Cost-effectiveness of HIV testing referral strategies among tuberculosis patients in India.
BACKGROUND
Indian guidelines recommend routine referral for HIV testing of all tuberculosis (TB) patients in the nine states with the highest HIV prevalence, and selective referral for testing elsewhere. We assessed the clinical impact and cost-effectiveness of alternative HIV testing referral strategies among TB patients in India.


RESULTS
We utilized a computer model of HIV and TB disease to project outcomes for patients with active TB in India. We compared life expectancy, cost, and cost-effectiveness for three HIV testing referral strategies: 1) selective referral for HIV testing of those with increased HIV risk, 2) routine referral of patients in the nine highest HIV prevalence states with selective referral elsewhere (current standard), and 3) routine referral of all patients for HIV testing. TB-related data were from the World Health Organization. HIV prevalence among TB patients was 9.0% in the highest prevalence states, 2.9% in the other states, and 4.9% overall. The selective referral strategy, beginning from age 33.50 years, had a projected discounted life expectancy of 16.88 years and a mean lifetime HIV/TB treatment cost of US$100. The current standard increased mean life expectancy to 16.90 years with additional per-person cost of US$10; the incremental cost-effectiveness ratio was US$650/year of life saved (YLS) compared to selective referral. Routine referral of all patients for HIV testing increased life expectancy to 16.91 years, with an incremental cost-effectiveness ratio of US$730/YLS compared to the current standard. For HIV-infected patients cured of TB, receiving antiretroviral therapy increased survival from 4.71 to 13.87 years. Results were most sensitive to the HIV prevalence and the cost of second-line antiretroviral therapy.


CONCLUSIONS
Referral of all patients with active TB in India for HIV testing will be both effective and cost-effective. While effective implementation of this strategy would require investment, routine, voluntary HIV testing of TB patients in India should be recommended.
Uhler
Lauren M
LM
Division of General Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA. luhler@partners.org
Kumarasamy
Nagalingeswaran
N
Mayer
Kenneth H
KH
Saxena
Anjali
A
Losina
Elena
E
Muniyandi
Malaisamy
M
Stoler
Adam W
AW
Lu
Zhigang
Z
Walensky
Rochelle P
RP
Flanigan
Timothy P
TP
Bender
Melissa A
MA
Freedberg
Kenneth A
KA
Swaminathan
Soumya
S
D000328:Adult; D019380:Anti-HIV Agents / Q000191:economics / Q000627:therapeutic use; D000995:Antitubercular Agents / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D005260:Female; D015658:HIV Infections / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy / Q000191:economics*; D017048:Health Care Costs; D006801:Humans; D007194:India; D008297:Male; D008875:Middle Aged; D014376:Tuberculosis / Q000150:complications* / Q000188:drug therapy
D019380:Anti-HIV Agents; D000995:Antitubercular Agents