Abstract
Tuberculosis is the leading cause of death among people living with HIV (PLH). Preventive tuberculosis therapy reduces mortality in PLH, especially in those with a positive tuberculin skin test (TST). New, more specific technologies for detecting latent tuberculosis infection (LTBI) are now commercially available. We sought to analyse the cost-effectiveness of four different strategies for the diagnosis of LTBI in PLH in Brazil, from the Brazilian public health care system perspective. We developed a Markov state-transition model comparing four strategies for the diagnosis of LTBI over 20 years. The strategies consisted of TST with the currently used protein purified derivative (PPD RT 23), two novel skin tests using recombinant allergens (Diaskintest [Generium Pharmaceutical, Moscow, Russia] and EC [Zhifei Longcom Biologic Pharmacy Co., Anhui, China]), and the QuantiFERON-TB-Gold-Plus (Qiagen, Hilden, Germany). The main outcome was cost (in 2020 US dollars) per quality-adjusted life years (QALY). For the base case scenario, the Diaskintest was dominant over all other examined strategies. The cost saving estimate per QALY was US $1375. In sensitivity analyses, the Diaskintest and other newer tests remained cost-saving compared to TST. For PLH, TST could be replaced by more specific tests in Brazil, considering the current national recommendations.
Highlights
Tuberculosis is the leading cause of death from an infectious disease globally, including in people living with HIV1
Recognizing the high risk for tuberculosis among people living with HIV, the World Health Organization (WHO), since 20188, recommends treatment of latent tuberculosis infection for people living with HIV in tuberculosis high-burden countries regardless of testing results
More recent isolated studies in people living with HIV suggest that those with negative test results might be at greater risk of developing tuberculosis, and might benefit from tuberculosis preventive therapy[4,12,13], testing is still recommended for this high risk population in Brazil and other countries
Summary
Tuberculosis is the leading cause of death from an infectious disease globally, including in people living with HIV1. The current standard for latent tuberculosis infection diagnosis in the public health system is TST with PPD RT 23 This policy is based on systematic reviews and large s tudies[3,5,10,11] that have repeatedly shown that benefit from treatment is higher in those with a positive tuberculin skin test (TST) compared with those with a negative TST result. More recent isolated studies in people living with HIV suggest that those with negative test results might be at greater risk of developing tuberculosis, and might benefit from tuberculosis preventive therapy[4,12,13], testing is still recommended for this high risk population in Brazil and other countries.
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