Cost-effectiveness of end-game strategies against sleeping sickness across the Democratic Republic of Congo

Gambiense human African trypanosomiasis (gHAT) is marked for elimination of transmission (EoT) by 2030. We examined the cost-effectiveness (CE) of EoT in the Democratic Republic of Congo, which has the highest global gHAT burden. In 165 health zones (HZs), we modelled the transmission dynamics, health outcomes, and economic costs of six strategies during 2024–40, including the cessation of activities after case reporting reduces to zero. Uncertainty in CE was assessed within the net monetary framework, which presents the optimal strategies at a range of willingness-to-pay (WTP) values, denominated in costs per disability-adjusted life-year averted. We assessed the optimal strategy for CE and EoT in each health zone separately, but we present results by health zone as well as aggregated by coordination and for the whole country. Status quo strategies, CE strategies (WTP=$500), and strategies with a high probability of EoT by 2030 are predicted to yield EoT by 2030 in 117 HZs, 130 HZs, and 138 HZs respectively, at a cost by 2040 of $171M (95% PI:$89.5M— 283M), $177M (95% PI: $97.9M—289M), $216M (95% PI: $119M–355M). A more lenient timeline of EoT by 2040 could lead to EoT in 153 HZs at a cost of $199M (95% PI: $109M–$327M), leaving 12 HZs shy of the goal. Costs would have to be front-loaded; in 2024, status quo strategies would cost $16.1M (95% PI: $8.44M—23.8M), minimum costs strategies would cost $17.0M (95% PI: $9.31M-–24.9M), and elimination strategies would cost $25.6M (95% PI: $15.8M—36.6M). Investing in EoT by 2030 is predicted to reduce 74% of gHAT deaths from 10,601 (95% PI: 1063—36,124) with status quo strategies to 2654 (95% PI: 301—9454).