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Sexually Transmitted Diseases:
doi: 10.1097/01.olq.0000245986.62775.b6
Article

Analysis of the Operational Costs of Using Rapid Syphilis Tests for the Detection of Maternal Syphilis in Bolivia and Mozambique

Levin, Carol E. PhD*; Steele, Matthew PhD, MPH*; Atherly, Deborah RPh, MPH*; García, Sandra G. ScM, ScD†; Tinajeros, Freddy MPH‡; Revollo, Rita MD, MPH‡; Richmond, Kara MPH§; Díaz-Olavarrieta, Claudia PhD†; Martin, Tom MPH∥; Floriano, Florencia¶; Massango, Isabel**; Gloyd, Stephen MD, MPH††

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Author Information

From *PATH, Seattle, Washington; †The Population Council, Regional Office for Latin America and the Caribbean, Mexico City, Mexico; ‡The Population Council, Bolivia–La Paz, Bolivia; §Independent consultant, Albuquerque, New Mexico; the ∥International Health Program, Department of Health Services. University of Washington, Seattle, Washington; ¶Health Alliance International, Beira, Mozambique; the **Ministry of Health, Division of Maternal and Child Health, Beira, Mozambique; and ††Health Alliance International, Seattle, Washington

The authors thank Health Alliance International and the Population Council Regional Office for Latin America who made the collaboration possible as well as the Bill & Melinda Gates Foundation for their support of this work. The authors are grateful to the many individuals who contributed to the success of this project, including Pablo Montoya and Noe Nhantumbo in Mozambique and Monica Gironas, Nayrha Villazon, and Carolina Montes in Bolivia. Thanks also go to the many nurses and public health officials who provided information and insights on syphilis screening in antenatal settings in Bolivia and Mozambique. The authors also thank 3 anonymous reviewers for their valuable comments.

Correspondence: Carol Levin, PhD, PATH, 1455 NW Leary Way, Seattle, WA 98107. E-mail: clevin@path.org.

Received for publication May 11, 2006, and accepted September 6, 2006.

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Abstract

Objective: The objective of this study was to compare the costs of antenatal syphilis screening with the rapid plasma reagin (RPR) test and the immunochromatographic strip (ICS) test in low-resource settings.

Goal: The goal of this study was to assess the costs of introducing rapid syphilis tests to reduce maternal and congenital syphilis.

Study Design: Cost data were collected from participating study hospitals and antenatal clinics during 4 field visits to the 2 countries in 2003 and 2004. Health utilization outcome data on the number of women screened and treated routinely during the demonstration projects were used with unit cost data to estimate the incremental costs and average cost per woman screened and treated for maternal syphilis.

Results: In Mozambique, the average cost per woman screened was U.S. $0.91 and U.S. $1.05 for the RPR and ICS tests, respectively. In Bolivia, the average cost of screening was U.S. $1.48 and U.S. $1.91 using the RPR and ICS test, respectively. In health centers without laboratories, the cost per woman screened using the ICS test ranged from U.S. $1.02 in Mozambique to U.S. $2.84 in Bolivia.

Conclusions: It is feasible to introduce rapid syphilis testing in settings without laboratory services at a small incremental cost per woman screened. In settings with laboratories, the cost of ICS is similar to that of RPR.

SYPHILIS IS A MAJOR CAUSE of adverse pregnancy outcomes in women and also an important cofactor for HIV acquisition and transmission in the developing world. Management of maternal syphilis relies on serologic screening in pregnancy and treatment with injectable penicillin. If left untreated, syphilis infection can lead to stillbirth, neonatal death, premature delivery, or congenital syphilis among newborns. Commonly, rapid plasma reagin (RPR) testing is carried out that identifies antibodies to phospholipid antigens on the surface of treponemes. This test is relatively easy to perform and has adequate sensitivity during early stages of infection. However, it does rely on basic laboratory equipment and may yield false-positive and -negative results depending on antibody presentation, the stage of infection, and carriage of other treponemal infections.1 In some cases, a positive screening test result with RPR will necessitate a second confirmatory test to prove that the treponemal infection is in fact syphilis. Rapid tests, those that can be performed with minimal equipment and skill and provide a result at the point of care, are now commonly available for screening pregnant women for syphilis.2,3 These tests, which are based on lateral flow immunochromatographic strip (ICS) platforms, detect specific syphilis treponemal antibodies similar to those used in confirmatory tests such as Treponema pallidum hemagglutination assay (TPHA) or T. pallidum particle agglutination (TPPA).1 The advantages of these rapid tests are that they are generally inexpensive, require no laboratory instrumentation and little training, and can be administered at the point of care, which allows for rapid diagnosis and treatment. The disadvantages of these rapid syphilis tests are that they do not distinguish between recent/current or historical infection because the antibodies are long-lived in the human body.

