title: Cost-effectiveness analysis of combination therapies for visceral leishmaniasis in the Indian subcontinent.
abstract: BACKGROUND
  Visceral leishmaniasis is a systemic parasitic disease that is fatal unless treated. We assessed the cost and cost-effectiveness of alternative strategies for the treatment of visceral leishmaniasis in the Indian subcontinent. In particular we examined whether combination therapies are a cost-effective alternative compared to monotherapies.
  
  
  RESULTS
  We assessed the cost-effectiveness of all possible mono- and combination therapies for the treatment of visceral leishmaniasis in the Indian subcontinent (India, Nepal and Bangladesh) from a societal perspective using a decision analytical model based on a decision tree. Primary data collected in each country was combined with data from the literature and an expert poll (Delphi method). The cost per patient treated and average and incremental cost-effectiveness ratios expressed as cost per death averted were calculated. Extensive sensitivity analysis was done to evaluate the robustness of our estimations and conclusions. With a cost of US$92 per death averted, the combination miltefosine-paromomycin was the most cost-effective treatment strategy. The next best alternative was a combination of liposomal amphotericin B with paromomycin with an incremental cost-effectiveness of $652 per death averted. All other strategies were dominated with the exception of a single dose of 10mg per kg of liposomal amphotericin B. While strategies based on liposomal amphotericin B (AmBisome) were found to be the most effective, its current drug cost of US$20 per vial resulted in a higher average cost-effectiveness. Sensitivity analysis showed the conclusion to be robust to variations in the input parameters over their plausible range.
  
  
  CONCLUSIONS
  Combination treatments are a cost-effective alternative to current monotherapy for VL. Given their expected impact on the emergence of drug resistance, a switch to combination therapy should be considered once final results from clinical trials are available.
authors.affiliation: Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium. fmeheus@itg.be
authors.forename: Filip
authors.initials: F
authors.lastname: Meheus
authors.forename: Manica
authors.initials: M
authors.lastname: Balasegaram
authors.forename: Piero
authors.initials: P
authors.lastname: Olliaro
authors.forename: Shyam
authors.initials: S
authors.lastname: Sundar
authors.forename: Suman
authors.initials: S
authors.lastname: Rijal
authors.forename: Md Abul
authors.initials: MA
authors.lastname: Faiz
authors.forename: Marleen
authors.initials: M
authors.lastname: Boelaert
mesh_terms: D000666:Amphotericin B / Q000008:administration & dosage / Q000191:economics; D000981:Antiprotozoal Agents / Q000008:administration & dosage* / Q000191:economics*; D001459:Bangladesh; D003362:Cost-Benefit Analysis; D004359:Drug Therapy, Combination / Q000191:economics / Q000379:methods; D006801:Humans; D007194:India; D007898:Leishmaniasis, Visceral / Q000188:drug therapy* / Q000191:economics*; D015233:Models, Statistical; D009390:Nepal; D010303:Paromomycin / Q000008:administration & dosage / Q000191:economics; D010767:Phosphorylcholine / Q000008:administration & dosage / Q000031:analogs & derivatives / Q000191:economics
chemical_list: D000981:Antiprotozoal Agents; C068538:liposomal amphotericin B; D010767:Phosphorylcholine; C039128:miltefosine; D010303:Paromomycin; D000666:Amphotericin B