Re-evaluating the health impact and cost-effectiveness of tuberculosis preventive treatment for modern HIV cohorts on antiretroviral therapy: a modelling analysis using data from Tanzania

Abstract

Background: Isoniazid preventive therapy (IPT) can prevent tuberculosis among people receiving antiretroviral therapy (ART). HIV programmes are now initiating patients on ART with higher average CD4 cell counts and lower tuberculosis risks under test-and-treat guidelines. We aimed to investigate how this change has affected the health impact and cost-effectiveness of IPT.

Methods: We constructed a tuberculosis-HIV microsimulation model parameterised using data from a large HIV treatment programme in Dar es Salaam, Tanzania. We simulated long-term health and cost outcomes for the 211 748 individuals initiating ART between Jan 1, 2014, and Dec 31, 2020, under three scenarios: no IPT access; observed levels of IPT access (75%) and completion (71%); and full (100%) IPT access and completion. We stratified results by ART initiation year and starting CD4 cell count.

Findings: Observed levels of IPT access were estimated to have averted 12 800 (95% uncertainty interval 7300 to 21 600) disability-adjusted life-years (DALYs) and saved US$23 000 (-2 268 000 to 1 388 000). Full IPT access would have averted 24 500 (15 100 to 38 300) DALYs and cost $825 000 (-1 594 000 to 4 751 000), equivalent to $23·4 per DALY averted. Lifetime health benefits of IPT were estimated to be greater for more recent ART cohorts, while lifetime costs were stable. In subgroup analyses, a higher CD4 cell count at ART initiation was associated with greater health gains from IPT (15 900 [10 300 to 22 500] DALYs averted by full IPT per 100 000 patients for CD4 count >500 cells per μL at ART initiation, versus 7400 [4500 to 11 600] for CD4 count <100 cells per μL) and lower incremental lifetime costs.

Interpretation: IPT remains highly cost-effective or cost-saving for recent ART cohorts. The health impact and cost-effectiveness of IPT are estimated to improve as patients initiate ART earlier in the course of infection.

Funding: US National Institutes of Health.

Figure 1

Model schematic Mortality is omitted in the diagram. ART=antiretroviral therapy. IPT=isoniazid preventive therapy.

Figure 2

Comparison of the projected epidemiological effect of IPT implementation scenarios in relation to no IPT All panels plot cumulative outcomes, so in panel D, no all-cause death was averted in the long term, but the timing of death was delayed by IPT. Solid lines represent mean estimates; shaded areas represent 95% uncertainty intervals. ART=antiretroviral therapy. IPT=isoniazid preventive therapy.

Figure 3

Projected undiscounted incremental health outcomes (A) and incremental costs (B) for full IPT compared with no IPT per 100 000 individuals by year of ART initiation Dashed lines represent the time trends of each outcome. ART=antiretroviral therapy. DALY=disability-adjusted life-year. IPT=isoniazid preventive therapy.