Early Tuberculosis Screening in People Living with HIV: A Cost-Effectiveness Analysis Alongside a Pragmatic Clinical Trial in Brazil

Abstract

Background: Although TB can be treated effectively, its early diagnosis in People Living with HIV (PLHIV) is still a challenge. We assessed the cost-effectiveness of a symptom-based screening for TB diagnosis in PLHIV compared with the hospital routine in Brazil. Methods: The economic evaluation was conducted alongside a randomized pragmatic clinical trial. We compared costs, Disability Adjusted Life Years (DALYs) and extra number of years lived between participants who were screened for TB at every appointment versus the hospital routine where TB screening is not mandatory. The cost-effectiveness was measured as the incremental cost-effectiveness ratio (ICER) per DALYs averted or life years saved. Sub-group analysis of the intervention group was conducted based on individuals who screened positive and negative at the first appointment. Lifelong costs and extra number of years lived were estimated through an individual-based simulation model. Findings: Between March 2014 and April 2017, 724 participants were included in the trial. The intervention did not avert DALYs (-0·1 [95% CI: -1·4, 1·3]), although it was cost saving by US$ 929 (95% CI: 342, 1 572) per patient. The intervention group with a negative screening at the first appointment had the highest cost-savings (US$ 1 324 [95% CI: 711, 1 977]) and more DALYs averted (1·1 [95% CI: -0·3, 2·6]) when compared with the control group. In the long term, screening for TB in HIV patients who reaced the health services at the earlier stages of the disease resulted in 3.8 life years gained (95% CI: 0·3, 7·4) and cost saving by $3 936 (95% CI: 2 317, $5 505) per patient. Interpretation: TB screening at every appointment was cost saving and more beneficial in HIV patients with less severe HIV disease both in the short term and for their full lifetime. Trial Registration: The clinical trial was registered at the Brazilian Registries for Clinical Trials (ReBec-22t943, http://www.ensaiosclinicos.gov.br/rg/RBR-22t943/). Funding Statement: CNPq, 470554/2013-4 and FACEPE, APQ-0184-4.06/13. We also thank the Institute for Health Technology Assessment (IATS) for the support with travel expenses and scholarships for the field work team. Declaration of Interests: The authors declare that they have no competing interests. Ethics Approval Statement: The study was approved by the Fundacao Oswaldo Cruz (No 279.324) and the London School of Hygiene and Tropical Medicine (Ref: 7371) ethics committees. All patients signed a consent form.