Feasibility and Cost-Effectiveness of Treating Multidrug-Resistant Tuberculosis: A Cohort Study in the Philippines

Background: Multidrug-resistant tuberculosis (MDR-TB) is an important global health problem, and a control strategy known as DOTS-Plus has existed since 1999. However, evidence regarding the feasibility, effectiveness, cost, and cost-effectiveness of DOTS-Plus is still limited. Methodology/Principal Findings: We evaluated the feasibility, effectiveness, cost, and cost-effectiveness of a DOTS-Plus pilot project established at Makati Medical Center in Manila, the Philippines, in 1999. Patients with MDR-TB are treated with regimens, including first- and second-line drugs, tailored to their drug susceptibility pattern (i.e., individualised treatment). We considered the cohort enrolled between April 1999 and March 2002. During this three-year period, 118 patients were enrolled in the project; 117 were considered in the analysis. Seventy-one patients (61%) were cured, 12 (10%) failed treatment, 18 (15%) died, and 16 (14%) defaulted. The average cost per patient treated was US$3,355 from the perspective of the health system, of which US$1,557 was for drugs, and US$837 from the perspective of patients. The mean cost per disability-adjusted life year (DALY) gained by the DOTS-Plus project was US$242 (range US$85 to US$426). Conclusions: Treatment of patients with MDR-TB using the DOTS-Plus strategy and individualised drug regimens can be feasible, comparatively effective, and cost-effective in low- and middle-income countries. Evaluation of 117 patients enrolled in a DOTS-Plus pilot project in the Philippines showed that in this setting the strategy is feasible. Background.: Tuberculosis (TB) causes the death of some 2 million people each year. An estimated one in three people worldwide are infected with Mycobacterium tuberculosis, the bacterium that causes the disease. Because single-drug treatment leads to treatment failure and antibiotic resistance, treatment for active TB is complicated, usually involving four different antibiotics, at least two of which are continued for six months or more. The World Health Organization (WHO) recommends a specific strategy (DOTS) for diagnosing and treating TB (see Web link below). Why Was This Study Done?: Because the use of second-line antibiotics is costly and the treatment of MDR-TB has a higher failure rate than that of fully drug-susceptible TB, policymakers responsible for allocation of limited healthcare resources need information on how well DOTS-Plus programmes work and how much they cost to operate. This study was undertaken to assess the feasibility, effectiveness, and cost-effectiveness of a DOTS-Plus project in the Philippines, a lower middle–income country with a high rate of TB and approximately 25,000 cases of MDR-TB. What Did the Researchers Do and Find? : The researchers reported on a DOTS-Plus pilot project at Makati Medical Center in Manila, analyzing information from 118 patients enrolled in the project between 1999 and 2002. The diagnosis of MDR-TB was based on laboratory culture and antibiotic resistance testing of specimens from patients who had continued symptoms of TB following DOTS treatment, or other evidence of possible MDR-TB. Patients were treated with five-drug combinations individually selected based on resistance testing results, and administered under direct observation. After cultures had remained consistently negative for six months, patients were switched to a four-drug regimen with intermittent clinic observation until cultures remained negative for at least 18 months. What Do These Findings Mean?: The cure rate for MDR-TB in this project compares favourably to rates in other resource-limited settings where second-line TB drugs are used, and is much higher than in areas where these drugs are not available. From the standpoint of efficacy and patient well-being, then, this study supports the necessity of DOTS-Plus treatment. In purely economic terms, the cost of US$200–US$250 per DALY gained is cost-effective in comparison with other healthcare interventions. Specifically, because the gross national income per person in the Philippines is US$1,080, someone who can return to work following MDR-TB treatment costing US$250 per year gained of working life will provide work that is worth four times more, on average, than the cost of the treatment. Additional Information. : Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030352.