Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
The Aurum Institute, Parktown, Johannesburg, South Africa.
Lancet Glob Health. 2023 Aug;11(8):e1205-e1216. doi: 10.1016/S2214-109X(23)00251-6.
Guidelines and implementation of tuberculosis preventive treatment (TPT) vary by age and HIV status. Specifically, TPT is strongly recommended for people living with HIV/AIDS (PLWHA) and household contacts younger than 5 years but only conditionally recommended for older contacts. Cost remains a major barrier to implementation. The aim of this study was to evaluate the cost-effectiveness of TPT for household contacts and PLWHA.
We developed a state-transition model to simulate short-course TPT for household contacts and PLWHA in 29 high-incidence countries based on data from previous studies and public databases. Our primary outcome was the incremental cost-effectiveness ratio, expressed as incremental discounted costs (2020 US$, including contact investigation costs) per incremental discounted disability-adjusted life year (DALY) averted, compared with a scenario without any TPT or contact investigation. We propagated uncertainty in all model parameters using probabilistic sensitivity analysis and also evaluated the sensitivity of results to the screening algorithm used to rule out active disease, the choice of TPT regimen, the modelling time horizon, assumptions about TPT coverage, antiretroviral therapy discontinuation, and secondary transmission.
Between 2023 and 2035, scaling up TPT prevented 0·9 (95% uncertainty interval 0·4-1·6) people from developing tuberculosis and 0·13 (0·05-0·27) tuberculosis deaths per 100 PLWHA, at an incremental cost of $15 (9-21) per PLWHA. For household contacts, TPT (with contact investigation) averted 1·1 (0·5-2·0) cases and 0·7 (0·4-1·0) deaths per 100 contacts, at a cost of $21 (17-25) per contact. Cost-effectiveness was most favourable for household contacts younger than 5 years ($22 per DALY averted) and contacts aged 5-14 years ($104 per DALY averted) but also fell within conservative cost-effectiveness thresholds in many countries for PLWHA ($722 per DALY averted) and adult contacts ($309 per DALY averted). Costs per DALY averted tended to be lower when compared with a scenario with contact investigation but no TPT. The cost-effectiveness of TPT was not substantially altered in sensitivity analyses, except that TPT was more favourable in analysis that considered a longer time horizon or included secondary transmission benefits.
In many high-incidence countries, short-course TPT is likely to be cost-effective for PLWHA and household contacts of all ages, regardless of whether contact investigation is already in place. Failing to implement tuberculosis contact investigation and TPT will incur a large burden of avertable illness and mortality in the next decade.
Unitaid.
结核病预防治疗（TPT）的指南和实施因年龄和 HIV 状况而异。具体而言，TPT 强烈推荐用于 HIV/AIDS 患者（PLWHA）和年龄小于 5 岁的家庭接触者，但对年龄较大的接触者仅给予条件性推荐。成本仍然是实施的主要障碍。本研究旨在评估 TPT 对家庭接触者和 PLWHA 的成本效益。
我们根据先前研究和公共数据库中的数据，为 29 个高发病率国家的家庭接触者和 PLWHA 开发了状态转换模型，以模拟短期 TPT。我们的主要结果是增量成本效益比，以每避免一个增量折扣残疾调整生命年（DALY）的增量折扣成本（2020 年美元，包括接触者调查成本）表示，与没有任何 TPT 或接触者调查的情况下相比。我们使用概率敏感性分析传播模型中所有参数的不确定性，还评估了结果对用于排除活动性疾病的筛查算法、TPT 方案的选择、建模时间范围、TPT 覆盖范围、抗逆转录病毒治疗停药以及二次传播的假设的敏感性。
到 2023 年至 2035 年，扩大 TPT 预防每 100 名 PLWHA 中有 0.9 人（95%置信区间 0.4-1.6）发生结核病和 0.13 人（0.05-0.27）死于结核病，每例 PLWHA 的增量成本为 15 美元（9-21 美元）。对于家庭接触者，TPT（伴有接触者调查）可避免每 100 名接触者中有 1.1 例（0.5-2.0）和 0.7 例（0.4-1.0）发生结核病，每例接触者的成本为 21 美元（17-25 美元）。对于年龄小于 5 岁的家庭接触者（每避免一个 DALY 的成本为 22 美元）和 5-14 岁的接触者（每避免一个 DALY 的成本为 104 美元），成本效益最为有利，但在许多国家，PLWHA（每避免一个 DALY 的成本为 722 美元）和成年接触者（每避免一个 DALY 的成本为 309 美元）的成本效益也在保守的成本效益阈值内。与进行接触者调查但不进行 TPT 的情况相比，每避免一个 DALY 的成本往往更低。TPT 的成本效益在敏感性分析中并没有发生实质性改变，除了在考虑较长时间范围或包括二次传播收益的分析中，TPT 更有利。
在许多高发病率国家，短期 TPT 可能对所有年龄的 PLWHA 和家庭接触者具有成本效益，无论是否已经进行了接触者调查。未能实施结核病接触者调查和 TPT 将在未来十年内导致大量可避免的疾病和死亡。
Unitaid。
