Enhancing Tuberculosis Case Finding among HIV-Infected Patients in Ethiopia Open Access

Abstract

Introduction: Tuberculosis (TB) is the leading cause of death among people living with HIV (PLHIV) worldwide. For PLHIV, the World Health Organization (WHO) recommends both active TB case finding in high-burden settings and a rapid molecular diagnostic test for TB case detection. There are limited data on the utility of combining these two recommendations. We evaluated the clinical utility and cost-effectiveness of combining a WHO-recommended symptom screen and rapid molecular diagnostic test (Xpert MTB/RIF) to enhance TB case finding among PLHIV.

Methods: This study was implemented at a large HIV Clinic in Addis Ababa, Ethiopia in two phases: (1) A cross-sectional implementation science study in which PLHIV were screened for TB with a symptom-based algorithm (cough, fever, night sweats, weight loss). Those with a positive symptom screen (PSS) (≥1 symptom) underwent diagnostic testing with sputum smear microscopy, AFB culture, and Xpert. (2) A model-based cost-effectiveness analysis comparing 15,000 PLHIV progressing through either a WHO-recommended TB diagnostic algorithm or current practice for TB diagnosis. Clinical and cost inputs were determined. Our primary outcome was US$ per disability-adjusted life year (DALY) averted.

Results: Among 828 PLHIV, 321 (39%) had a PSS. In multivariate analysis, an unscheduled clinic visit (aOR=3.8, 95% CI 2.7-5.3), CD4 count <100 (aOR=2.6, 95% CI 1.2-5.6) and prior history of TB (aOR=1.6, 95% CI 1.1-2.3) were predictors of a PSS. Among those with a PSS, 6% had active pulmonary TB. Smear microscopy sensitivity was 30% compared to culture and Xpert. Combining a symptom screen with Xpert for TB diagnosis at Ethiopian HIV clinics had an incremental cost of US$36/DALY averted. In a model of 15,000 patients, this algorithm would avert 2059 false positive and 54 false negative cases, but at higher cost (US$251,000) than current practice (US$206,000).

Conclusions: A high proportion of PLHIV had a PSS. Xpert enhanced TB case finding among PLHIV compared to smear microscopy, and a WHO-recommended algorithm for TB diagnosis among PLHIV would be highly cost-effective. However, its incremental cost (US$45,000 per 15,000 patients) may limit its feasibility. Additional resources will be needed to implement the WHO recommended TB screening algorithm in combination with Xpert.

Table of Contents

INTRODUCTION. 1

BACKGROUND. 3

METHODS. 6

RESULTS. 13

DISCUSSION. 19

REFERENCES. 26

TABLES. 34

Table 1. 34

Table 2. 36

Table 3. 37

Table 4. 39

Table 5. 41

Table 6. 42

Table 7. 44

FIGURES. 45

Figure 1. 45

Figure 2. 47

About this Master's Thesis

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School	Laney Graduate School
Department	Clinical Research Curriculum Program
Degree	MS
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Medicine and Surgery
Keyword	Developing countries Tuberculosis Cost-effectiveness Operational research
Committee Chair / Thesis Advisor	McFarland, Deborah A, Emory University Blumberg, Henry Michael, Emory University Kempker, Russell Ryan, Emory University
Committee Members	McGowan Jr., John E, Emory University Klein, Mitchel, Emory University

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