RESUMEN
Testing for latent tuberculosis infection (LTBI) in HIV-infected persons in low tuberculosis (TB) incidence areas is often recommended. Using contemporary, clinical data, we report the yield and cost-effectiveness of testing all HIV attendees, two current UK strategies and no LTBI testing. Economic modelling was performed utilising 10-year follow up data from a large HIV clinical cohort. Outcomes were numbers of cases of active TB and incremental cost per quality-adjusted life year (QALY) gained. Between 2000 and 2010, 256 people were treated for TB/HIV co-infection. 72 (28%) occurred ≥3â months after HIV diagnosis and may have been prevented by LTBI testing. Between 2000 and 2005, the incremental cost per QALY gained for the British HIV Association (BHIVA) and UK National Institute of Care Excellence (NICE) strategies, and testing all clinic attendees was 6270, 6998 and 33,473, respectively. These rose to 9332, 32,564 and 74,067, respectively, between 2005 and 2010. Probabilistic sensitivity analysis suggested that at a threshold of 24,000 per additional QALY, the most cost-effective strategies would be NICE or testing all in 2000-2005 and BHIVA during 2005-2010. Both UK testing regimens missed cases but are cost-effective compared with no testing. Using recent data, they all became more expensive, suggesting that alternative or more targeted TB testing strategies must be considered.
Asunto(s)
Control de Enfermedades Transmisibles/economía , Infecciones por VIH/diagnóstico , Infecciones por VIH/economía , Tuberculosis Latente/diagnóstico , Tuberculosis Latente/economía , Algoritmos , Estudios de Cohortes , Coinfección , Análisis Costo-Beneficio , Infecciones por VIH/complicaciones , Humanos , Incidencia , Tuberculosis Latente/complicaciones , Londres , Tamizaje Masivo/economía , Modelos Económicos , Prevalencia , Probabilidad , Años de Vida Ajustados por Calidad de VidaRESUMEN
PURPOSE OF REVIEW: Using the evidence published over the last 2 years, this review discusses the epidemiology, diagnosis, treatment and prevention of HIV-related pulmonary infections other than mycobacterial disease. RECENT FINDINGS: Longstanding, vertically acquired and apparently stable HIV infection is associated with significant and symptomatic small airways disease in African adolescents. The use of population-based pneumococcal vaccination in children is changing the severity and serotypes associated with HIV-related pneumococcal disease. Data on the use of blood 1,3,ß-D-glucan show it has promise as a rule-out test for Pneumocystis pneumonia (PCP). SUMMARY: With widespread antiretroviral medication usage, the pattern of HIV-associated pulmonary disease is changing. Whereas opportunistic infections such as PCP still occur in people not using antiretroviral therapy (ART), HIV-related infections are similar to those present in the general population. Chronic lung disease is more prevalent, leading to its own infectious complications. The use of specific immunizations against infections is important, though their precise benefit with concomitant widespread ART and population-based vaccination programmes in the non-HIV community is undetermined.
Asunto(s)
Infecciones Oportunistas Relacionadas con el SIDA , Antirretrovirales/uso terapéutico , Infecciones por VIH/complicaciones , Infecciones Neumocócicas , Infecciones del Sistema Respiratorio , Infecciones Oportunistas Relacionadas con el SIDA/diagnóstico , Infecciones Oportunistas Relacionadas con el SIDA/tratamiento farmacológico , Infecciones Oportunistas Relacionadas con el SIDA/epidemiología , Humanos , Enfermedades Pulmonares/diagnóstico , Enfermedades Pulmonares/tratamiento farmacológico , Enfermedades Pulmonares/epidemiología , Infecciones Neumocócicas/diagnóstico , Infecciones Neumocócicas/epidemiología , Infecciones Neumocócicas/prevención & control , Infecciones del Sistema Respiratorio/diagnóstico , Infecciones del Sistema Respiratorio/tratamiento farmacológico , Infecciones del Sistema Respiratorio/epidemiología , beta-Glucanos/sangreAsunto(s)
Ensayos de Liberación de Interferón gamma , Interferón gamma/análisis , Tuberculosis Latente , Tamizaje Masivo , Mycobacterium tuberculosis , Adulto , Femenino , Humanos , Ensayos de Liberación de Interferón gamma/métodos , Ensayos de Liberación de Interferón gamma/normas , Tuberculosis Latente/diagnóstico , Tuberculosis Latente/inmunología , Recuento de Linfocitos/métodos , Masculino , Tamizaje Masivo/métodos , Tamizaje Masivo/normas , Mycobacterium tuberculosis/inmunología , Mycobacterium tuberculosis/aislamiento & purificación , Valor Predictivo de las Pruebas , Reproducibilidad de los Resultados , Estudios Retrospectivos , Prueba de Tuberculina , Reino UnidoAsunto(s)
Infecciones por VIH/complicaciones , Infecciones por VIH/microbiología , Trastornos Respiratorios/complicaciones , Trastornos Respiratorios/microbiología , Adulto , Antirretrovirales/uso terapéutico , Linfocitos T CD4-Positivos/citología , Linfocitos T CD4-Positivos/microbiología , Estudios de Cohortes , Femenino , Seropositividad para VIH , Humanos , Masculino , Persona de Mediana Edad , Infecciones por Pneumocystis/microbiología , Neumonía/microbiología , Neumonía/prevención & control , Reacción en Cadena de la Polimerasa , Sistema Respiratorio/microbiología , Espirometría , Encuestas y Cuestionarios , Reino UnidoRESUMEN
OBJECTIVES: Guidelines recommend routine testing for latent TB infection (LTBI) in people living with HIV. However there are few cost-effectiveness studies to justify this in contemporary high resource, low TB/HIV incidence settings. We sought to assess the uptake, yield and cost-effectiveness of testing for latent and active TB. METHODS: Adults attending an ambulatory HIV clinic in London, UK were prospectively recruited by stratified selection and tested for TB infection using symptom questionnaires, chest radiograph (CXR), tuberculin skin test (TST), T-Spot.TB and induced sputum. From this, 30 testing strategies were compared in a cost-effectiveness model including probabilistic sensitivity analysis using Monte Carlo simulation. RESULTS: 219 subjects were assessed; 95% were using antiretroviral therapy (ART). Smear negative, culture positive TB was present in 0.9% asymptomatic subjects, LTBI in 9%. Only strategies testing those from subSaharan Africa with a TST or interferon gamma release assay (IGRA) with or without CXR, or testing those from countries with a TB incidence of >40/100,000 with TST alone were cost-effective using a £30,000/QALY threshold. CONCLUSIONS: Cost-effectiveness analysis in an adult HIV cohort with high ART usage suggests there is limited benefit beyond routine testing for latent TB in people from high and possibly medium TB incidence settings.
