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Global Health Econ Sustain MDR-TB and the road ahead

(Carter et al., 2018; Ferreira et al., 2023). In addition, cash availability of qualified staff and the underlying prevalence
transfer programs, such as the Bolsa Familia Programme of MDR-TB and HIV. Sputum smear microscopy costs
(BFP) in Brazil, have demonstrated the ability to reduce approximately $8.15 USD, compared to $19.23 USD for
health inequalities and improve nutrition in both the LPA and $30.75 for GeneXpert, and the costs per positive
general population and in those with TB, offering a viable TB diagnosis for first- and second-line DST are $96 and
method to achieve the End TB goal (Oliosi et al., 2019). $221 USD, respectively. However, as consumables and
reagents may represent up to half of all total laboratory
Even after successful treatment of TB, up to 41% of
patients experience persistent respiratory symptoms, costs in MDR-TB, the costs utilizing such rapid tests may
which can limit their ability to resume work (Maleche- increase considerably from $12.41 to $218 USD, with
consumables costing between $1.13 and $74.60 USD per
Obimbo et al., 2022). In addition, mental health often test (Cates et al., 2021; Saderi et al., 2023). Importantly,
deteriorates during TB treatment and recovery and is these costs do not consider laboratory overheads, which
often left unmanaged, further impeding recovery. In a can be substantial with the shift toward molecular testing
systematic review, the pooled prevalence of depression, requiring changes in infrastructure, equipment, and staff
anxiety, and psychosis among MDR-TB patients was found training. The cost of machinery, for example, may be
to be 25%, 24%, and 10%, respectively, with health-related substantial, with the BD Bactec MGIT costing $38,950
quality of life metrics significantly lower than those in USD and the GeneXpert XVI module costing $71,500
DS-TB patients (p = 0.01) (Alene et al., 2018). Alongside USD (Yadav et al., 2022). At present, it would appear that
psychological morbidity, TB-related stigma often persists GeneXpert/LPA followed by MODS is likely the most
after treatment, particularly when patients have been beneficial testing protocol in endemic areas.
forcibly isolated, affecting their reintegration into societal
groups and future employment opportunities. Therefore, 4. Conclusion
the integration of mental health services, social support
services, and pulmonary rehabilitation is essential and MDR-TB presents a global challenge, entailing suboptimal
should be factored into economic analyses of MDR-TB clinical and societal outcomes. While novel therapeutic
(Meghji et al., 2021). regimens offer the opportunity for superior treatment
outcomes, cost reduction, and enhanced adherence, their
To effectively manage MDR-TB, early detection is success relies on the accurate diagnosis of MDR-TB, which
crucial. At present, GeneXpert/Xpert-Ultra and first- and necessitates access to sensitive and timely diagnostic tests.
second-line line probe assays (LPAs) are the molecular To mitigate both total and catastrophic costs, decentralized
techniques advocated by the WHO over traditional LED- care models alongside social programs emerge as promising
fluorescent microscopy and phenotypic drug susceptibility avenues for providing tangible benefits to MDR-TB
testing (DST) (WHO, 2021). This preference stems from patients. Moving forward, it is imperative that future
their superior sensitivity (88%), specificity (100% for LPA), studies incorporate considerations for the psychological
rapid turnaround time (<1 – 2 days), and ability to detect and treatment-related sequelae in economic analysis. This
resistance (94% sensitivity for rifampicin), which provides approach will allow for more robust planning of national
an advantage over loop-mediated isothermal amplification TB programs and the realization of the End TB promise.
(LAMP) testing. LPAs can detect both rifampicin (rpoB)
and isoniazid (KatG) resistance, although they may miss Acknowledgments
certain isoniazid resistance mutations (e.g., KatG S315N) None.
with pooled sensitivities of 91.1% and 84.3%, respectively
(Zijenah, 2018). The development of GeneXpert Ultra Funding
has further improved molecular diagnostic testing in key None.
populations, including children, HIV-infected individuals,
and those with extrapulmonary disease (Zijenah, 2018). Conflict of interest
Among culture methods, microscopic-observation drug-
susceptibility assay (MODS) has proven to be cost-effective The author declares having no competing interests.
and rapid, providing results in 17 days compared to 39 days Author contributions
for liquid culture (MGIT), allowing for simultaneous
growth and resistance detection (Makamure et al., 2017). This is a single-authored article.
However, the cost-effectiveness of such diagnostics is
influenced by factors such as the cost and life expectancy Ethics approval and consent to participate
of consumables, reagents, and equipment, as well as the Not Applicable.

Volume 2 Issue 2 (2024) 4 https://doi.org/10.36922/ghes.2876