MDR-TB ELIMINATION: WHAT WILL IT COST?

Transcription

1 MDR-TB ELIMINATION: WHAT WILL IT COST? Emily A. Kendall, MD Assistant Professor, Infectious Diseases, Johns Hopkins University School of Medicine 48 th Union World Conference on Lung Health, Guadalajara, Mexico, 14 October, 2017

2 OUTLINE Trends and drivers of MDR-TB epidemics What interventions will elimination require? At what price? Are they worth the cost?

3 Observed trends in DS and MDR TB

4 Drivers of MDR TB epidemics: What we know Acquisi(on: Treatment of drug-suscep(ble TB seeds MDR epidemics 1,2 Transmission: TransmiAed MDR exceeds new resistance acquisi(on 3,4,5 Under-diagnosis: Failure to diagnose and treat prolongs transmission Ineffec(ve treatment: Prolongs transmission and promotes 2 nd -line resistance Recent spread: Known MDR TB contacts at high risk 6,7 1. Menzies Plos Med Rockwood JID Yang Lancet ID Kendall Lancet Respir Med WHO Global Report 2016 no(fica(ons 6. Grandjean Plos Med Prajapa( Peds Int Child Health 2015

5 SuggesAng a mula-faceted approach Treatment of drug-suscep(ble TB seeds MDR epidemics à BeAer DS-TB control may help Transmission exceeds new resistance acquisi(on à Must interrupt MDR-TB transmission Failure to diagnose and treat prolongs transmission à Xpert scale-up, case finding Ineffec(ve treatment prolongs transmission and promotes second-line drug resistance à Second-line DST, op(mized regimens, treatment monitoring, beaer regimens Recent transmission predominates; known MDR TB contacts at high risk à Contact tracing, second-line preven(ve therapy, biomarkers for progression

6 As for DS-TB, mulaple strategies needed Components of drugsuscep(ble TB elimina(on:

7 As for DS-TB, mulaple strategies needed Example of projected impact of more MDR-TB treatment and a moreeffec(ve regimen, Southeast Asia: (Repeatedly, modeling analyses like this one show that more and beaer MDR treatment can have a large impact, but s(ll won t get us to elimina(on on its own.) Kendall et al, Lancet Respir Med 2017

8 MDR-TB requires a mula-faceted approach Treatment of drug-suscep(ble TB seeds MDR epidemics à BeAer DS-TB control may help Transmission exceeds new resistance acquisi(on à Must interrupt MDR-TB transmission Failure to diagnose and treat prolongs transmission à Xpert scale-up, case finding Ineffec(ve treatment prolongs transmission and promotes second-line drug resistance à Second-line DST, op(mized regimens, treatment monitoring, beaer regimens Recent transmission predominates; known MDR TB contacts at high risk à Contact tracing, second-line preven(ve therapy, biomarkers for progression Most-efficient combina/ons will depend on local epidemiology & economics.

9 ProhibiAve costs of MDR-TB control? Rifampin DST: GeneXpert IV machine: $17,000, $10 per Xpert MTB/RIF cartridge 1 MDR-TB treatment course, LIC: median $3,300 2 No(fica(ons, 30 TB HBCs Budgets, 30 TB HBCs Second-line DST: $100? (volume and assay-dependent, laboratory intensive) 3 DS MDR/RR DS MDR/RR Contact inves(ga(ons: ~$ per contact screened 4 Result of costs and complexity: under-u/liza/on 24% rifampin DST coverage, for new TB diagnoses 2 23% MDR/RR no(fica(on, per incident MDR/RR TB cases 2 36% second-line DST coverage, for MDR/RR TB diagnoses 2?? screening, for MDR TB contacts (7% of under-5 [DS] TB contacts receive preven(ve therapy) 2 1. FIND nego(ated pricing 2. WHO Global Report Vassall PLOS Med Yadav AJTMH 2014, Steffen PLOS One 2013, A(f Springerplus 2012, Mandalakas Thorax 2013

10 Two perspecaves on acceptable cost, illustrated for a novel RR-TB regimen: 1. Affordability perspec/ve, e.g. at what price would beeer drugs/regimens be budget-neutral? Budget-neutral regimen price, per treatment course Other fixed costs Other fixed costs $18,000 $16,000 $14,591 $16,242 Fixed perpa(ent costs Regimen- and dura(ondependent management costs Drug costs One year Shorter regimen reduces management costs, frees resources for drugs Fixed perpa(ent costs Reduced management costs Increase in available drug budget One year $14,000 $12,000 $10,000 $8,000 $6,000 $4,745 $2,940 $4,000 $2,700 $1,754 $1,579 $980 $2,000 $0 DRC India South Africa Russia Current average regimen cost, 2015 standard of care (reference) Novel 6mo MDR regimen; ~50% lower delivery & monitoring costs

11 Example of epidemiologic projec(on: 2. Cost effec/veness perspec/ve: Over (me, beaer regimens reduce number of pa(ents requiring treatment. Reduc(ons in morbidity and mortality also have value. Other fixed costs Fixed per-pa(ent costs Regimen- and dura(on-dependent management costs Time Drug costs Shorter and beaer regimen also reduces incidence and improves health outcomes Addi(onal value of improved health outcomes Other fixed costs Per-pa(ent costs decrease with declining incidence Further increase in poten(al drug spending Management costs decrease with dura(on and decline further over (me Time Increase in available drug budget $300/DALY averted (120, 1040) with mortality and prevalence projec(ons that we can translate into DALYs averted: Actual epidemiologic projec(ons used for this analysis are based on Kendall et al, PLOS Med 2017

12 2. Cost effec/veness perspec/ve: Over (me, beaer regimens reduce number of pa(ents requiring treatment. Reduc(ons in morbidity and mortality also have value. Addi(onal value of improved health outcomes Other fixed costs Other fixed costs Fixed per-pa(ent costs Regimen- and dura(on-dependent management costs Drug costs Shorter and beaer regimen also reduces incidence and improves health outcomes Per-pa(ent costs decrease with declining incidence Further increase in poten(al drug spending Management costs decrease with dura(on and decline further over (me Increase in available drug budget $300/DALY averted (120, 1040) Time Time * In Peru and Philippines, per Fitzpatrick and Floyd Pharmcoeconomics 2012, converted to 2015 USD

13 Economic benefits to acang now Example: second-line DST + regimen op(miza(on. Suppose it: reduces risk of MDR treatment failure from 30% to 20%, and reduces acquired pre-xdr/xdr (costly to re-treat) from 10% to 5%.! DST + regimen adjustments would be cost-neutral at >$400/pa@ent even before accoun(ng for the prevented MDR and XDR transmissions. 40 RR TB cases 12 RR TB not cured *Assuming that retreatment costs $3000 for MDR alone, $6000 for pre-xdr/xdr

14 To eliminate MDR TB, we must reduce the cost of diagnosis and effec(ve treatment as well as increase investments in MDR-TB now.

15 So what will MDR TB eliminaaon cost? I can t name a price. Hard to cost global TB elimina(on even in absence of drug resistance Depends in part on future technological advances But

16 So what will MDR TB eliminaaon cost? MDR elimina(on requires a mul(-pronged strategy. We must work to make these more affordable Understand local epidemics to iden(fy most efficient packages Such efforts may be cost-effec(ve or even cost-saving given downstream costs of not doing them ü Case-finding ü Contact tracing ü Preven(on ü Regimen selec(on ü Treatment monitoring ü Pa(ent support But will strain current budgets and capacity. Global commitment and investment are required.

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