Abstract

Background. Increasing numbers of developing/middle income countries are implementing the DOTS-Plus strategy that uses second-line drugs to treat patients with multidrug-resistant tuberculosis (MDR-TB). However, data on the feasibility, clinical effectiveness, cost and cost-effectiveness of the DOTS-Plus strategy is limited. More data are required to inform global and national policy development.
Aim. To evaluate the feasibility, clinical effectiveness, cost and cost-effectiveness of the national DOTS-Plus programme implemented nation-wide in Estonia since August 2001 by 3 alternative strategies.
Subjects and methods. We compared three alternative strategies: DOTS-Plus (100 randomly selected MDR-TB patients out of 149, who started their individualized treatment regimens form August 2001 through August 2002), pre-DOTS-Plus (54 patients starting individualized but not directly observed treatment defined by the individual physician during 1995–1997), and DOTS (100 randomly selected patients with non-MDR-TB out of 543 patients, who started their treatment between August 2001 and August 2002). The costs (based on prices for health care services valid in the year 2002, in EEK) and effectiveness (deaths, DALYs lost) and cost- effectiveness (cost per DALY averted) were estimated and expressed as the additional (incremental) cost and effectiveness for the three alternative strategies.
Results. In the DOTS-Plus cohort, 61% of the patients achieved success, 17% defaulted, 13% died, and 9% failed, while among the pre-DOTS-Plus patients, the respective figures were 52, 20, 24, and 4%. Death rate was significantly lower in the DOTS-Plus cohort than in the pre-DOTS-Plus cohort (p = 0.039). The average costs per treated patient were 132 110 EEK (€ 8417), 72 931 EEK (€ 4647), and 50 718 EEK (€ 3232) for DOTS-Plus, pre-DOTS-Plus, and DOTS, respectively. In general, hospitalization costs were responsible for about half of the average costs per patient in all cohorts. The average cost of anti-TB drugs accounted for 25% in MDRTB patients, whereas only 1.5% in non-MDR-TB patients. The costs per DALY averted were 8570 EEK (€ 546) and 6623 EEK (€ 422) for DOTS-Plus vs pre-DOTS-Plus and vs DOTS, respectively.
Conclusion. DOTS-Plus strategy for treatment MDR-TB using individualized drug regimens is feasible, clinically effective and cost-effective in Estonia, a middleincome country of the former Soviet Union.