Elsevier

Health Policy

Volume 75, Issue 3, February 2006, Pages 272-279
Health Policy

The cost to health services of human immunodeficiency virus (HIV) co-infection among tuberculosis patients in Sudan

https://doi.org/10.1016/j.healthpol.2005.01.006Get rights and content

Abstract

Objective

To compare the cost of managing HIV-positive and HIV-negative tuberculosis (TB) patients in Sudan.

Methods

A prospective cohort of 1797 consecutive TB patients referred to the chest clinics within the general health services from March 1998 to March 2000 were included in this study. Patients were tested blindly for HIV; 1724 were HIV-negative and 73 were HIV-positive.

Findings

The total cost associated with management of tuberculosis was significantly higher for HIV-positive, as compared with HIV-negative TB patients (US $ 105.08 versus 73.92, p = 0.003). This difference was due mainly to greater costs for hospitalization of those HIV-positive, as compared with those HIV-negative (190.80 versus 141.00, p = 0.001). The differences in cost for diagnostic tests, for drugs, for management of adverse reactions and for intercurrent symptoms were not significant (p > 0.05) between HIV-positive TB patients and HIV-negative TB patients. Side effects of treatment were slightly more common among persons without HIV infection than among HIV-positive patients (14 and 9.6%, respectively). The total cost of management of HIV-positive patients in this series of patients was 6% of all costs for TB case management and the marginal cost attributable to HIV-positivity was 0.9% of the total cost.

Conclusion

The management of the HIV-positive TB case was more costly than that of the HIV-negative case in this stage of the HIV/AIDS epidemic in Sudan.

Introduction

The escalating tuberculosis (TB) case rates in many countries of Sub-Saharan Africa over the past decade are largely attributable to the human immunodeficiency virus (HIV) epidemic [1], [2], [3], [4], [5]. In this region, more than 20% of new tuberculosis cases had been attributed to HIV infection by the mid 1990s [6]. The cost of managing tuberculosis in HIV-positive TB patients, however, has been speculated to be substantially higher than the cost of care for TB patients without HIV infection [7]. This raises the concern that treating TB patients who are also HIV-positive may be less cost-effective [7].

Case management of tuberculosis has been standardized internationally, following a strategy that is termed Directly Observed Treatment, Short-Course (DOTS). This strategy encompasses policies of political commitment, standardized diagnosis and follow up based on bacteriological examination, standardized treatment regimens according to the category of patient, ensured supply of medications and standard recording and reporting of the results of case finding and of treatment.

Although current information suggests that response to chemotherapy is generally good among those who survive [8], [9], [10], [11], adverse and paradoxical reactions to anti-TB drugs appear to be more frequent in HIV-positive TB patients [12], [13], [14]. The proportion of HIV-positive TB patients in Africa who die during treatment has been reported to be 31% and an additional 26% die within a year after finishing TB treatment [15]. The excess deaths in HIV-positive TB patients during and after treatment is partly due to TB itself and partly due to other HIV-related problems [16], [17].

In populations where HIV co-infection is frequent among TB patients, health services struggle to cope with the large and rising numbers of TB patients. Consequences include the over-diagnosis of sputum smear-negative pulmonary TB [18], under-diagnosis of sputum smear-positive pulmonary TB, inadequate supervision of anti-TB chemotherapy [19], low cure rates, high death rates during treatment, high default rates [20], [21], high rates of TB recurrence and an increased emergence of drug resistance [22].

There are few studies reporting the increment in resource consumption resulting from the additional burden of HIV on TB [23]. Previous studies have looked at the cost-effectiveness of different treatment regimens [24], chemoprophylaxis [25], preventive therapy [26] or management of drug reactions in HIV-positive TB patients [24]. One study in New York State reported expenditure for HIV-positive TB patients of more than 2.5 times the total cost for HIV-negative TB cases. While use of all categories of health service was significantly higher among the co-infected group, this difference was largely due to a greater use of inpatient service among the co-infected persons [27].

HIV/AIDS is an emerging disease in Sudan. The prevalence of HIV/AIDS is reported to be 1.6% in northern Sudan and 5–7% in the south [28]. The annual case notification rate of tuberculosis is 180 cases per 100,000 population. The prevalence of HIV among TB patients was 7.7% in 2001.

This study aimed to compare the costs of management of TB between those HIV-positive and those HIV-negative.

Section snippets

Materials and methods

A prospective cohort study was performed including consecutive tuberculosis patients diagnosed from March 1998 to March 2000. Patients were recruited from an area with a population of approximately 850,000 in the states of Bahr El-Jebel, West Bahr El-Gazal, Khartoum, Gezira, Red Sea, Gadarif, North Kordofan and Kassala. These sites were chosen because the tuberculosis services in these states had fully implemented the internationally recommended tuberculosis control measures (the DOTS

Results

A total of 1797 tuberculosis patients (1724 HIV-negative and 73 HIV-positive) were enrolled in the study. The outcome of treatment among individuals in these two groups is compared in Table 1. The proportion of patients who died while on treatment was significantly higher among the HIV-positive (12%) than among HIV-negative TB cases (2%; OR = 7.7, 95%CI, 3.51–16.8). Other treatment outcomes were not significantly different between HIV-positive and HIV-negative TB patients.

The total cost

Discussion

Few studies have compared the cost of diagnosis and treatment of tuberculosis patients according to their HIV status. Previous studies have looked into the cost-effectiveness of treating TB in HIV-positive patients without providing details on resource consumption [7]. A number of studies stated that HIV-associated TB is likely to present diagnostic difficulties such as a lower number of smear-positive samples and fewer cavitations [30].

High mortality among HIV-positive TB patients has been

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