Economic Viability of 6-Month Bpal/Bpalm Regimens Versus Legacy MDR-Tb Therapies: A Systematic Review

This systematic review synthesizes and quantifies evidence regarding the economic viability, cost-effectiveness, and budget impact of 6-month BPaL/BPaLM regimens compared with legacy longer (18–24 months) and shorter (9–11 months) MDR-TB therapies across varied income settings. Multidrug-resistant and rifampicin-resistant tuberculosis (MDR/RR-TB) presents a severe global health threat, historically managed with 9-to-24-month regimens plagued by poor adherence, severe drug toxicity, and substantial economic toxicity. The introduction of 6-month, all-oral bedaquiline, Pretomanid and linezolid with or without moxifloxacin (BPaL/BPaLM) regimens has redefined clinical management. However, national tuberculosis programs (NTPs) require systematic health economic evaluations to justify programmatic transition. Following PRISMA 2020 and CHEERS 2022 guidelines, peer-reviewed economic evaluation literature was evaluated. BPaL/BPaLM regimens consistently demonstrate economic dominance or high cost-effectiveness across high-burden environments (e.g., South Africa, India, Georgia, Philippines, Moldova, Indonesia, Kyrgyzstan, Nigeria). Direct treatment cost reductions ranged from 20% to 78%, driven by a 60–80% decrease in health service utilization, outpatient monitoring visits, and inpatient bed-days. Budget impact models project overall 5-year programmatic expenditure reductions of 9–32% once scaled, alongside marked decreases in catastrophic household costs.