title: Cost-effectiveness of HIV testing referral strategies among tuberculosis patients in India.
abstract: 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.
authors.affiliation: Division of General Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA. luhler@partners.org
authors.forename: Lauren M
authors.initials: LM
authors.lastname: Uhler
authors.forename: Nagalingeswaran
authors.initials: N
authors.lastname: Kumarasamy
authors.forename: Kenneth H
authors.initials: KH
authors.lastname: Mayer
authors.forename: Anjali
authors.initials: A
authors.lastname: Saxena
authors.forename: Elena
authors.initials: E
authors.lastname: Losina
authors.forename: Malaisamy
authors.initials: M
authors.lastname: Muniyandi
authors.forename: Adam W
authors.initials: AW
authors.lastname: Stoler
authors.forename: Zhigang
authors.initials: Z
authors.lastname: Lu
authors.forename: Rochelle P
authors.initials: RP
authors.lastname: Walensky
authors.forename: Timothy P
authors.initials: TP
authors.lastname: Flanigan
authors.forename: Melissa A
authors.initials: MA
authors.lastname: Bender
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Freedberg
authors.forename: Soumya
authors.initials: S
authors.lastname: Swaminathan
mesh_terms: 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
chemical_list: D019380:Anti-HIV Agents; D000995:Antitubercular Agents