Drug policy for visceral leishmaniasis: a cost-effectiveness analysis.
OBJECTIVE
To facilitate the choice of the best visceral leishmaniasis (VL) treatment strategy for first-line health services in (VL)-endemic areas, we compared in a formal decision analysis the cost and the cost-effectiveness of the different available options.


METHODS
We selected four drug regimens for VL on the basis of frequency of use, feasibility and reported efficacy studies. The point estimates and the range of plausible values of effectiveness and cost were retrieved from a literature review. A decision tree was constructed and the strategy minimizing the cost per death averted was selected.


RESULTS
Treatment with amphotericin B deoxycholate was the most effective approach in the baseline analysis and averted 87.2% of all deaths attributable to VL. The least expensive and the most cost-effective treatment was the miltefosine regimen, and the most expensive and the least cost-effective was AmBisome treatment. The cost of drug and medical care are the main determinants of the cost-effectiveness ranking of the alternative schemes. Sensitivity analysis showed that antimonial was competitive with miltefosine in the low-resistance regions.


CONCLUSIONS
In areas with >94% response rates to antimonials, generic sodium stibogluconate remains the most cost-effective option for VL treatment, mainly due to low drug cost. In other regions, miltefosine is the most cost-effective option of treatment, but its use as a first-line drug is limited by its teratogenicity and rapid resistance development. AmBisome in mono- or combination therapy is too expensive to compete in cost-effectiveness with the other regimens.
Vanlerberghe
V
V
Epidemiology and Disease Control Unit, Prince Leopold Institute of Tropical Medicine, Antwerp, Belgium. vvanlerberghe@itg.be
Diap
G
G
Guerin
P J
PJ
Meheus
F
F
Gerstl
S
S
Van der Stuyft
P
P
Boelaert
M
M
D000666:Amphotericin B / Q000191:economics / Q000627:therapeutic use; D000965:Antimony / Q000191:economics / Q000627:therapeutic use; D000981:Antiprotozoal Agents / Q000191:economics / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis / Q000379:methods; D003663:Decision Trees; D003840:Deoxycholic Acid / Q000191:economics / Q000627:therapeutic use; D004338:Drug Combinations; D019353:Endemic Diseases; D017048:Health Care Costs; D006801:Humans; D007898:Leishmaniasis, Visceral / Q000188:drug therapy* / Q000191:economics; D010767:Phosphorylcholine / Q000031:analogs & derivatives / Q000191:economics / Q000627:therapeutic use; D016896:Treatment Outcome
D000981:Antiprotozoal Agents; D004338:Drug Combinations; C068538:liposomal amphotericin B; D003840:Deoxycholic Acid; D010767:Phosphorylcholine; C039128:miltefosine; D000666:Amphotericin B; C059765:amphotericin B, deoxycholate drug combination; D000965:Antimony