What is the Cost of Diagnosis and Management of Drug Resistant Tuberculosis in South Africa?

Background: Drug-resistant tuberculosis (DR-TB) is undermining TB control in South Africa. However, there are hardly any data about the cost of treating DR-TB in high burden settings despite such information being quintessential for the rational planning and allocation of resources by policy-makers, and to inform future cost-effectiveness analyses. Methodology: We analysed the comparative 2011 United States dollar ($) cost of diagnosis and treatment of drug sensitive TB (DS-TB), MDR-TB and XDR-TB, based on National South African TB guidelines, from the perspective of the National TB Program using published clinical outcome data. Principal Findings: Assuming adherence to national DR-TB management guidelines, the per patient cost of XDR-TB was $ 26,392, four times greater than MDR-TB ($ 6772), and 103 times greater than drug-sensitive TB ($ 257). Despite DR-TB comprising only 2.2% of the case burden, it consumed,similar to 32% of the total estimated 2011 national TB budget of US $ 218 million. 45% and 25% of the DR-TB costs were attributed to anti-TB drugs and hospitalization, respectively. XDR-TB consumed 28% of the total DR-TB diagnosis and treatment costs. Laboratory testing and anti-TB drugs comprised the majority (71%) of MDR-TB costs while hospitalization and anti-TB drug costs comprised the majority (92%) of XDR-TB costs. A decentralized XDR-TB treatment programme could potentially reduce costs by $ 6930 (26%) per case and reduce the total amount spent on DR-TB by,similar to 7%. Conclusion/Significance: Although DR-TB forms a very small proportion of the total case burden it consumes a disproportionate and substantial amount of South Africa's total annual TB budget. These data inform rational resource allocation and selection of management strategies for DR-TB in high burden settings.