Part

01

*of three*

Part

01

## Tuberculosis Drug Costs: Brazil

To provide an estimate of the costs of prescription medications used to treat Tuberculosis (TB) in Brazil, we found the standard treatment regimen for TB and pricing for each medication. Below, I will explain the standard treatment regimen for non-drug-resistant TB and the calculations performed to estimate average cost. All the prices are Brazilian reals.

### TB Treatment in Brazil

Prior to 2010, Brazil used to use a combination of three drugs in two phases to treat TB. This treatment, called 2RHZ/4RH, included an intensive two-month phase in which a patient took rifampin, isoniazid, and pyrazinamide daily, followed by a four-month phase in which a patient took rifampin and isoniazid daily. After seeing drug resistances increase over a decade, the Brazilian National Tuberculosis Control Program decided to include another drug in the intensive phase — ethambutol. The new treatment, called 2RHZE/4RH, had a two-month intensive phase of rifampin, isoniazid, pyrazinamide, and ethambutol daily, followed by a four-month phase of rifampin and isoniazid.

Fixed-dose treatment is a treatment that combines fixed doses of each medication into one pill for a patient to take daily. Without information on pricing of these kinds of medications, we provided pricing for each medication separately, which is still a common form of treatment.

### Calculations

The following approach was taken to calculate the costs of drug treatment.

1. The number of pills needed for each medication was calculated using 30 days as a substitute for one month. Each pill is taken daily, meaning one day is equal to one pill.

Six (two intensive + four non-intensive) months of rifampin - 180 pills

Six (two intensive + four non-intensive) months of isoniazid - 180 pills

Two (two intensive) months of pyrazinamide - 60 pills

Two (two intensive) months of ethambutol - 60 pills

2. The Brazilian Chamber of Market Regulation of Medications (CMED) was used to find prices for each medication. CMED lists each drug by active ingredient and includes the factory price (PF) and the maximum consumer price (PMC) for each drug divided into several tax levels. Taxes on drugs differ by state, so I have listed the prices at the lowest and highest tax rates. The PF is the price that pharmacies and drugstores pay for drugs, and the PMC is the maximum price that pharmacies and drugstores can charge for each drug.

Not every drug was allowed to be sold to consumers, so I have broken the costs into PMC and PF pricings for more accuracy. Additionally, as these are the absolute highest prices that are allowed, if multiple generics exist I have chosen the lowest priced drug to avoid overestimation.

### Factory price (pf)

Rifampin (also known as rifampicin) costs R$10.53 - R$13.16 per 6 pills. TB treatment requires 180 rifampin pills, so the total cost would be between R$315.90 and R$394.80.

Isoniazid costs R$31.2 - R$39 per 10 pills. Treatment requires 180 pills, so the total cost would be between R$561.6 and R$702.

Pyrazinamide costs $R111.08 for 10 pills. Treatment requires 60 pills, so the total cost would be R$666.48.

Ethambutol costs R$162.99 for 5 pills. Treatment requires 60 pills, so the total cost would be R$1,955.88.

Based on the above, the total cost for TB treatment drugs purchased by a factory to treat one person is between R$3,499.86 and R$3,719.16.

### Maximum Consumer price (PMC)

For this calculation, I had to present prices for a drug other than ethambutol, is it is not available for purchase by consumers. A recent study showed that moxifloxacin can be a good substitute for ethambutol when treating TB, so I have included the PMC pricing for moxifloxacin in this estimate. Moxifloxacin is considerably cheaper than ethambutol, but without PMC pricing for it, ethambutol cannot be included in this estimation.

Rifampin (also known as rifampicin) costs R$14.56 - R$18.19 per 6 pills. TB treatment requires 180 rifampin pills, so the total cost would be between R$436.8 and R$545.7.

Isoniazid costs R$43.13 - R$53.92 per 10 pills. Treatment requires 180 pills, so the total cost would be between R$776.34 and R$970.56.

Pyrazinamide costs $R153.6 for 10 pills. Treatment requires 60 pills, so the total cost would be R$921.36.

Moxifloxacin costs R$80.72 -R$100.9 for 5 pills. Treatment requires 60 pills, so the total cost would be between R$968.64 and R$1,210.8.

Based on the figures provided above, the total cost for TB treatment drugs purchased by a consumer to treat one person ranges between R$3,103.14 and R$3,648.42.

### Note on pricing and purchasing

Drug pricing for consumers is a bit of a nebulous way to calculate the cost of prescription medications because essential medicines that treat the most common diseases (like TB) are distributed free of charge to Brazilian citizens, which means some people pay nothing for their TB treatment. However, the availability of these free medications is not always enough to satisfy need, so the Brazilian government launched a “popular pharmacy” program that sells medications at low prices. Even though medication is supposed to be free to citizens, Brazilians spend about 2% of all household income on medications. About a quarter of families in Brazil pay for private health insurance, which does not cover all medications. Due to the inaccessibility of free medicines and the use of private insurance, medication still has consumer pricing.

### Conclusion

The factory price for the drugs needed to treat TB in one person in Brazil ranges between R$3,499.86 and R$3,719.16. The consumer price for this treatment is R$3,103.14 and R$3,648.42, with ethambutol substituted with commercially available moxifloxacin. If the medications are available, some people in Brazil may not even pay for their TB treatment as the government may provide essential medicines free of charge.