Background:
Estimated annual incidence of MDR-TB is 480,000, representing 5% of TB incidence, but 20% of mortality. Multiple drugs have recently been developed or re-purposed for the treatment of MDR-TB. Currently, treatment for MDR-TB costs thousands of dollars per course.

Objectives:
To estimate generic prices for novel TB drugs that would be possible given large-scale competitive manufacture.

Methods:
Prices for linezolid, moxifloxacin, and clofazimine were estimated based on per-kilogram prices of active pharmaceutical ingredient (API). Other costs were added, including formulation, packaging and a profit margin. The costs of projection for sutezolid were estimated to be equivalent to those for linezolid, based on chemical similarit
y. Generic prices for bedaquiline, delamanid, and pretomanid were estimated by assessing routes of synthesis, costs/kg of chemical reagents, routes of synthesis, and per-step yields. Costing algorithms reflected variable regulatory requirements, efficiency of scale based on demand, and were validated by testing predictive ability against widely-available TB medicines.

Results:
Estimated generic prices were USD $8-$17/month for bedaquiline, $5-$16/month for delamanid, $11-$3 /month for pretomanid, $4-$9/month for linezolid, $4-$9/month for sutezolid, $4-$11/month for clofazimine, and $4-$8/month for moxifloxacin. Estimated generic prices were 87%-94% lower than current lowest available prices for bedaquiline, 95%-98% for delamanid, 94%-97% for linezolid. Estimated generic prices were $168-$395 per course for the STREAM trial modified Bangladesh regimens (current cost
s $734-$1,799), $53-$276 for pretomanid-based three-drug regimens, and $238-$507 for a delamanid-based four-drug regimen.

Conclusions:
Competitive large-scale generic manufacture could allow supplies of treatment for 5-10 times more MDR-TB cases within current procurement budgets.