WHO TB diagnostics may prevent more deaths than standard of care
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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