Cost-effectiveness of a Novel Lipoarabinomannan Test for Tuberculosis in Patients With Human Immunodeficiency Virus.

Krishna P Reddy,Rochelle P Walensky,Katherine L Fielding,Mark P Nicol,Graeme Meintjes,Fatma M Shebl,Robin Wood,Tobias Broger,Ankur Gupta-Wright,Andrew D Kerkhoff,Pamela P Pei,Claudia M Denkinger,Kenneth A Freedberg,C Robert Horsburgh,Nicole C Mccann

doi:10.1093/cid/ciaa1698

Abstract

BackgroundA novel urine lipoarabinomannan assay (FujiLAM) has higher sensitivity and higher cost than the first-generation AlereLAM assay. We evaluated the cost-effectiveness of FujiLAM for tuberculosis testing among hospitalized people with human immunodeficiency virus (HIV), irrespective of symptoms.MethodsWe used a microsimulation model to project clinical and economic outcomes of 3 testing strategies: (1) sputum Xpert MTB/RIF (Xpert), (2) sputum Xpert plus urine AlereLAM (Xpert+AlereLAM), (3) sputum Xpert plus urine FujiLAM (Xpert+FujiLAM). The modeled cohort matched that of a 2-country clinical trial. We applied diagnostic yields from a retrospective study (yields for Xpert/Xpert+AlereLAM/Xpert+FujiLAM among those with CD4 <200 cells/µL: 33%/62%/70%; among those with CD4 ≥200 cells/µL: 33%/35%/47%). Costs of Xpert/AlereLAM/FujiLAM were US$15/3/6 (South Africa) and $25/3/6 (Malawi). Xpert+FujiLAM was considered cost-effective if its incremental cost-effectiveness ratio (US$/year-of-life saved) was <$940 (South Africa) and <$750 (Malawi). We varied key parameters in sensitivity analysis and performed a budget impact analysis of implementing FujiLAM countrywide.ResultsCompared with Xpert+AlereLAM, Xpert+FujiLAM increased life expectancy by 0.2 years for those tested in South Africa and Malawi. Xpert+FujiLAM was cost-effective in both countries. Xpert+FujiLAM for all patients remained cost-effective compared with sequential testing and CD4-stratified testing strategies. FujiLAM use added 3.5% (South Africa) and 4.7% (Malawi) to 5-year healthcare costs of tested patients, primarily reflecting ongoing HIV treatment costs among survivors.ConclusionsFujiLAM with Xpert for tuberculosis testing in hospitalized people with HIV is likely to increase life expectancy and be cost-effective at the currently anticipated price in South Africa and Malawi. Additional studies should evaluate FujiLAM in clinical practice settings.

Highlights

Tuberculosis (TB) is the leading cause of death of people with HIV (PWH) worldwide [1]
We used the results to generate a cost-effectiveness a acceptability curve. d M Alternative Testing Strategies te We evaluated alternative TB testing strategies, including: solo strategies (Xpert, AlereLAM, or ep Fujifilm SILVAMP TB-LAM assay (FujiLAM) alone); sequential strategies; and CD4-stratified strategies
In the base u case analysis in South Africa and Malawi, Xpert+AlereLAM and Xpert+FujiLAM both reduced two-year n mortality and increased life expectancy compared with Xpert (Table 2)

Summary

Methods

We used a microsimulation model to project clinical and economic outcomes of three t testing strategies: 1) sputum Xpert MTB/RIF (Xpert); 2) sputum Xpert plus urine AlereLAM rip (Xpert+AlereLAM); 3) sputum Xpert plus urine FujiLAM (Xpert+FujiLAM). Costs of Xpert/AlereLAM/FujiLAM were USD15/3/6 n (South Africa) and USD25/3/6 (Malawi). Xpert+FujiLAM was considered cost-effective if its a incremental cost-effectiveness ratio (USD/year-of-life saved) was

Conclusions

INTRODUCTION

Findings

METHODS