Long, Lawrence C.Bezuidenhout, Charl2025-05-122025-05-122025https://hdl.handle.net/2144/503952025BACKGROUND: Early detection and treatment of tuberculosis (TB) are critical for reducing TB-related mortality and disease transmission. Delayed and missed diagnosis are a persistent barrier to TB control, partly driven by limitations associated with sputum collection and an unmet need for decentralized testing. The TB Home Study aimed to optimize the delivery of in-home point-of-care (POC) TB testing of household contacts of people with TB using a portable molecular testing platform, as part of household contact investigations. The acceptability, feasibility, and cost-effectiveness of in-home POC TB testing strategies are hitherto undescribed and may offer a plausible solution to persistent barriers hampering the effectiveness of community-based active case finding. METHODS: Cost and intermediate outcome data collected during phase 1 of the TB Home Study were used to conduct a cost- and cost-effectiveness analysis of different testing strategies implementable during household contact investigations. The cost from the provider’s perspective of program implementation over a 2-year period was estimated and compared across different strategies. Decision analytic modeling was used to estimate and compare the incremental cost-effectiveness ratio, measured as the incremental cost per additional household contact with TB disease detected and linked to a clinic for treatment, between competing testing strategies. As part of a subsequent analysis, data collected during phase 2 of the TB Home Study were used to assess the acceptability of targeted universal TB testing (TUTT) from the client’s perspective. In parallel, a feasibility assessment was conducted to assess and compare different sampling and testing methods employed in the delivery of in-home TUTT. RESULTS: The total combined cost of conducting household contact investigations and TB testing to 300 households over a 2-year period ranged from $84,962 (standard of care, SOC) to $93,969 (POC Combined Sputum and Individual Tongue Swab Testing). The average cost-per-test was highest for testing strategies employing sputum-based testing ($20.08). Individual tongue swab- ($19.29) and pooled tongue swab tests ($15.73) showed a 4% and 22% lower cost-per-test, respectively. The cost per household contact with TB detected and linked to a clinic for treatment was the least expensive ($131.38) but also the least effective under the SOC. Household contact investigations employing any of the in-home POC testing strategies consistently showed higher effectiveness compared to SOC albeit at a higher cost per household contact. Analysis from the decision analytic modeling showed POC Sputum Testing and POC Combined Sputum and Individual Tongue Swab Testing to be the most cost-effective strategies with incremental cost-effectiveness ratios of $543.74 and $547.29, respectively, both below the $2,760 willingness to pay threshold. Of 313 eligible household contacts in phase 2, 267/313 (85.3%) consented to in-home POC TUTT. The mean in-home POC TUTT acceptability score (5=highly acceptable) was 4.5/5 (SD= 0.2). In-home POC TUTT using either sputum or tongue swab specimens was highly feasible and acceptable. Tongue swab specimens greatly increase the proportion of household contacts tested compared to sputum. CONCLUSION: An in-home POC molecular testing strategy utilizing combined testing of tongue swabs and sputum specimens would increase program cost by 10.6%, compared to SOC, over a 2-year period. The increased sample yield from tongue swabs combined with immediate result notification following in-home POC testing would increase the number of new TB cases detected and linked to care by more than 800%. In-home POC TUTT using a combination of sputum and tongue swab specimens is acceptable and feasible and could mitigate shortcomings to existing active case finding strategies.en-USPublic healthActive case findingCost-effectivenessTuberculosisThesis/Dissertation2025-05-090009-0009-7545-6188