Asunto(s)
Infecciones por VIH , Tuberculosis Latente , Adulto , Análisis Costo-Beneficio , Infecciones por VIH/complicaciones , Humanos , Ensayos de Liberación de Interferón gamma , Tuberculosis Latente/diagnóstico , Tuberculosis Latente/epidemiología , Londres/epidemiología , Prueba de TuberculinaAsunto(s)
Amicacina/sangre , Amicacina/uso terapéutico , Antituberculosos/sangre , Antituberculosos/uso terapéutico , Monitoreo de Drogas/métodos , Tuberculosis Resistente a Múltiples Medicamentos/tratamiento farmacológico , Adulto , Amicacina/efectos adversos , Antituberculosos/efectos adversos , Audiología , Femenino , Pérdida Auditiva/inducido químicamente , Humanos , Riñón/efectos de los fármacos , Masculino , Estudios RetrospectivosAsunto(s)
COVID-19 , Hospitales , Humanos , Pruebas en el Punto de Atención , Estudios Prospectivos , SARS-CoV-2RESUMEN
Tuberculosis (TB) is a leading cause of global morbidity, yet there is limited information regarding its impact on quality of life and health status. This is surprising given the implications for patient care, the evaluation of novel treatments or preventative strategies, and also health policy. Furthermore, there is no validated TB-specific instrument that measures health status, and thus a wide and non-standardized range of assessment tools have been employed. The studies to date have chosen a number of different comparator populations, and in many TB endemic areas there is a lack of normative data regarding the health status of the general population. Systematic evaluations of quality of life are urgently needed in specific groups, including those with extrapulmonary TB, drug-resistant disease, HIV co-infection, and latent TB infection, and in children with TB; the assessment of post-treatment disability is also required.
Asunto(s)
Estado de Salud , Calidad de Vida , Tuberculosis/diagnóstico , Adulto , Niño , Coinfección , Femenino , Infecciones por VIH/complicaciones , Humanos , Morbilidad , Tuberculosis/complicaciones , Tuberculosis/terapiaRESUMEN
BACKGROUND AND AIMS: Testing for LTBI is recommended prior to anti-TNFα agents. This includes an assessment of TB risk factors, chest radiograph, and interferon-gamma release assay alone or with concurrent Tuberculin skin testing. Here we review our experience and cost-effectiveness of using T-SPOT.TB IGRA to detect mycobacterial infection in patients with IBD suitable for anti-TNFα therapy. METHODS: This was a single-centre, retrospective review and economic evaluation (compared to British Thoracic Society guidance) of 125 adult IBD patients (90 anti-TNFα naïve, 35 established on anti-TNFα) tested for LTBI using T-SPOT.TB IGRA. RESULTS: All subjects had normal chest radiographs and no clinical evidence for TB. 109 (87%) were BCG vaccinated. 27 (22%) of all patients tested were not using immunomodulation at the time of testing. 66 (53%) were taking thiopurines, 22 (18%)corticosteroids, and 35 (28%) anti-TNFα agents. One hundred twenty two (98%) had a negative IGRA result, two (2%) had positive results, and one (1%) had an indeterminate IGRA. A strategy using IGRA to guide TB preventative treatment produced cost savings of £10.79 per person compared to the BTS guidance. Eighty eight percent of the anti-TNFα naïve group have subsequently received treatment with either infliximab or adalimumab (median follow-up of 24 months, IQR 18-30) with no cases of TB disease occurring. CONCLUSIONS: The use of a simple screening protocol for LTBI incorporating T-SPOT.TB IGRA in place of TST in a largely BCG vaccinated population, many using immunomodulatory agents, appears to work well and is a cost-effective strategy in our IBD service.