An economic analysis of BPaL for multidrug-resistant TB in South Africa and the Philippines

Abstract

Background: The WHO endorses bedaquiline, pretomanid, and linezolid (BPaL)-based regimens for multidrug-resistant/rifampicin-resistant TB, and both the Philippines (PH) and South Africa (SA) have adopted these regimens.

Methods: Using a Markov model, we assessed the cost per successful treatment and 5-year budgetary and economic impact of BPaL-based regimens in SA and PH. Treatment outcomes were informed by national electronic registries, SA BPaL Clinical Access Program, and PH operational research. Costs were estimated from the provider perspective.

Results: Over 5 years, BPaL-based regimens reduce total costs by 20%-25% in SA and 9%-11% in PH compared with a standard short oral regimen (SSOR) when achieving the same number of successful treatments, due to lower cost per successful treatment from reduced loss to follow-up and mortality. BPaL-based regimens improve treatment success by 22%, leading to more patients completing full treatment and higher overall resource use. Therefore, the budget for BPaL-based regimens is projected to increase by 7%-8% (SA) and 6% (PH) from 2023/24 to 2027/28.

Conclusion: BPaL-based regimens reduce cost per successful treatment compared with SSOR and require smaller budgets for similar treatment outcomes. Implementation may involve initial budget increases, but improvements in treatment success and long-term health outcomes outweigh these costs, presenting a strong rationale for rollout.

Keywords: BPaL; MDR-TB; bedaquiline; budget impact; economic impact; tuberculosis.

Figure 1.

Structure of the Markov model and the relationship between different health states. Patients are assigned to A: SSOR or B: a BPaL-based regimen (BPaLM/L or BPaL), based on eligibility and country rollout strategy. BPaL = short, all-oral, 24-week regimen comprising bedaquiline (400 mg daily for 2 weeks followed by 200 mg three times per week for 22 weeks), pretomanid (200 mg daily), and linezolid (600 mg daily for 16 weeks, then 300 mg daily for 8 weeks), with or without 400 mg moxifloxacin (M) or levofloxacin (L). SSOR = standard short oral regimen. SLOR = standard long oral regimen; LTFU = loss to follow-up; Tx_Failure = treatment failure; Tx_Completed = treatment completed.

Figure 2.

One-way sensitivity analysis of individual key input parameters. Cost per successful treatment as estimated in year 2027/28 for Strategy 2 in South Africa. SSOR = standard short oral regimen; SLOR = standard long oral regimen; LTFU = loss to follow-up; tx failure = treatment failure.