Multicomponent strategy with decentralised molecular testing for tuberculosis in Uganda: a cost and...

Area of Science:

• Global Health
• Infectious Disease Diagnostics
• Health Economics

Background:

• Decentralised molecular testing for tuberculosis (TB) offers a potential solution to reduce missed diagnoses and follow-up losses in high-burden regions.
• The Xpert Performance Evaluation for Linkage to Tuberculosis Care (XPEL-TB) study aimed to assess the cost and cost-effectiveness of a decentralised TB testing strategy in Uganda.

Purpose of the Study:

• To evaluate the cost and cost-effectiveness of the XPEL-TB strategy, which incorporates decentralised molecular testing for tuberculosis.
• To compare the costs and outcomes of decentralised versus centralised tuberculosis testing approaches in Ugandan community health centers.

Main Methods:

• A costing and cost-effectiveness analysis was conducted, nested within a pragmatic cluster-randomised trial comparing onsite (decentralised) and hub-and-spoke (centralised) Xpert MTB/RIF Ultra testing.
• Empirical data on costs were collected from a health system perspective, including workflow redesign and performance feedback for the decentralised strategy.
• Time-and-motion studies were used to estimate activity-based service costs, with cost-effectiveness measured as incremental cost per TB diagnosis and per 14-day treatment initiation.

Main Results:

• Per-test costs for decentralised and centralised Xpert testing were similar ($20.46 vs. $18.20).
• The per-patient cost was higher for decentralised testing ($20.28 vs. $9.59) due to increased appropriate testing rates.
• The XPEL-TB strategy incurred an estimated incremental cost of $1332 per TB diagnosis and $687 per patient initiating treatment within 14 days; cost-effectiveness decreased at sites with <150-250 annual tests.

Conclusions:

• The XPEL-TB strategy increased Xpert testing rates for tuberculosis with similar per-test costs and modest incremental costs per diagnosis and treatment initiation.
• Decentralised Xpert testing, when supported by appropriate implementation, should be scaled up in clinics with sufficient testing volume for single-module devices.
• This approach holds promise for improving tuberculosis case detection and linkage to care in resource-limited settings.