Active cases of tuberculosis (TB) cost low- and middle-income countries (LMICs) with heavy TB burdens $3.5 billion more in current annual and future lost earnings and medical expenses than HIV, yet receives substantially less funding, researchers in Peru and the United States write in a new study published in BMJ Global Health.

The researchers used a model to estimate the economic costs of TB and HIV to households and the economy, including factors such as the effects of parental disability or death on children’s future earnings, in 25 LMICs. The analysis was based on data from sources such as the World Health Organization (WHO) Global Tuberculosis Report, the Institute for Health Metrics and Evaluation’s Global Burden of Disease dataset, and Demographic Household Surveys.

TB incidence per 100,000 people ranges from 58 in China to 615 in South Africa, while HIV rates per 1,000 people range from 0.01 in Bangladesh to 4.70 in Mozambique, the authors noted. 

“Tuberculosis (TB) poses a significant disease burden in 25 low- and middle-income countries (LMICs), comparable to that of HIV in these countries,” they wrote. “Despite TB prevention and treatment being more cost-effective (in terms of cost per health outcome), its funding is merely a fraction of HIV’s, fluctuating between 10–20% since 2000.” 

Costs of less consumption, lost education

TB led to a total estimated loss of $36.6 billion per year in study countries. Active cases led to $3.7 billion in losses from reduced consumption and $11.6 billion from lost education. Fatal TB cases added losses of $10 billion in reduced consumption and $5.6 billion from lost education, with medical expenses adding another $5.7 billion each year. 

India had the greatest estimated loss, at $9.8 billion, which accounted for 27% of total costs, followed by China, at $5.1 billion. 

HIV illness led to $2 billion in losses from reduced consumption and $17.7 billion from lost education. Deaths from HIV accounted for another $3.5 billion in reduced consumption and $3.2 billion from lost schooling, with estimated yearly losses of $5.4 billion currently and $20.9 billion in the future. 

Medical HIV expenses totaled $6.1 billion per year. South Africa bore the largest burden of these costs, with losses of $16.3 billion, representing half of all HIV-associated costs in the countries studied.

Household-level losses, including medical costs, varied widely by country, reflecting differences in education level, financial returns on education, fertility rates, average income, and disease age distribution. 

For example, TB current costs ranged from 24% in Zimbabwe to 88% in Afghanistan. When total medical expenses were taken into account, the variability in the percentage of total TB costs is even higher, ranging from 3% in Indonesia to over 80% in Ukraine and the Kyrgyz Republic.

Treatment for TB is time-limited, while HIV is lifelong

The cost of preventing and treating TB is much lower than that for HIV, mainly because TB treatment is time-limited and that for HIV is lifelong, the researchers said. As a result, the economic return on investments in TB prevention and treatment is substantially higher than that of HIV. 

These results advocate for increased funding for TB relative to funding for HIV in these countries because the returns to incremental funding for TB are greater than those for HIV at current funding levels.

Averting one TB death, for example, prevents an average economic loss of $12,480, with the cost of prevention estimated at $1,313, for a net savings of $11,167.

“This contrasts sharply with HIV, where the cost of preventing a death exceeds the economic savings,” the authors wrote. “Thus, the net estimated savings for TB prevention are estimated at US$3421 in low-income countries (LICs) and US$12 113 in lower-middle-income countries, versus net costs for HIV at US$13 709 and US$28 094, respectively.”

“These results advocate for increased funding for TB relative to funding for HIV in these countries because the returns to incremental funding for TB are greater than those for HIV at current funding levels,” they concluded.