title: Cost and cost-effectiveness of tuberculosis treatment shortening: a model-based analysis.
abstract: Despite improvements in treatment success rates for tuberculosis (TB), current six-month regimen duration remains a challenge for many National TB Programmes, health systems, and patients. There is increasing investment in the development of shortened regimens with a number of candidates in phase 3 trials.
  
  
  
  We developed an individual-based decision analytic model to assess the cost-effectiveness of a hypothetical four-month regimen for first-line treatment of TB, assuming non-inferiority to current regimens of six-month duration. The model was populated using extensive, empirically-collected data to estimate the economic impact on both health systems and patients of regimen shortening for first-line TB treatment in South Africa, Brazil, Bangladesh, and Tanzania. We explicitly considered 'real world' constraints such as sub-optimal guideline adherence.
  
  
  
  From a societal perspective, a shortened regimen, priced at USD1 per day, could be a cost-saving option in South Africa, Brazil, and Tanzania, but would not be cost-effective in Bangladesh when compared to one gross domestic product (GDP) per capita. Incorporating 'real world' constraints reduces cost-effectiveness. Patient-incurred costs could be reduced in all settings. From a health service perspective, increased drug costs need to be balanced against decreased delivery costs. The new regimen would remain a cost-effective option, when compared to each countries' GDP per capita, even if new drugs cost up to USD7.5 and USD53.8 per day in South Africa and Brazil; this threshold was above USD1 in Tanzania and under USD1 in Bangladesh.
  
  
  
  Reducing the duration of first-line TB treatment has the potential for substantial economic gains from a patient perspective. The potential economic gains for health services may also be important, but will be context-specific and dependent on the appropriate pricing of any new regimen.
authors.affiliation: Amsterdam Institute for Global Health and Development and Department of Global Health, Academic Medical Center, University of Amsterdam, Trinity Building C, Pietersbergweg 17, Amsterdam, 1105 BM, The Netherlands. g.gomez@aighd.org.|Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK. g.gomez@aighd.org.
authors.forename: G B
authors.initials: GB
authors.lastname: Gomez
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
authors.forename: D W
authors.initials: DW
authors.lastname: Dowdy
authors.affiliation: Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.|Tuberculosis Scientific League, Rio de Janeiro, Brazil.
authors.forename: M L
authors.initials: ML
authors.lastname: Bastos
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
authors.forename: A
authors.initials: A
authors.lastname: Zwerling
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: S
authors.initials: S
authors.lastname: Sweeney
authors.affiliation: Health Economics Unit, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: N
authors.initials: N
authors.lastname: Foster
authors.affiliation: Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.|Tuberculosis Scientific League, Rio de Janeiro, Brazil.|McGill University, Montreal, Canada.
authors.forename: A
authors.initials: A
authors.lastname: Trajman
authors.affiliation: BRAC Health Nutrition and Population Programme, BRAC Centre, Dhaka, Bangladesh.
authors.forename: M A
authors.initials: MA
authors.lastname: Islam
authors.affiliation: Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania.
authors.forename: S
authors.initials: S
authors.lastname: Kapiga
authors.affiliation: Health Economics Unit, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: E
authors.initials: E
authors.lastname: Sinanovic
authors.affiliation: TB Modelling Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: G M
authors.initials: GM
authors.lastname: Knight
authors.affiliation: TB Modelling Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: R G
authors.initials: RG
authors.lastname: White
authors.affiliation: Global Alliance for TB Drug Development, New York, USA.|Present address: United States Agency for International Development, Washington, DC, USA.
authors.forename: W A
authors.initials: WA
authors.lastname: Wells
authors.affiliation: Amsterdam Institute for Global Health and Development and Department of Global Health, Academic Medical Center, University of Amsterdam, Trinity Building C, Pietersbergweg 17, Amsterdam, 1105 BM, The Netherlands.|KNCV Tuberculosis Foundation, The Hague, Netherlands.
authors.forename: F G
authors.initials: FG
authors.lastname: Cobelens
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: A
authors.initials: A
authors.lastname: Vassall
mesh_terms: D000995:Antitubercular Agents / Q000191:economics*; D001459:Bangladesh; D001938:Brazil; D003362:Cost-Benefit Analysis; D003695:Delivery of Health Care / Q000191:economics; D016527:Drug Costs; D017048:Health Care Costs; D005102:Health Expenditures; D006296:Health Services / Q000191:economics; D006801:Humans; D008962:Models, Theoretical; D013019:South Africa; D013636:Tanzania; D016896:Treatment Outcome; D014376:Tuberculosis / Q000188:drug therapy* / Q000191:economics*
chemical_list: D000995:Antitubercular Agents
keywords: Cost-effectiveness; Economic evaluation; New technologies; Tuberculosis