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.
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About this Master's Thesis
|Committee Chair / Thesis Advisor|
|Enhancing Tuberculosis Case Finding among HIV-Infected Patients in Ethiopia ()||2018-08-28 10:23:41 -0400||