Xpert MTB/RIF

Potential for engaging private sector in TB control

Evan Lee, MD

Lille conference

October 2011

Source of Healthcare by Income, India Treatment prior 2 weeks for diarrhea/fever/cough

Source: www.ps4h.org/globalhealthdata.html

Use of anti-TB drugs confirms demand for TB

diagnostics in private sector

Country Coverage by first line, private sector drugs*

India 117%

Indonesia 116%

Philippines 86%

Pakistan 65%

China 23%

Thailand 17%

Russia 13%

Vietnam 7%

Bangladesh 7%

South Africa 3%

Weighted average 66%

10 country total, as % of global incidence

39%

Source: Wells WA, Ge CF, Patel N, Oh T, Gardiner E,

Kimerling ME. Size and Usage Patterns of Private TB

Drug Markets in the High Burden Countries. PLoS

ONE. 2011 May 4;6(5):e18964.

However, private sector susceptible to overuse of

inappropriate diagnostic assays

9% 9% 3%

8%

71%

Proportion of testing Total ~4000/mo.

Microscopy

Culture

IGRA

Molecular

Serology

Assay Price (USD)

Microscopy 4.5 - 7

Culture 16

IGRA 55

Molecular 45-90

Serology 12 Source: private communication, India

Diagnostic services through the private sector

• Diverse set of providers – Medical colleges

– For-profit private hospitals and clinics

– Not-for-profit hospitals and clinics

– Workplaces

– For-profit stand alone private labs ranging from large established, internationally accredited networks to benchtops

• Link to healthcare providers variable (integrated, referral…)

Capacities of private sector

Xpert: advantages and attraction for laboratory

networks in private sector

- Attractive tool – state of the art - Easy to implement, follow market

demand (placement) – choice - Capacity for reporting via

Internet, cellphone - Flexibility for use with other

assays, e.g. MRSA, C. Diff, EBV, HPV, others inc. potential for HIV viral load (random access)

- Rapid TAT strengthens link to referring provider

Uptake of Xpert

0

5

10

15

20

25

30

35

0

20'000

40'000

60'000

80'000

100'000

120'000

140'000

160'000

2010 Q2 2010 Q3 2010 Q4 2011 Q1 2011 Q2 2011 Q3

# Tests # Countries

0

500

1000

1500

2000

2500

3000

3500

Specimen packing & transport Cost to perform test

Collection/Referral Profit

Reagent

Potential options for Xpert in private sector have

to link to existing cost structures

Cost of Cartridge

Cost

of t

est (

Rs)

• Different models possible Fully subsidized instrument

and reagents Access to negotiated

prices for instrument and reagents

No subsidy at all Private lab refers all

specimens to public lab

• Role of subsidy to “crowd out” TB serology

Laboratory Survey Central Kampala

Private lab survey, Kampala

Diffusion model

Medical colleges

NGOs Private-for-profit

Other

Top Quintile

4th Quintile

3rd Quintile

2nd Quintile

Bottom Quintile

Further areas for investigation

• Improving quality of diagnostics services – Improve reliability of diagnosis (quality/reliability, ability to

implement in stand-alone labs

– Need to displace use of poor quality tests

– Facilitate measuring impact on national case detection rates

• Need to understand diagnostic services in private

sector – Market share of different TB diagnostic tests

– Mapping of laboratory services available outside of the public

sector

• Understand cost structure, to develop different

models

• Roles of partners (NTP, professional associations,

accreditation)

• Link to treatment – what to do with MTB/RIF + result

Thank you!