Abstract
BackgroundIndia is considering the scale-up of the Xpert MTB/RIF assay for detection of tuberculosis (TB) and rifampicin resistance. We conducted an economic analysis to estimate the costs of different strategies of Xpert implementation in India.MethodsUsing a decision analytical model, we compared four diagnostic strategies for TB patients: (i) sputum smear microscopy (SSM) only; (ii) Xpert as a replacement for the rapid diagnostic test currently used for SSM-positive patients at risk of drug resistance (i.e. line probe assay (LPA)); (iii) Upfront Xpert testing for patients at risk of drug resistance; and (iv) Xpert as a replacement for SSM for all patients.ResultsThe total costs associated with diagnosis for 100,000 presumptive TB cases were: (i) US$ 619,042 for SSM-only; (ii) US$ 575,377 in the LPA replacement scenario; (iii) US$ 720,523 in the SSM replacement scenario; and (iv) US$ 1,639,643 in the Xpert-for-all scenario. Total cohort costs, including treatment costs, increased by 46% from the SSM-only to the Xpert-for-all strategy, largely due to the costs associated with second-line treatment of a higher number of rifampicin-resistant patients due to increased drug-resistant TB (DR-TB) case detection. The diagnostic costs for an estimated 7.64 million presumptive TB patients would comprise (i) 19%, (ii) 17%, (iii) 22% and (iv) 50% of the annual TB control budget. Mean total costs, expressed per DR-TB case initiated on treatment, were lowest in the Xpert-for-all scenario (US$ 11,099).ConclusionsThe Xpert-for-all strategy would result in the greatest increase of TB and DR-TB case detection, but would also have the highest associated costs. The strategy of using Xpert only for patients at risk for DR-TB would be more affordable, but would miss DR-TB cases and the cost per true DR-TB case detected would be higher compared to the Xpert-for-all strategy. As such expanded Xpert strategy would require significant increased TB control budget to ensure that increased case detection is followed by appropriate care.
Highlights
According to the 2015 World Health Organization (WHO) Global TB Report, India has the highest tuberculosis (TB) burden in the world
India is considering the scale-up of the Xpert MTB/RIF assay for detection of tuberculosis (TB) and rifampicin resistance
Total cohort costs, including treatment costs, increased by 46% from the sputum smear microscopy (SSM)-only to the Xpertfor-all strategy, largely due to the costs associated with second-line treatment of a higher number of rifampicin-resistant patients due to increased drug-resistant TB (DR-TB) case detection
Summary
According to the 2015 World Health Organization (WHO) Global TB Report, India has the highest tuberculosis (TB) burden in the world. A previous economic evaluation found Xpert to be cost-effective as a replacement for SSM in India [5], with the benefit of increased case detection. A multisite, phased implementation study conducted to collect evidence for the scale-up of the Xpert assay for TB and MDR-TB diagnosis in India found that the proportion of bacteriologically-confirmed TB cases identified, out of the presumptive TB cases tested, increased by 33% (95% CI 16–52%), while the detection of all patients diagnosed with bacteriologically-confirmed or clinically-diagnosed pulmonary TB, combined, increased by 11% (95% CI 3–21%) compared to SSM [6,7]. India is considering the scale-up of the Xpert MTB/RIF assay for detection of tuberculosis (TB) and rifampicin resistance.
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