Both the RPR and ICS rapid tests represent strategies for screening pregnant women for syphilis infections. It is unclear which strategy yields the most efficient diagnosis and treatment per unit investment given the monetary, human resource, and opportunity costs associated with each test. Recent studies in sub-Saharan Africa have shown that an antenatal syphilis screening and treatment program using the RPR test is a very cost-effective intervention and provides good value for the investment. In Tanzania, the cost-effectiveness of antenatal syphilis screening using RPR was $10.56 per disability-adjusted life-year (DALY) saved. Data from other studies conducted in Zambia and Kenya provided cost-effectiveness estimates of $3.97 per DALY averted in Zambia and between $9.57 and $9.84 per DALY averted in Kenya (all costs are presented in 2001 U.S. dollars).4 Unfortunately, there are currently no published data on the cost-effectiveness of using rapid ICS tests as part of antenatal syphilis screening programs. Yet, there is an urgent need for information on the cost and cost-effectiveness of introducing rapid ICS tests to screen and test women for maternal syphilis. The rapid ICS syphilis test offers the potential to strengthen antenatal syphilis screening to reach greater numbers of women, especially in areas where screening with RPR is difficult to implement, faces operational challenges, or performs poorly.5

This study represents a first step in assessing the value and affordability of introducing the rapid ICS syphilis test in 2 different contexts in Bolivia and Mozambique. Both countries had already demonstrated a commitment to national programs to control congenital syphilis through antenatal syphilis screening. In Mozambique, universal syphilis screening has been a national policy since 1979, but it has been implemented inconsistently, especially in more remote areas at the provincial level. Poor laboratory quality, supply shortages, and late prenatal attendance contribute to the low screening rates.

In Bolivia, all women are eligible for universal maternal–child insurance, which reimburses health providers for up to 8 Bolivianos (approximately U.S. $1.00) for each syphilis test conducted as part of antenatal care. However, most antenatal testing clinics in rural settings lack the laboratory infrastructure and guidelines for providing screening and treatment for maternal syphilis.6,10

The specific objectives of this analysis were 1) to compare the cost of the rapid ICS and RPR tests in urban maternal hospitals with laboratories in Bolivia and in antenatal health clinics with laboratories in Mozambique, and 2) to evaluate the costs of introducing the rapid ICS tests during prenatal care visits conducted at rural health care centers that do not have the laboratory infrastructure or personnel to perform traditional syphilis tests in both countries. This analysis was designed from its beginning with the practical intention of generating critical evidence for policymakers on the costs of scaling up rapid syphilis testing in 2 country settings with existing national programs to control congenital syphilis.

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Methods

Study Setting

Two separate cost studies were conducted in Bolivia and Mozambique as part of larger demonstration projects supported by the Bill and Melinda Gates Foundation to evaluate the clinical and economic impact of rapid diagnostic tests in prenatal care clinics in both countries. Although the protocol of each demonstration project was tailored to meet the specific context and need in the 2 countries, the cost analyses were designed and implemented in both countries using the same methods to ensure that the analyses would be comparable. Each country selected their own commercially available rapid tests based on ease of use among healthcare workers, price, and long-term availability by local distributors. In Bolivia, the economic analysis was complementary to the Population Council’s evaluation to assess the feasibility and acceptability of the Abbott Determine rapid test for syphilis detection in 4 provinces in Bolivia. The demonstration project was implemented in 4 large maternity hospitals with high patient volumes in urban areas in La Paz, Santa Cruz, and Cochabamba and 37 rural health centers in the 4 study provinces. In the urban maternity hospitals, consenting women received their ICS test from nurses or laboratory technicians. Laboratory technicians also took an intravenous blood specimen from the same women and tested it using the RPR. In rural health facilities, women received their ICS tests from health workers. All women testing positive for syphilis by ICS were offered a single dose of benzathine penicillin immediately. For a full description of the study setting and study protocol, see Garcia et al in this issue.6 Cost data were collected during 2 field visits, in February 2004 and November 2004, from each of the project’s 4 urban maternity hospitals and from one rural health clinic participating in the study in the departments of La Paz, Santa Cruz, Cochabamba, and Chuquisaca (rural only).

