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Cost-effectiveness of ART and the Three I’s for HIV/TB to prevent tuberculosis among people living with HIV. Somya Gupta, Taiwo Abimbola , Anand Date, Amitabh B. Suthar , Rod Bennett , Nalinee Sangrujee , Reuben Granich. July, 2013 Kuala Lumpur, Malaysia.
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Cost-effectiveness of ART and the Three I’s for HIV/TB to prevent tuberculosis among people living with HIV Somya Gupta, TaiwoAbimbola, AnandDate, Amitabh B. Suthar, Rod Bennett, NalineeSangrujee, Reuben Granich July, 2013 Kuala Lumpur, Malaysia
Person living with HIV (including pregnant women and those on ART) Screen for TB using: Current cough; Fever; Weight loss; Night Sweat No Yes • Assess IPT contraindications Investigate for TB & other disease No Yes Other diagnosis Not TB TB Appropriate treatment & consider IPT Follow up; consider IPT Treat for TB Give IPT Defer IPT WHO 2011 IPT/ICF recommendations * Duration of IPT: 6 months (conditional recommendation: 36 months)
Objective of analysis Evaluate the health outcomes, costs, and cost-effectiveness of policy scenarios with different TB prevention interventions • Expanded ART coverage of 90% • (at CD4 count ≤ 350 cells/mm3) • ICF using four-symptom screening • IPT for all/TST+ for 6 or 36 months • Outcomes: • 1. TB cases • 2. Total costs • 3. Cost-effectiveness • TB infection control in • health-care facilities • Base scenario: • 55% ART coverage • Standard TB screening (cough)
Policy alternatives TB diagnostic algorithms: Sputum smear microscopy and chest radiography Xpert MTB/RIF
Methodology • Developed decision-analytic model to evaluate policies • Setting : generalized HIV epidemic with active TB prevalence of 5% • Population : cohort of 10,000 people living with HIV presenting to health facilities • Timeframe and analytic horizon : 36 months • Model parameters taken from published studies • Costs (2010 USD) : healthcare utilization costs from South Africa
Cost-effectiveness analysis • All policy alternatives were evaluated for TB cases and total cost over 3 years • ICER = Difference in total costs Difference in TB cases • Strategies excluded: • Strongly dominated (higher cost and less TB cases prevented) • Weakly dominated (higher ICER than the next alternative) • ICER calculated for the cost-effective strategies
Results TB diagnostic algorithm: Sputum smear and chest radiography --- non-dominated
Results TB diagnostic algorithm: Xpert MTB/RIF --- non-dominated
ICER for cost-effective strategies TB diagnostic algorithm: Sputum smear and chest radiography TB diagnostic algorithm: Xpert MTB/RIF Incremental cost-effectiveness ratio (ICER) is expressed in US $ per TB case averted
Limitations • Impact of ART at CD4 count ≤ 500 cells/mm3 and immediate ART on TB incidence not considered • Cost of developing and maintaining diagnostic capacity excluded • Efficacy and cost of TB infection control package are an estimate • Estimated the costs and health benefits of one-time TB screening per person over 3 years
Conclusion and recommendation • Combination strategy with expanded ART coverage, infection control and 36-months IPT averted the most TB cases • Combination TB prevention strategy was more cost-effective when compared with other strategies • Accelerated scale-up of ART and the Three I’s for HIV/TBwill reduce TB burden among people living with HIV
Thank you… Reuben Granich (UNAIDS) TaiwoAbimbola (CDC) AnandDate (CDC) Rod Bennett (Hexor) Amitabh Suthar (consultant) NalineeSangrujee (CDC)