title: Rapid diagnosis of tuberculosis with the Xpert MTB/RIF assay in high burden countries: a cost-effectiveness analysis.
abstract: BACKGROUND
  Xpert MTB/RIF (Xpert) is a promising new rapid diagnostic technology for tuberculosis (TB) that has characteristics that suggest large-scale roll-out. However, because the test is expensive, there are concerns among TB program managers and policy makers regarding its affordability for low- and middle-income settings.
  
  
  RESULTS
  We estimate the impact of the introduction of Xpert on the costs and cost-effectiveness of TB care using decision analytic modelling, comparing the introduction of Xpert to a base case of smear microscopy and clinical diagnosis in India, South Africa, and Uganda. The introduction of Xpert increases TB case finding in all three settings; from 72%-85% to 95%-99% of the cohort of individuals with suspected TB, compared to the base case. Diagnostic costs (including the costs of testing all individuals with suspected TB) also increase: from US$28-US$49 to US$133-US$146 and US$137-US$151 per TB case detected when Xpert is used "in addition to" and "as a replacement of" smear microscopy, respectively. The incremental cost effectiveness ratios (ICERs) for using Xpert "in addition to" smear microscopy, compared to the base case, range from US$41-$110 per disability adjusted life year (DALY) averted. Likewise the ICERS for using Xpert "as a replacement of" smear microscopy range from US$52-$138 per DALY averted. These ICERs are below the World Health Organization (WHO) willingness to pay threshold.
  
  
  CONCLUSIONS
  Our results suggest that Xpert is a cost-effective method of TB diagnosis, compared to a base case of smear microscopy and clinical diagnosis of smear-negative TB in low- and middle-income settings where, with its ability to substantially increase case finding, it has important potential for improving TB diagnosis and control. The extent of cost-effectiveness gain to TB programmes from deploying Xpert is primarily dependent on current TB diagnostic practices. Further work is required during scale-up to validate these findings.
authors.affiliation: Department of Global Health, Amsterdam Institute of Global Health and Development, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Anna
authors.initials: A
authors.lastname: Vassall
authors.forename: Sanne
authors.initials: S
authors.lastname: van Kampen
authors.forename: Hojoon
authors.initials: H
authors.lastname: Sohn
authors.forename: Joy S
authors.initials: JS
authors.lastname: Michael
authors.forename: K R
authors.initials: KR
authors.lastname: John
authors.forename: Saskia
authors.initials: S
authors.lastname: den Boon
authors.forename: J Lucian
authors.initials: JL
authors.lastname: Davis
authors.forename: Andrew
authors.initials: A
authors.lastname: Whitelaw
authors.forename: Mark P
authors.initials: MP
authors.lastname: Nicol
authors.forename: Maria Tarcela
authors.initials: MT
authors.lastname: Gler
authors.forename: Anar
authors.initials: A
authors.lastname: Khaliqov
authors.forename: Carlos
authors.initials: C
authors.lastname: Zamudio
authors.forename: Mark D
authors.initials: MD
authors.lastname: Perkins
authors.forename: Catharina C
authors.initials: CC
authors.lastname: Boehme
authors.forename: Frank
authors.initials: F
authors.lastname: Cobelens
mesh_terms: D019411:Clinical Laboratory Techniques / Q000191:economics* / Q000379:methods; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D006801:Humans; D007194:India; D013019:South Africa; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis* / Q000191:economics; D014454:Uganda
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