In Mozambique, the economic evaluation was conducted in tandem with a collaborative project between Health Alliance International and Mozambique’s Ministry of Health to scale up the use of rapid syphilis testing in all health facilities providing antenatal care in Sofala and Manica provinces. An assessment of the introduction of the Standard Diagnostics rapid ICS test was carried out in 32 facilities with laboratories and 132 health facilities without laboratories. Nurses performed the ICS test as part of women’s antenatal care visit. Women were treated onsite with a single dose of benzathine penicillin based on the test results from the ICS. In facilities where RPR was conducted, laboratory staff took an intravenous sample from women and tested it using RPR. In these facilities, treatment was based on the test results from the RPR. For a more complete description of this project, see Gloyd et al in this issue.7 Cost data were collected during 2 field visits in August 2003 and March 2004 from a convenience sample of 6 health centers in Sofala and 3 health centers in Manica during the implementation of the project.

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Economic Analysis

We performed a partial economic analysis of the costs and health utilization outcomes of prenatal syphilis screening with RPR and ICS tests in Bolivia and Mozambique. Because this analysis was originally intended to inform decision-makers about the cost of scaling up antenatal syphilis screening services, we calculated the total and average costs for health utilization outcomes such as the number of pregnant women tested and treated for syphilis. Data were not available for a full cost-effectiveness analysis.

Both countries already conducted maternal syphilis screening and treatment as part of ongoing antenatal care services; therefore, this study estimated the incremental cost of screening and treating maternal syphilis using the rapid ICS test and did not estimate the full cost of antenatal care services. The viewpoint for the economic analyses was from the government perspective, because the Ministry of Health in each respective country is responsible for the decision to expand the use of syphilis testing using rapid syphilis tests and for allocating increased resources to cover the costs of improving antenatal syphilis screening programs.

The main outcomes of interest for the economic analyses were the average cost per woman tested using the RPR test, the average cost per woman tested using ICS, the average cost per woman treated for each testing method, and the average cost per woman treated with a true active case (in urban maternity hospitals or antenatal care clinics with laboratories only). The average cost per woman screened was simply the total cost of screening and treatment divided by the number of women screened. The average cost per woman treated was calculated by dividing the total costs of screening and treatment by the number of women treated. The average cost per woman treated with a true active case was the total costs of screening and treatment divided by the number of “true” active cases of syphilis. In Bolivia, the “true” active cases were determined by the gold standard, RPR confirmed by TPPA, as evaluated by the national reference laboratory (INLASA, La Paz, Bolivia). The prevalence of syphilis among participating women using the gold standard was only assessed for women participating at urban maternity hospitals, because syphilis testing using RPR was not available at rural health clinics. In Mozambique, true active cases were estimated based on the results of a clinical study conducted in Sofala comparing the test accuracy of the ICS and the positive results on RPR.8 In the Sofala study, active cases met the gold standard criteria of RPR, TPHA, and direct immunofluorescence stain. True active cases were then calculated by multiplying the positive predictive values of the ICS and RPR by our positive cases.

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Health Outcomes

Data on intermediate health outcomes such as coverage, syphilis prevalence among participating women, the number of “true” active cases detected (urban areas only), and the treatment of women were collected as part of the larger project in both Bolivia and Mozambique. In Bolivia, health outcome data for the RPR and ICS tests were estimated using data collected from January to April 2005.6 In Mozambique, utilization of syphilis screening services (e.g., the number of women screened, the number of women treated) was collected on a regular basis as part of the larger Health Alliance International (HAI) demonstration project.7 In Mozambique, participating antenatal clinics with laboratories switched from using the RPR to using the ICS for a 3-month period and then resumed screening using the RPR test. To compare typical screening and treatment rates for clinics already conducting syphilis screening, we used health utilization data on the number of women tested by RPR in the 2 months before the start of the project and the number of women tested by ICS 2 months after its introduction.

For introduction of the ICS test into antenatal health facilities without laboratories, the health utilization outcome data were for the project dates from June to December 2003.

