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July, 2013 Kuala Lumpur, Malaysia

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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July, 2013 Kuala Lumpur, Malaysia

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  1. 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

  2. The Three I’s for HIV/TB activities

  3. 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)

  4. 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)

  5. Policy alternatives TB diagnostic algorithms: Sputum smear microscopy and chest radiography Xpert MTB/RIF

  6. 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

  7. 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

  8. Results TB diagnostic algorithm: Sputum smear and chest radiography --- non-dominated

  9. Results TB diagnostic algorithm: Xpert MTB/RIF --- non-dominated

  10. 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

  11. 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

  12. 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

  13. Thank you… Reuben Granich (UNAIDS) TaiwoAbimbola (CDC) AnandDate (CDC) Rod Bennett (Hexor) Amitabh Suthar (consultant) NalineeSangrujee (CDC)

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