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The Cost-effectiveness of a Point-of-Care Paper Transaminase Test for Monitoring Treatment of HIV/TB Co-Infected Persons.

ABSTRACT: Background:Persons with HIV and tuberculosis (TB) co-infection require transaminase monitoring while on hepatotoxic medications. A novel paper-based, point-of-care transaminase test is in development at an anticipated cost of $1 per test. Methods:To project long-term clinical outcomes and estimate the cost-effectiveness of using a paper-based fingerstick test to monitor for drug-induced liver injury (DILI), as compared with automated testing and with no laboratory monitoring. The design was a decision analytic model, including deterministic and probabilistic sensitivity analyses. Data sources were observational cohorts and a validation study of the paper-based test. The target population was HIV/TB co-infected persons in South Africa on antiretroviral therapy who were initiating TB therapy. Interventions: (1) clinical (no laboratory) monitoring; (2) monitoring using the paper-based test with a ?120 IU/mL threshold for positivity; (3) monitoring using the paper-based test with a ?200 IU/mL threshold for positivity; (4) monitoring using the paper-based test using 1 of 3 categories: <120 IU/mL, 120 to 200 IU/mL, and >200 IU/mL ("bin placement"); (5) monitoring using automated ALT testing using the same 3 categories ("automated testing"). The outcome measures were discounted quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs). Results:The ICER of automated testing was $5180/QALY. Use of the paper-based test with the bin placement strategy was cost-effective compared with clinical monitoring alone. Conclusion:At its current performance, monthly DILI monitoring by bin placement using the paper-based test was cost-effective, compared with clinical monitoring, in HIV/TB co-infected persons in South Africa.

SUBMITTER: Rajasingham R

PROVIDER: S-EPMC6197379 | biostudies-literature | 2017

REPOSITORIES: biostudies-literature

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The Cost-effectiveness of a Point-of-Care Paper Transaminase Test for Monitoring Treatment of HIV/TB Co-Infected Persons.

Rajasingham Radha R Pollock Nira R NR Linas Benjamin P BP

Open forum infectious diseases 20170908 4

<h4>Background</h4>Persons with HIV and tuberculosis (TB) co-infection require transaminase monitoring while on hepatotoxic medications. A novel paper-based, point-of-care transaminase test is in development at an anticipated cost of $1 per test.<h4>Methods</h4>To project long-term clinical outcomes and estimate the cost-effectiveness of using a paper-based fingerstick test to monitor for drug-induced liver injury (DILI), as compared with automated testing and with no laboratory monitoring. The ...[more]

PMID: 30364559

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Project description:BackgroundThe cost-effectiveness of routine viral load (VL) monitoring of HIV-infected patients on antiretroviral therapy (ART) depends on various factors that differ between settings and across time. Low-cost point-of-care (POC) tests for VL are in development and may make routine VL monitoring affordable in resource-limited settings. We developed a software tool to study the cost-effectiveness of switching to second-line ART with different monitoring strategies, and focused on POC-VL monitoring.MethodsWe used a mathematical model to simulate cohorts of patients from start of ART until death. We modeled 13 strategies (no 2nd-line, clinical, CD4 (with or without targeted VL), POC-VL, and laboratory-based VL monitoring, with different frequencies). We included a scenario with identical failure rates across strategies, and one in which routine VL monitoring reduces the risk of failure. We compared lifetime costs and averted disability-adjusted life-years (DALYs). We calculated incremental cost-effectiveness ratios (ICER). We developed an Excel tool to update the results of the model for varying unit costs and cohort characteristics, and conducted several sensitivity analyses varying the input costs.ResultsIntroducing 2nd-line ART had an ICER of US$1651-1766/DALY averted. Compared with clinical monitoring, the ICER of CD4 monitoring was US$1896-US$5488/DALY averted and VL monitoring US$951-US$5813/DALY averted. We found no difference between POC- and laboratory-based VL monitoring, except for the highest measurement frequency (every 6 months), where laboratory-based testing was more effective. Targeted VL monitoring was on the cost-effectiveness frontier only if the difference between 1st- and 2nd-line costs remained large, and if we assumed that routine VL monitoring does not prevent failure.ConclusionCompared with the less expensive strategies, the cost-effectiveness of routine VL monitoring essentially depends on the cost of 2nd-line ART. Our Excel tool is useful for determining optimal monitoring strategies for specific settings, with specific sex-and age-distributions and unit costs.

Project description:In locations with a high rate of tuberculosis (TB) and HIV infection, there are a number of strategies to prevent negative outcomes such as opportunistic infections, hospitalizations and death, and this article investigates risk factors for the occurrence of hospitalization and death in cases of TB/HIV co-infection in the south of Brazil. The data are taken from a population-based retrospective cohort study on cases of TB/HIV co-infection from 2009 to 2013 in Porto Alegre, Brazil. Sociodemographic, epidemiological and clinical variables were analyzed. Relative risk (RR) estimates for hospitalization and death were determined by regression models. There were 2,419 co-infection cases, of which 1,527 (63.1%) corresponded to hospitalizations, and 662 (27.4%) to death. The occurrence of hospitalization was associated with ? 7 years of schooling (RR = 3.47, 95%CI: 1.97-6.29), 8-11 years of schooling (RR = 2.56, 95%CI: 1.44-4.69), place of origin-district health authorities Northwest/Humaitá/Navegantes/Ilhas (RR = 2.01, 95%CI: 1.44-2.82), type of entry into the surveillance system as in cases of reentry after withdrawal (RR = 1,35, 95%CI: 1.07-1.70), closure in surveillance as in withdrawal of treatment (RR = 1.47, 95%CI: 1.18-1.83) and multidrug-resistant tuberculosis (RR = 3.94, 95%CI: 1.97-8.81). The occurrence of death was associated with age (RR = 1.07, 95%CI: 1,01-1,14), ? 7 years of schooling (RR = 3.94, 95%CI: 2.26-7.09), 8-11 years of schooling (RR = 2.84, 95%CI: 1.61-5.16), place of origin-district health authorities Baltazar (RR = 2.05, 95%CI: 1.48-2.86), type of entry in the surveillance system as cases of re-entry after withdrawal (RR = 1.53, 95%CI: 1.22-1.91), relapse (RR = 1.33, 95%CI: 1.03-1.73). The occurrence of hospitalizations and deaths is high among co-infected patients. Our estimation approach is important in order to identify, from the surveillance data, the risk factors for hospitalization and death in co-infected patients, so that they may receive more attention from the Brazilian national healthcare system.

Dataset Information

The Cost-effectiveness of a Point-of-Care Paper Transaminase Test for Monitoring Treatment of HIV/TB Co-Infected Persons.

Publications

The Cost-effectiveness of a Point-of-Care Paper Transaminase Test for Monitoring Treatment of HIV/TB Co-Infected Persons.

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