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Costs

Cost data were collected using an ingredients-based costing methodology based on recommended World Health Organization guidelines.9 Each main activity of the antenatal syphilis screening program was defined (startup costs, including social mobilization, information, education, and communication (IEC) and training, clinical screening, laboratory analysis, and treatment) and the resources used to test and treat women were described for both the RPR and the ICS methods. Project staff interviewed health personnel and hospital administrators to obtain information on staff time (nursing staff, supervision, and laboratory staff), salaries, clinical consumable supplies, and laboratory equipment and supplies to run the RPR test and their associated costs. When available, price and expenditure data from project expense reports were used because many of the supplies for implementing syphilis testing using the rapid strip tests were procured directly by the Population Council in Bolivia or by HAI in Mozambique. The cost data captured both the financial and economic costs associated with the required startup and service delivery activities for implementing rapid ICS testing.* To the greatest extent possible, project expenses related to coordination and evaluation were excluded from this analysis.

The introduction of the rapid ICS test required startup activities such as social mobilization, IEC materials, guidelines, and training of health workers. Startup costs were treated as a form of fixed costs because these activities have an impact on the provision and utilization of services beyond the project through health worker training and raising women’s awareness of the need for maternal syphilis testing during pregnancy. In Bolivia, social mobilization costs included nationally distributed radio spots, posters, and promotional events. Because it was difficult to attribute the reach, impact, and cost-per-woman for nationwide promotion activities, these costs were omitted from the analysis. However, other startup costs for IEC materials, national syphilis testing and treatment guidelines, and national and provincial launches were included. In Mozambique, HAI used radio spots to promote women attending all maternal health services, including antenatal syphilis screening. We estimated that 25% of the total budget for radio spots was directly related to increasing awareness of syphilis testing. In both Bolivia and Mozambique, health workers received a one-time training on how to use the ICS rapid syphilis test for facilities in both urban and rural settings and in facilities with and without laboratories. We included the annualized cost of training prorated for the number of women included in each analysis for Bolivia and Mozambique. This analysis did not include any recurrent training for the RPR test. All the startup costs were annualized over a period of 5 years.

For service delivery, the annual costs of capital goods were calculated for laboratory equipment, including a centrifuge, RPR shaker, and refrigerator. In Mozambique, equipment was given an estimated life of 10 years and in Bolivia, the estimated life of equipment was between 8 and 10 years. All cost data were collected in the local currencies and converted to 2004 U.S. dollars using an exchange rate of U.S. $1.00 = 8 Bolivianos for the Bolivia analysis and U.S. $1.00 = 23,500 Metical for the Mozambique analysis. A discount rate of 3% was used to annualize capital costs. Appendix 1 provides additional details for specific cost categories for Bolivia and Mozambique.

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Results

Health Outcomes

The number of women tested using the ICS rapid test and RPR in Bolivia and Mozambique is presented in Table 1. Of the 11,618 women screened by the project in Bolivia, 8,900 were screened in urban maternity hospitals. Of these, 417 (4.7%) were treated with a single dose of penicillin based on the results of the ICS test. In rural facilities without laboratories, 2,178 women were screened. Of these, 121 (5.6%) were treated with a single dose of antibiotics. Because all women were treated on the basis of the ICS test results, even in urban settings, the hospital’s RPR test results were only used to get an estimate of the number of women who would have been treated based on the results from the RPR test only. Table 1 also presents the number of “true” active cases screened and treated using ICS and RPR results for urban hospitals with laboratories only where these data were available from the reference laboratory participating in the study. Fewer cases of syphilis were detected using the gold standard, RPR confirmed by TPPA, than either RPR alone or the ICS test. The number of false-positives was 23% higher using the RPR test results and 29% higher using the ICS test results.

Table 1
Table 1
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In Mozambique, the health outcome data capture the number of women tested by RPR in the 2 months before the start of the project. Of the 9,788 women tested by RPR, 704 (7.2%) tested positive and were treated with a single dose of penicillin. In Table 1, the number of women receiving the ICS test during 2 months after the start of the project was 9,119. Of these, 704 (7.7%) were treated with a single dose of penicillin. For the facilities without laboratories, 23,978 women were treated from June to December 2003. Of these, 1,653 (6.89%) tested positive and were treated based on the ICS results. Both tests resulted in false-positive results; however, the RPR test had both a greater number and higher percentage compared with the ICS test. The RPR resulted in 35% more false-positives compared with 29% with the ICS test.

