Cost-effectiveness analysis of visceral leishmaniasis treatment in Bihar, India S. Gerstl,1 S. Sundar,2 V. Vanlerberghe,3 M. Boelaert,3 J-A Rottingen,4 G. Diap,5 P.J. Guerin,1 P.L. Olliaro6
1 2
Epicentre, Paris, France Kala-Azar Medical Research Centre, Dept of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India 3 Department of Public Health/Epidemiology, Institute of Tropical Medicine, Antwerp, Belgium 4 Norwegian Health Services Research Centre, Oslo, Norway; Centre for Prevention of Global Infections, University of Oslo, Norway 5 Médecins Sans Frontières 6 UNICEF/UNDP/World Bank/WHO Special Programme on Research & Training in Tropical Diseases, World Health Organization, Geneva, Switzerland; University of Oxford, Centre for Tropical Medicine and Vaccinology, Churchill Hospital, UK Introduction Current care of visceral leishmaniasis requires prolonged hospitalisation and generates high costs to patients and health systems. Resistance to first-line antimony (SSG) is established in India. Adapted replacement first-line treatment for visceral leishmaniasis is urgently needed in India. Methods To assess and compare the implications of different treatment choices in India, we retrieved and analysed efficacy and related direct costs of nine alternative treatments in India (SSG, amphotericin B in different regimens, paromomycin -alone or combined with SSG-, and miltefosine) and derived their relative cost-effectiveness. Treatment strategies included second line treatment for failures and were analysed using a decision tree. Results Drug costs for a full course first-line treatment range widely between US$38 for SSG to US$1 800 for AmBisome (10mg/kg). A full course treatment costs less than US$100 for 4/9 strategies (SSG, amphotericin B, paromomycin, SSG/paromomycin-combination). Hospital costs range between US$24 for a 1-day treatment with AmBisome (5 and 7.5mg/kg) to US$250 for a 15-day treatment with amphotericin B. All first-line treatments, except SSG (50% cure rate), were highly effective. Taking into account the combined effects of first-line and second-line treatment, all treatment strategies considered are >90% effective. Total costs range from US$194 (miltefosine) to US$1 291 (AmBisome 10mg/kg). Six strategies have a negative incremental effectiveness (i.e. less effective and more expensive than miltefosine). Only two treatment strategies were more effective than miltefosine, but their incremental costs versus miltefosine were US$143 for amphotericin B and US$1 097 for AmBisome (10mg/kg). Discussion Our analyses suggest that the most cost-effective treatment strategy for Bihar, India is miltefosine given to outpatients with supervision. However, additional elements must be taken into consideration which may affect the cost-effectiveness of a miltefosine-based treatment strategy (i.e. weekly supervision costs). Further, the drug is teratogenic and cannot be administered during pregnancy or to women of childbearing age who cannot avoid pregnancy during treatment and for 3 months post-treatment, which is 20-25% of all visceral leishmaniasis patients in India. The effectiveness of unsupervised treatment and parasite resistance must be carefully monitored. AmBisome is highly effective and acts fast, but its price makes it at present unaffordable. Since the different strategies all have comparable efficacy levels, their hospital and drug costs were the prime determinant of differences in cost-effectiveness. This research highlights the importance of performing country-specific cost-effectiveness analyses.
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