Is DOTS-Plus a Feasible and Cost-Effective Strategy?

M ultidrug-resistant tuberculosis (MDR-TB) is on the increase, with several Eastern European countries having a prevalence of more than ten percent [1]. This resistance means that patients may not be cured with standard regimens even if they adhere well to treatment. An MDR-TB programme requires advanced medical care, infection control measures, counselling, and good follow-up, as one centre in the Philippines reports in a study published in PLoS Medicine [2]. The DOTS-Plus (directly observed treatment, short-course) project is run by the Makati Medical Center, supported by the Tropical Disease Foundation. The Center has exceptional management capacity, and was one of the fi rst few nongovernmental organizations to be a principal recipient of grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria (known as the Global Fund). The Center itself provides high-quality tertiary care. Within this setting, clinicians from the Makati Medical Center used drug history and sensitivity testing to provide individualised regimens of expensive second-line drugs, estimated to cost more than US$1,500 per patient. The authors report on a cohort of 171 patients with MDR-TB, of whom 117 were enrolled and analysed, with 61 percent cured. Indirect outcome data from patients from other countries were then combined with local cost data to estimate the number of premature deaths and secondary cases averted in order to provide an estimate of the mean cost per disability-adjusted life year gained. conclude that treating MDR-TB patients is feasible and cost-effective in low-and middle-income countries. The World Health Organization and other agencies are promoting services to treat MDR-TB [3]; the Global Fund is waiting in the wings, able to fund them. This promotion may cause pressure for countries to rapidly implement and expand such programmes. It is therefore imperative that expansion be based on sound evidence that such programmes work when scaled up. Hence, policy makers need to carefully appraise the evidence rather than just the conclusions of this paper and other papers, and consider the following four points. First, this present analysis is not an independent evaluation. As is clearly stated, the authors include World Health Organization staff (who are promoting DOTS-Plus) and Tropical Disease Foundation staff (who are receiving Global Fund money for providing services). Further evaluations are needed to boost the evidence base. Second, readers need to consider whether these specialist medical services can actually be provided at scale. This paper reports on a relatively small programme provided under ideal …