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Incremental Costs

Table 2 presents the average unit costs used to estimate the incremental screening and treatment costs associated with the ICS and RPR used in Bolivia and Mozambique. Table 3 presents the incremental costs for the project period, including startup costs. The total incremental costs are essential for calculating the average costs per health utilization outcomes in each country. However, a comparison of total costs across the 2 countries is less meaningful because the project periods and the numbers of women screened are not directly comparable. Therefore, we briefly describe the total costs focusing on shares of total costs attributable to the main cost categories associated with syphilis screening and treatment.

Table 2
Table 2
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Table 3
Table 3
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In Bolivia, the total costs using the RPR in urban maternity hospitals with laboratories were $12,698 compared with $17,001 with the ICS. The total costs in rural health facilities without laboratories were $7,728, reflecting the lower number of women being treated in rural health centers. In the urban maternity hospitals, startup costs for promoting antenatal screening accounted for approximately 17% to 20% of total costs. Approximately 80% of total costs were for personnel and supplies. In rural health facilities, startup costs for promotion and training accounted for 48% of total costs, and personnel and supplies for testing and treatment accounted for 50%. In Mozambique, the total cost using the RPR was $8,937 and $9,538 for the ICS test. The incremental costs for introducing the ICS test in clinics without laboratories were $24,389. In Mozambique, startup costs to introduce the ICS test accounted for 11% to 12% in health facilities with and without laboratories. Personnel and supplies accounted for 88% to 89% of total costs associated with ICS testing in both types of facilities. For the RPR, recurrent costs for personnel and supplies accounted for 94%.

Treatment costs comprise a relatively small proportion of total costs of the total prevention program in both countries. In Bolivia, treatment costs accounted for less than 4% of total costs in urban maternity hospitals and less than 2% in rural health clinics. In Mozambique, treatment costs accounted for between 5% and 6% of total costs across facilities with and without laboratories.

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Cost Outcome Analyses
Bolivia

Table 4 presents cost estimates for the RPR and ICS tests using health utilization outcomes. In urban maternity hospitals with laboratories, the average cost per women screened was $1.43 using the RPR test and $1.91 using the ICS rapid test. The cost per woman screened was $2.84 in rural health facilities without laboratories. The higher average cost per woman screened in facilities without laboratories reflects relatively higher training costs in rural facilities where syphilis testing had not been previously offered to women during their antenatal care visits.

Table 4
Table 4
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Table 4 provides a comparison of the cost per woman treated using RPR and ICS. In urban maternity hospitals, the cost per woman treated by RPR was $40.09 and the cost per woman treated using the ICS test was only slightly higher at $40.77. The average cost per woman treated is slightly higher for the ICS test because the test is both more expensive and more sensitive than the RPR. One might expect the difference to be greater, but because treatment costs comprise only a small percentage of total costs, the greater number of women treated based on the ICS test results does not translate into much larger average costs. In rural health centers, the average cost per woman treated based on the ICS test was $63.87. Using the results from the reference laboratory to estimate the number of women with true active cases of syphilis, the cost per true case treated increased to $51.50 for the RPR test and $57.19 for the ICS test. The cost of both tests increased when the number of false-positives increased compared with the gold standard.

In Bolivia, the ICS test accounts for 62% of total screening and treatment costs, and the Abbott test was priced at $1.00 per test at the time of the study. If a less expensive test were used such as the Standard Diagnostic test ($0.35 per test), the average cost per woman screened would be $1.35, which is less than the RPR test at $1.43 per woman screened. At that price, the average cost per woman screened and treated using the ICS test declines to $28.77, which lowers the average cost per woman treated by 28% compared with using the RPR test.

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Mozambique

At health facilities with laboratories, the average cost per women screened was $1.05 using the ICS rapid test and $0.91 using the RPR test (Table 4). The cost per woman screened was $1.02 in health facilities without laboratories. This is slightly lower than the average cost per woman screened with the ICS test in facilities with laboratories, reflecting lower staff costs associated with health workers working in health centers in more remote clinics.

The average cost per woman treated in facilities with laboratories was $12.25 per woman treated based on the RPR test and $13.45 per woman treated based on the ICS test.

In facilities without laboratories, the average cost per woman treated based on the ICS test was $14.76. The increased cost of the ICS rapid syphilis test relative to the RPR reflects the lower sensitivity of the RPR. More women will be treated when using the ICS compared with the RPR, resulting in a higher average cost per woman treated using the ICS. Table 4 also compares the cost per woman with true active cases who were treated. The average cost per woman treated increased to $18.62 for the ICS rapid test and $19.14 for the RPR test. In Mozambique, the relatively larger decrease in true-positives compared with the decrease for the ICS resulted in a higher average cost per woman treated compared with the ICS test.

