Table 4.
TB Screening Algorithm Costs in PLHIV
| First author, Year | Country | Screening algorithm | Source of Unit Costs | Type of unit costs | Average cost1,2 of the screening algorithm per person | Average cost1,2 of diagnosis per person | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Screening | Diagnostic Tests | Staff | Equipment | Consumables | Overhead | Transport | |||||
| PLHIV—using molecular rapid diagnostic tests (i.e., Xpert MTB/RIF) for screening (N = 7)a | |||||||||||
| Bassett 2010 | South Africa | WHO 4SS, sputum | Xpert MTB/RIF | Reported by study | ✓ | ✓ | ✓ | $52 per person screened | $324 per additional TB case diagnosed | ||
| Andrews 2012 | South Africa | Two Xperts for everyone | Xpert MTB/RIF | Reported by study | ✓ | ✓ | ✓ | $37 per person screened | $4,096 per YLS | ||
| Abimbola 2012 | South Africa | WHO 4SS | Xpert MTB/RIF | Reported by study | ✓ | ✓ | $26 per person screened | $48,542 per death averted | |||
| Zwerling 2015 | Malawi | WHO 4SS, Xpert | Xpert MTB/RIF | Reported by study | ✓ | ✓ | ✓ | ✓ |
50 tests/year: $116 per person screened |
$1,980 per DALY averted (UR: $1544-$3552) |
|
|
1000 tests/year: $18 per person screened |
$398 per DALY averted (UR: $80–1682) |
||||||||||
| Adelman 2017 | Ethiopia | WHO 4SS, Xpert | Xpert MTB/RIF | Reported by study | ✓ | ✓ | ✓ | NR | $5 per death averted | ||
| Orlando 2018 | Mozambique | Screening with Xpert | Xpert MTB/RIF | Reported by study | ✓ | ✓ | $10 per person screened | $37 per DALY averted | |||
| CD4 count < 200 then LF-LAM |
Xpert; LF-LAM |
Reported by study | ✓ | ✓ | $3 per person screened | $51 per DALY averted | |||||
| Reddy 2019 | South Africa | Sputum/urine Xpert, TB-LAM | Xpert MTB/RIF | Calculated from study data | ✓ | ✓ |
$31 per person screened* (Range: $11-$73) |
$802 per YLS | |||
| Malawi |
$72 per person screened* (Range: $18-$105) |
$596 per YLS | |||||||||
| PLHIV—using CXR for screening (N = 6)b | |||||||||||
| Shah 2008 | Vietnam | Monthly home visits to PLHIV with a CXR voucher | NR | Calculated from study data | ✓ | ✓ | ✓ | ✓ | $7-$11 per person screened | $115 per TB case diagnosed | |
| Shah 2009 | Ethiopia | CXR for all PLHIV at entry to the clinic | SSM on all positive CXR | Calculated from study data | ✓ | ✓ | $6 per person screened | $106 per TB case diagnosed | |||
| Bassett 2010 | South Africa | WHO 4SS, CXR | Xpert MTB/RIF | Reported by study | ✓ | ✓ | ✓ | $52 per person screened | $324 per additional TB case diagnosed | ||
| Mahesawaran 2012 | Sub-Saharan Africa (SSA) | Symptom screen for any symptom | SSM then CXR if smear negative | Reported by study | ✓ | ✓ |
$11 per person screened (Range: $10-$29) |
$6,245 per QALY (UR: $6,245-$19,581) | |||
| Murray 2016 | Uganda | Screening for cough, CXR triage test | Xpert MTB/RIF | Reported by study | ✓ | ✓ | $22 per person screened |
$536 per YLG (UR: $176-$2,514) |
|||
| Bogdanova 2019 | Russian Federation | Mass CXR screening programs in PLHIV | NR | Calculated from study data | ✓ | ✓ | ✓ | ✓ | $4-$7 per person screened | $570 per TB case diagnosed | |
| PLHIV—using CRP for screening (N = 2)c | |||||||||||
| Murray 2016 | Uganda | Screening for cough, CRP triage test | Xpert MTB/RIF | Reported by study | ✓ | ✓ | $21 per person screened |
$517 per YLG (UR: $194-$1,535) |
|||
| Yoon 2019 | Uganda | POC CRP; TB-LAM | Xpert MTB/RIF | Calculated from study data | ✓ | ✓ | $13-$34 per person screened | $69-$92 per additional TB case diagnosed | |||
| Outpatient PLHIV—SSM only for screening (N = 1)d | |||||||||||
| Kranzer 2012 | South Africa | WHO 4SS; SSM at a mobile HIV testing clinic | SSM | Reported by study | ✓ | ✓ | ✓ | NR | $762 per TB case diagnosed | ||
aIn Sub-Saharan Africa, the average cost per person screened using rapid molecular diagnostic tests ranged from $3 to $116. Screening programs were found to be cost-effective in 6/7 (86%) of studies, with the following ICERs reported: $324 per additional TB case diagnosed; $37-$79 per DALY averted; $596–$4096 per YLS; and $517 per YLG. However, one study in Malawi found that screening with Xpert was not cost-effective at low test volumes, with an ICER of $1,980 per DALY averted. Cost-effectiveness depended on the volume of tests conducted annually and prevalence of TB
bData was available for among outpatient PLHIV using CXR as a screening tool from six studies of good quality overall. Three studies, from South Africa, Russia and Vietnam, included health system costs as well as unit tests costs, and reported an average cost per person screened using CXR ranging from $4 to $29. Three studies in Sub-Saharan Africa reported the average cost per person screened using CXR ranged from $6 to $52. The average cost per TB case diagnosed ranged from $106-$570. Screening with CXR was shown to be cost-effective among PLHIV with ICERs of $6245 per QALY and $536 per YLS
cLimited data was available for screening among outpatient PLHIV using CRPs from two studies both of which were of good quality. The average cost for test costs alone of outpatient PLHIV in Uganda screened using CRP with Xpert, TB-LAM and culture for diagnosis ranged from $13 to $34 per person screened and was shown to be cost-effective with an ICER of $517 per YLS or $69–$92 per additional TB case diagnosed in Uganda
dLimited data was available from one study conducted at an HIV testing clinic in South Africa for screening using SSM alone. This study reported an average cost of $762 per TB case diagnosed at a mobile testing clinic
CRP C-reactive protein, CXR chest x-ray, mWRDs molecular WHO-approved rapid diagnostics, NR not reported, PLHIV people living with HIV, POC point-of-care, WHO 4SS, four symptom screen, Xpert GeneXpert, YLG year of life gained, YLS year of life saved
1Costs in 2019 USD unless stated otherwise
2All costs reported in 2019 USD unless stated otherwise