or cost-effectiveness when deployed at point of care, 22,25,26 and no studies have calculated cost-effectiveness using clinical outcome data obtained from a pragmatic real-world prospective study. [19][20][21][22]24,25 To address these questions, we analysed prospectively collected cost and clinical outcome data from a large randomised control parent trial that recruited patients from primary care clinics in four southern African countries (South Africa, Zambia, Zimbabwe, Tanzania).…”

Section: Introductionmentioning

confidence: 99%

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Point of care Xpert MTB/RIF versus smear microscopy for tuberculosis diagnosis in southern African primary care clinics: a multicentre economic evaluation

Pooran

Theron

Zijenah

et al. 2019

The Lancet Global Health

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Background Rapid on-site diagnosis facilitates tuberculosis control. Performing Xpert MTB/RIF (Xpert) at point of care is feasible, even when performed by minimally trained health-care workers, and when compared with point-of-care smear microscopy, reduces time to diagnosis and pretreatment loss to follow-up. However, whether Xpert is cost-effective at point of care remains unclear. Methods We empirically collected cost (US$, 2014) and clinical outcome data from participants presenting to primary health-care facilities in four African countries (South Africa, Zambia, Zimbabwe, and Tanzania) during the TB-NEAT trial. Costs were determined using an bottom-up ingredients approach. Effectiveness measures from the trial included number of cases diagnosed, initiated on treatment, and completing treatment. The primary outcome was the incremental cost-effectiveness of point-of-care Xpert relative to smear microscopy. The study was performed from the perspective of the health-care provider. Findings Using data from 1502 patients, we calculated that the mean Xpert unit cost was lower when performed at a centralised laboratory (Lab Xpert) rather than at point of care ($23•00 [95% CI 22•12-23•88] vs $28•03 [26•19-29•87]). Per 1000 patients screened, and relative to smear microscopy, point-of-care Xpert cost an additional $35 529 (27 054-40 025) and was associated with an additional 24•3 treatment initiations ([-20•0 to 68•5]; $1464 per treatment), 63•4 same-day treatment initiations ([27•3-99•4]; $511 per same-day treatment), and 29•4 treatment completions ([-6•9 to 65•6]; $1211 per completion). Xpert costs were most sensitive to test volume, whereas incremental outcomes were most sensitive to the number of patients initiating and completing treatment. The probability of point-of-care Xpert being cost-effective was 90% at a willingness to pay of $3820 per treatment completion. Interpretation In southern Africa, although point-of-care Xpert unit cost is higher than Lab Xpert, it is likely to offer good value for money relative to smear microscopy. With the current availability of point-of-care nucleic acid amplification platforms (eg, Xpert Edge), these data inform much needed investment and resource allocation strategies in tuberculosis endemic settings. Funding European Union European and Developing Countries Clinical Trials Partnership and the South African Medical Research Council.

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“…First, we looked at patient volume, which determined the number of tests done per day. Test volume has been found to be a major factor in the cost-effectiveness of POC tests [13, 14]. The baseline scenario used the total number of patients enrolled in both arms as the volume.…”

Section: Methodsmentioning

confidence: 99%

Initiating antiretroviral therapy for HIV at a patient's first clinic visit

Long

Maskew

Brennan

et al. 2017

Aids

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Objective Determine the cost and cost-effectiveness of single-visit (same-day) antiretroviral treatment (ART) initiation compared to standard of care initiation. Design Cost-effectiveness analysis of individually randomized (1:1) pragmatic trial of single-visit initiation, which increased viral suppression at 10 months by 26% (relative risk [95% CI] 1.26 [1.05–1.50]). Setting Primary health clinic in Johannesburg, South Africa. Subjects, participants HIV positive, adult, non-pregnant patients not yet on ART or known to be eligible who presented at the clinic 8 May 2013–29 August 2014. Intervention Same-day ART initiation using point-of-care laboratory instruments and accelerated clinic procedures to allow treatment-eligible patients to receive ARVs at the same visit as testing HIV-positive or having an eligible CD4 count. Comparison was to standard of care ART initiation, which typically required 3–5 additional clinic visits. Main outcome measure(s) Average cost per patient enrolled and per patient achieving the primary outcome of initiated ≤90 days and suppressed ≤10 months, and production cost per patient achieving primary outcome (=all costs/primary outcome patients). Results The average cost per patient enrolled, per patient achieving the primary outcome, and production cost were $319, $487, and $738 in the standard arm and $451, $505, and $707 in the rapid arm. Conclusions Same-day treatment initiation was more effective than standard initiation, more expensive per patient enrolled, and less expensive to produce a patient achieving the primary outcome. Omitting POC tests at initiation and focusing on high volume clinics have the potential to reduce costs substantially and should be evaluated in routine settings.

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Screening for Tuberculosis Among Adults Newly Diagnosed With HIV in Sub-Saharan Africa

Cited by 19 publications

References 21 publications

Cost-effectiveness of GeneXpert Compared to Smear Microscopy for Diagnosis of Tuberculosis in Ethiopia

Cost-effectiveness of GeneXpert Compared to Smear Microscopy for Diagnosis of Tuberculosis in Ethiopia

Point of care Xpert MTB/RIF versus smear microscopy for tuberculosis diagnosis in southern African primary care clinics: a multicentre economic evaluation

Initiating antiretroviral therapy for HIV at a patient's first clinic visit

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