Treatment options for rifampicin-resistant tuberculosis (RR-TB) remain limited, with existing regimens frequently prolonged and associated with poor tolerability. In light of emerging data from the TB-PRACTECAL trial, nations are evaluating the programmatic implementation of 6-month, fully oral regimens. A Markov model was employed to assess the incremental cost-effectiveness of three bedaquiline-, pretomanid-, and linezolid-based regimens (BPaL, with or without moxifloxacin [BPaLM] or clofazimine [BPaLC]) relative to the prevailing combination of longer and shorter standard-of-care (SOC) approaches for managing RR-TB, adopting the healthcare provider perspective in India, Georgia, the Philippines, and South Africa. Total costs (in 2019 USD) and disability-adjusted life years (DALYs) were projected over a 20-year horizon, applying a 3% discount rate in the base-case analysis. Univariate and probabilistic sensitivity analyses were conducted to address parameter uncertainty. Results indicated that all three regimens enhanced health outcomes while lowering costs compared to the existing mix of prolonged and abbreviated SOC protocols across the four countries. The BPaL regimen emerged as the most cost-saving option overall, yielding per-person savings of $112 to $1,173. At a willingness-to-pay threshold of 0.5 times GDP per capita per averted DALY, BPaLM was identified as the optimal choice in every setting. These results suggest that regimens built on BPaL are highly likely to be both cost-saving and more efficacious than current standards across diverse contexts. Nations should prioritize the programmatic adoption of BPaL-based treatments.
