title: Cost-effectiveness of the Three I's for HIV/TB and ART to prevent TB among people living with HIV.
abstract: OBJECTIVE
  To evaluate the cost-effectiveness of the Three I's for HIV/TB (human immunodeficiency virus/tuberculosis): antiretroviral therapy (ART), intensified TB case finding (ICF), isoniazid preventive treatment (IPT), and TB infection control (IC).
  
  
  METHODS
  Using a 3-year decision-analytic model, we estimated the cost-effectiveness of a base scenario (55% ART coverage at CD4 count ⩿350 cells/mm(3)) and 19 strategies that included one or more of the following: 1) 90% ART coverage, 2) IC and 3) ICF using four-symptom screening and 6- or 36-month IPT. The TB diagnostic algorithm included 1) sputum smear microscopy with chest X-ray, and 2) Xpert® MTB/RIF.
  
  
  RESULTS
  In resource-constrained settings with a high burden of HIV and TB, the most cost-effective strategies under both diagnostic algorithms included 1) 55% ART coverage and IC, 2) 55% ART coverage, IC and 36-month IPT, and 3) expanded ART at 90% coverage with IC and 36-month IPT. The latter averted more TB cases than other scenarios with increased ART coverage, IC, 6-month IPT and/or IPT for tuberculin skin test positive individuals. The cost-effectiveness results did not change significantly under the sensitivity analyses.
  
  
  CONCLUSIONS
  Expanded ART to 90% coverage, IC and a 36-month IPT strategy averted most TB cases and is among the cost-effective strategies.
authors.affiliation: Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland.
authors.forename: S
authors.initials: S
authors.lastname: Gupta
authors.affiliation: US Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
authors.forename: T
authors.initials: T
authors.lastname: Abimbola
authors.affiliation: US Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
authors.forename: A
authors.initials: A
authors.lastname: Date
authors.affiliation: South African Centre for Epidemiological Modelling and Analysis, University of Stellenbosch, Cape Town, South Africa.
authors.forename: A B
authors.initials: AB
authors.lastname: Suthar
authors.affiliation: Independent Consultant, Huntingdon, UK.
authors.forename: R
authors.initials: R
authors.lastname: Bennett
authors.affiliation: US Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
authors.forename: N
authors.initials: N
authors.lastname: Sangrujee
authors.affiliation: Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland.
authors.forename: R
authors.initials: R
authors.lastname: Granich
mesh_terms: D000465:Algorithms; D000995:Antitubercular Agents / Q000627:therapeutic use; D018791:CD4 Lymphocyte Count; D003362:Cost-Benefit Analysis; D024881:Drug Resistance, Bacterial; D015658:HIV Infections / Q000188:drug therapy* / Q000382:microbiology; D006801:Humans; D007538:Isoniazid / Q000627:therapeutic use; D018803:Models, Economic; D009169:Mycobacterium tuberculosis / Q000187:drug effects; D011859:Radiography; D012293:Rifampin / Q000627:therapeutic use; D012680:Sensitivity and Specificity; D014376:Tuberculosis / Q000175:diagnosis / Q000191:economics / Q000517:prevention & control*
chemical_list: D000995:Antitubercular Agents; D007538:Isoniazid; D012293:Rifampin