Cost-effectiveness of competing diagnostic-therapeutic strategies for visceral leishmaniasis

Reported are the results of a formal decision analysis which facilitated th e choice of the most appropriate test-treatment strategy for visceral leish maniasis in areas where the disease is endemic. The following strategies we re compared: treatment of all suspects (strategy A); testing by means of pa rasitological investigation followed by treatment of positives (strategy B) ; two-step testing by means of the direct agglutination test (DAT) followed by treatment of patients with high titres as well as those with parasitolo gically confirmed borderline titres (strategy C); and DAT followed by treat ment of positives (strategy D). The results for each strategy were expressed as costs in US$ per death aver ted. The effectiveness of strategies C and D was close to that of strategy A and far better than that of strategy B. The cost-effectiveness ratio for strategies C and D (US$ 465 per death averted) was not substantially higher than that of testing by means of parasitological investigation followed by treatment of positives (strategy B), which was the most cost-effective str ategy at US$448 per death averted. At current prices of antimonial drugs, t he cost of lest-treatment strategies depends more on the cost of treatment than on that of testing. The use of a sensitive serological test such as th e DAT is recommended as the basis of test-treatment strategies for visceral leishmaniasis in areas where the disease is endemic.