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

被引：32

作者：

Reddy, Krishna P. ^{[1
,2
,5
]}

Gupta-Wright, Ankur ^{[6
,7
]}

Fielding, Katherine L. ^{[6
,8
]}

Costantini, Sydney ^{[1
]}

Zheng, Amy ^{[1
,5
]}

Corbett, Elizabeth L. ^{[6
,7
]}

Yu, Liyang ^{[1
]}

Van Oosterhout, Joep J. ^{[9
,10
]}

Resch, Stephen C. ^{[11
]}

Wilson, Douglas P. ^{[12
]}

Horsburgh, C. Robert, Jr. ^{[13
,14
]}

Wood, Robin ^{[15
]}

Alufandika-Moyo, Melanie ^{[9
]}

Peters, Jurgens A. ^{[6
]}

Berg, Kenneth A. Freed ^{[1
,3
,4
,5
,11
,13
]}

Lawn, Stephen D. ^{[6
,15
]}

Walensky, Rochelle P. ^{[1
,3
,4
,5
]}

机构：

[1] Massachusetts Gen Hosp, Med Practice Evaluat Ctr, 16th Floor,100 Cambridge St, Boston, MA 02114 USA

[2] Massachusetts Gen Hosp, Div Pulm & Crit Care Med, Boston, MA 02114 USA

[3] Massachusetts Gen Hosp, Div Gen Internal Med, Boston, MA 02114 USA

[4] Massachusetts Gen Hosp, Div Infect Dis, Boston, MA 02114 USA

[5] Harvard Med Sch, Boston, MA USA

[6] London Sch Hyg & Trop Med, TB Ctr, London, England

[7] Malawi Liverpool Wellcome Trust Clin Res Program, Blantyre, Malawi

[8] Univ Witwatersrand, Johannesburg, South Africa

[9] Dignitas Int, Zomba, Malawi

[10] Univ Malawi, Dept Med, Coll Med, Blantyre, Malawi

[11] Harvard TH Chan Sch Publ Hlth, Dept Hlth Policy & Management, Boston, MA USA

[12] Univ KwaZulu Natal, Edendale Hosp, Dept Internal Med, Pietermaritzburg, South Africa

[13] Boston Univ, Sch Med, Dept Epidemiol, Boston, MA 02118 USA

[14] Boston Univ, Sch Med, Dept Med, Sect Infect Dis, Boston, MA 02118 USA

[15] Univ Cape Town, Desmond Tutu HIV Fdn, Cape Town, South Africa

来源：

LANCET GLOBAL HEALTH | 2019年 / 7卷 / 02期

基金：

英国惠康基金; 美国国家卫生研究院; 英国医学研究理事会;

关键词：

TB;

D O I：

10.1016/S2214-109X(18)30436-4

中图分类号：

R1 [预防医学、卫生学];

学科分类号：

1004 ; 120402 ;

摘要：

Background 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. Methods 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. Findings 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. Interpretation Urine-based tuberculosis screening of all hospitalised patients with HIV could increase life expectancy and be cost-effective in resource-limited settings. Urine TB-LAM is especially attractive because of high incremental diagnostic yield and low additional cost compared with sputum Xpert, making a compelling case for expanding its use to all hospitalised patients with HIV in areas with high HIV burden and endemic tuberculosis. Funding UK Medical Research Council, UK Department for International Development, Wellcome Trust, US National Institutes of Health, Royal College of Physicians, Massachusetts General Hospital. Copyright (c) 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.

引用

页码：E200 / E208

页数：9