Cost-effectiveness of urine-based tuberculosis screening in hospitalised patients with HIV in Africa: a microsimulation modelling study

• Published in: The Lancet global health 2019-02, Vol.7 (2), p.e200-e208
• Main Authors: Reddy, Krishna P, Gupta-Wright, Ankur, Fielding, Katherine L, Costantini, Sydney, Zheng, Amy, Corbett, Elizabeth L, Yu, Liyang, van Oosterhout, Joep J, Resch, Stephen C, Wilson, Douglas P, Horsburgh, C Robert, Wood, Robin, Alufandika-Moyo, Melanie, Peters, Jurgens A, Freedberg, Kenneth A, Lawn, Stephen D, Walensky, Rochelle P
• Format: Article
• Language: English
• Subjects: Adult; Anti-HIV Agents - therapeutic use; Computer Simulation; Cost-Benefit Analysis; Female; HIV Infections - drug therapy; HIV Infections - epidemiology; Hospitalization; Humans; Lipopolysaccharides - urine; Malawi; Male; Mass Screening - economics; Mass Screening - methods; Middle Aged; Mortality; Nucleic Acid Amplification Techniques; South Africa; Sputum - microbiology; Tuberculosis - diagnosis; Tuberculosis - epidemiology; Tuberculosis - urine; Tuberculosis, Pulmonary - diagnosis; Tuberculosis, Pulmonary - epidemiology; Tuberculosis, Pulmonary - urine
• ISSN: 2214-109X; 2214-109X
• DOI: 10.1016/S2214-109X(18)30436-4

Testing urine improves the number of tuberculosis diagnoses made among patients in hospital with HIV. In conjunction with the two-country randomised Rapid Urine-based Screening for Tuberculosis to Reduce AIDS-related Mortality in Hospitalised Patients in Africa (STAMP) trial, we used a microsimulation model to estimate the effects on clinical outcomes and the cost-effectiveness of adding urine-based tuberculosis screening to sputum screening for hospitalised patients with HIV. We compared two tuberculosis screening strategies used irrespective of symptoms among hospitalised patients with HIV in Malawi and South Africa: a GeneXpert assay (Cepheid, Sunnyvale, CA, USA) for Mycobacterium tuberculosis and rifampicin resistance (Xpert) in sputum samples (standard of care) versus sputum Xpert combined with a lateral flow assay for M tuberculosis lipoarabinomannan in urine (Determine TB-LAM Ag test, Abbott, Waltham, MA, USA [formerly Alere]; TB-LAM) and concentrated urine Xpert (intervention). A cohort of simulated patients was modelled using selected characteristics of participants, tuberculosis diagnostic yields, and use of hospital resources in the STAMP trial. We calibrated 2-month model outputs to the STAMP trial results and projected clinical and economic outcomes at 2 years, 5 years, and over a lifetime. We judged the intervention to be cost-effective if the incremental cost-effectiveness ratio (ICER) was less than US$750/year of life saved (YLS) in Malawi and $940/YLS in South Africa. A modified intervention of adding only TB-LAM to the standard of care was also evaluated. We did a budget impact analysis of countrywide implementation of the intervention. The intervention increased life expectancy by 0·5–1·2 years and was cost-effective, with an ICER of $450/YLS in Malawi and $840/YLS in South Africa. The ICERs decreased over time. At lifetime horizon, the intervention remained cost-effective under nearly all modelled assumptions. The modified intervention was at least as cost-effective as the intervention (ICERs $420/YLS in Malawi and $810/YLS in South Africa). Over 5 years, the intervention would save around 51 000 years of life in Malawi and around 171 000 years of life in South Africa. Health-care expenditure for screened individuals was estimated to increase by $37 million (10·8%) and $261 million (2·8%), respectively. Urine-based tuberculosis screening of all hospitalised patients with HIV could increase life expectancy and be cost-effective in resour