Managing multidrug-resistant tuberculosis in South Africa: a budget impact analysis

Abstract

SETTING: In South Africa prior to 2016, the standard treatment regimen for multidrug- and rifampicin-resistant tuberculosis (MDR/RR-TB) was 24 months long and required daily injectable aminoglycoside (IA) treatment during the first 6 months. Recent evidence supports the replacement of IA with well-tolerated oral bedaquiline (BDQ) and a shortened 9-12 month regimen.DESIGN: Using a Markov model, we analyzed the 5-year budgetary impact and cost per successful treatment outcome of four regimens: 1) IA long-course, 2) oral long-course, 3) IA short-course, and 4) oral short-course. We used the South African MDR/RR-TB case register (2013-2015) to assess treatment outcomes for the then-standard IA long-course. Data on the improvement in outcomes for BDQ-based regimens were based on the literature. Costs were estimated from the provider perspective using costs incurred to provide decentralized treatment for MDR-TB at a Johannesburg hospital.RESULTS: Based on our analysis, by 2023, the cost/successful outcome for the four regimens was respectively 1) US$7374, 2) US$7860, 3) US$5149, and 4) US$4922. The annual total cost of each regimen was US$37 million, US$43 million, US$26 million, and US$28 million.CONCLUSION: Despite the high cost of BDQ, a BDQ-based shortened regimen for the treatment of MDR/RR-TB will result in improved treatment outcomes and cost savings for South Africa.

Conflict of interest statement

Conflicts of interest: none declared.

Figures

Figure 1

Structure of the Markov model. * IA long-course (baseline)=18–24 month regimen with 6-month IA. † Oral long-course=18–20 month regimen with BDQ as a substitute for IA. § IA short-course=9–12 month regimen with 6-month IA. ‡ Oral short-course=9–12 month regimen with BDQ as a substitute for IA. IA = injectable aminoglycoside; BDQ = bedaquiline.

Figure 2

Cost per patient treated by regimen. * IA long-course (baseline) = 18–24 month regimen with 6-month IA. † Oral long-course = 18–20 month regimen with BDQ as a substitute for IA. § IA short-course = 9–12 month regimen with 6-month IA. ‡ Oral short-course = 9–12 month regimen with BDQ as a substitute for IA. IA = injectable aminoglycoside; BDQ = bedaquiline.

Figure 3

One-way sensitivity analysis for the oral short course. Cost per successful treatment as estimated in year 2023 for the oral short-course. BDQ = bedaquiline; IA = injectable aminoglycoside.