Impact of DOTS expansion on tuberculosis related outcomes and costs in Haiti

Using decision analysis incorporating multiple Markov processes (Markov modelling), we compared expected tuberculosis morbidity, mortality and costs in Haiti with DOTS expansion to reach all of the country, and achieve WHO benchmarks, or if the current situation did not change. Probabilities of tuberculosis related outcomes were derived from the published literature. Government health expenditures, patient and family costs were measured in direct surveys in Haiti and expressed in 2003 US$.Starting in 2003, DOTS expansion in Haiti is anticipated to cost $4.2 million and result in 63,080 fewer tuberculosis cases, 53,120 fewer tuberculosis deaths, and net societal savings of $131 million, over 20 years. Current government spending for tuberculosis is high, relative to the per capita income, and would be only slightly lower with DOTS. Societal savings would begin within 4 years, and would be substantial in all scenarios considered, including higher HIV seroprevalence or drug resistance, unchanged incidence following DOTS expansion, or doubling of initial and ongoing costs for DOTS expansion.A modest investment for DOTS expansion in Haiti would provide considerable humanitarian benefit by reducing tuberculosis-related morbidity, mortality and costs for patients and their families. These benefits, together with projected minimal Haitian government savings, argue strongly for donor support for DOTS expansion.Between 1997 and 2002 the incidence of active TB increased in most low and middle income countries [1]. This occurred despite the availability of adequate tools for diagnosis and treatment, and an effective TB control strategy – which has been labelled DOTS. This strategy, originally developed in sub-Saharan Africa, is being promoted by the World Health Organisation (WHO) [2] because it is feasible in high-burden settings [3], cost-effective even in low income countries [4], and can result in substantial reduction in TB incidence [5].However, between $290 – $500 millio