Health system and household costs of preventive treatment delivery for children exposed to multidrug-resistant tuberculosis in South Africa

BackgroundTuberculosis (TB) preventive treatment (TPT) is a core component of TB control. Levofloxacin was recently recommended by the World Health Organization as TPT in children exposed to multidrug-resistant tuberculosis (MDR-TB). However, the affordability and feasibility of TPT provision for governments, health services, individual households and global donors is uncertain. MethodsTB-CHAMP was a cluster-randomized, double-blind, placebo-controlled trial investigating levofloxacin TPT in children exposed to MDR-TB in South Africa and included cost analysis of TPT delivery. We modelled the societal (health system and household) cost of levofloxacin TPT, other potential future (but not currently recommended) MDR-TB exposure TPT options, and compared with drug-susceptible TPT options in children and adolescents under 15 years old. We modelled costs across 12 different medicine and formulation options for 11 paediatric dosing weight-bands using TB-CHAMP and household survey data, with national and international procurement medicine pricing. ResultsTotal societal costs of providing levofloxacin TPT and its monitoring per child were US$252 (0-<5-years) and US$256 (5-<15-years) and had comparable costs to drug-susceptible TPT regimens when using Global Drug Facility pricing. Pharmaceutical costs for a course of TPT using paediatric formulations in children <5 years varied between US$38 (levofloxacin), US$80 (bedaquiline) and US$582 (delamanid). Household costs associated with accessing TPT and ongoing monitoring ranged from 1.6%-2.1% of median annual income of affected households, with shorter TPT courses incurring lower household costs. Global Drug Facility procurement achieved TPT pricing at 70% of the costs of national South African procurement, and enabled access to a wider range of child-friendly formulations. DiscussionCosts of TPT are influenced by factors including medicine pricing and procurement, the use of child-friendly formulations, implementation approach, the duration of treatment, and choice of TPT regimen across childrens weight and age distributions. Costs to households are relatively small but may be significant for impoverished households already managing the financial disruption of a family member with MDR-TB disease