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. 2010 Sep 7;4(9):e818.
doi: 10.1371/journal.pntd.0000818.

Cost-effectiveness analysis of combination therapies for visceral leishmaniasis in the Indian subcontinent

Filip Meheus  1 , Manica Balasegaram, Piero Olliaro, Shyam Sundar, Suman Rijal, Md Abul Faiz, Marleen Boelaert
Affiliations

Cost-effectiveness analysis of combination therapies for visceral leishmaniasis in the Indian subcontinent

Filip Meheus et al. PLoS Negl Trop Dis. .

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.

Methods and findings: 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.

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Conflict of interest statement

All authors declare that there are no conflicts of interest. The opinions expressed in this paper are those of the authors and may not reflect those of their employing organizations. PO is a staff member of the WHO; the authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the WHO.

Figures

Figure 1
Figure 1. Root decision tree with different pathways depending on whether miltefosine is included in the strategy.
Figure 2
Figure 2. Cost-effectiveness ratio (US$/death averted) of 10 treatment strategies for visceral leishmaniasis.
Line CBH shows dominance. All strategies left of this line are dominated by C, B and H, meaning they are equally or less effective and more costly.
Figure 3
Figure 3. Two-way sensitivity analysis on price of AmBisome and miltefosine.
See this image and copyright information in PMC

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