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Discussion

In both Bolivia and Mozambique, introducing rapid syphilis tests increased screening coverage among pregnant women, thus reducing the risk of congenital syphilis.6,7,10 In both countries, the average costs for the ICS tests were found to be slightly higher than the RPR. The increased cost was primarily the result of awareness raising and training expenses at the start of the project that are not required where syphilis screening with RPR is already well established. The difference in costs associated with introducing the ICS test in facilities with and without laboratories was more pronounced in Bolivia, where the training costs associated with introducing the rapid ICS test in rural health facilities were higher than in urban areas and also high relative to the number of rural women who were screened. The average cost of treatment was slightly higher when based on the ICS test results in both countries, reflecting the higher sensitivity of the ICS test to detect positive cases of syphilis. Although the RPR is cheaper, it is cheaper because it is missing women with syphilis and the treatment costs are saved for those women.

The analysis compared the average treatment costs on clinical data with the average costs based on the number of true cases determined by the gold standard assessment, demonstrating that the average cost per woman treated is sensitive to the test’s performance. As expected, the gold standard was more accurate in identifying true positives compared with either the RPR alone or the ICS test. Misclassifying the test results as false-positives led to a higher average cost per woman treated for both the RPR and the ICS test.

The cost outcome results for RPR and ICS testing for antenatal syphilis screening were context-dependent. In general, the variation in costs within and across countries reflects differences in the epidemiology of the disease, treatment patterns, and the complexity of healthcare service delivery systems in urban and rural areas with varying infrastructures and human resource capacities. In this analysis, the average cost of syphilis testing was higher in Bolivia than in Mozambique primarily because of higher healthcare costs and the use of a different, more expensive commercial test.

In Bolivia’s urban maternal hospitals, the RPR is slightly less expensive than the ICS test. Efficient laboratory systems and organized antenatal care laboratory testing protocols are already in place in many of Bolivia’s maternity hospitals. Although this analysis did not quantify the potential impact of rapid testing on women’s out-of-pocket expenses, the rapid test’s potential impact on saving women’s time and travel costs by reducing the number of follow-up visits would be limited, because most women are already attending antenatal care services on a regular basis. Still, even in urban hospital settings, a rapid syphilis test may have the potential to save women time and travel costs by offering same-day testing and treatment, especially for women traveling longer distances. Although the ease of use and quality concerns may favor the use of the ICS in urban settings, the potential for overtreatment of previously infected individuals—who will test positive with the ICS—must also be considered.8

The ICS test is an affordable screening option in rural health centers without laboratories in both Bolivia and Mozambique. In rural healthcare facilities without laboratories, screening was not conducted on a systematic, effective basis before introduction of the ICS test. Alternatives to the rapid ICS test such as building a laboratory or transporting blood to other clinics were not considered feasible. In Mozambique, significant disease will be averted for a cost of around $1.00 per woman screened and approximately $15.00 per woman treated. In Bolivia, the cost is higher, at around $2.85 per woman screened and approximately $60.00 per woman treated. However, if a less expensive test were used in Bolivia, these costs would be significantly lower. In Bolivia, where the government was already supporting syphilis screening for approximately $1.00 per woman, the incremental cost of increasing syphilis screening in rural areas will be an additional $1.85 per woman reached.

The cost per woman screened and treated for syphilis as part of antenatal care programs will vary by country and depend on which rapid syphilis test is used. The results in this study are similar to those found by other investigators in sub-Saharan Africa. Terris-Prestholt and colleagues reported the average cost of screening with the RPR as $1.44 per woman and an average cost per woman treated of $20.05.4 A Centers for Disease Control and Prevention-sponsored study in South Africa found a cost per woman screened of approximately U.S. $2 to U.S. $4.11

This study provided valuable information for policymakers and public health practitioners seeking to implement rapid syphilis screening programs in antenatal care settings in resource-poor settings. The cost analyses of the use of rapid syphilis testing in Bolivia and Mozambique made available very timely, relevant information for decision-makers alongside evidence on the increase in prenatal syphilis testing and the reduction of maternal syphilis in Mozambique and Bolivia.10 The study results summarized in this article were presented to the respective Ministries of Health in Bolivia and Mozambique, providing critical information into national-level policy decisions to expand coverage through the use of rapid syphilis tests in remote areas in Bolivia6 and contributed to ongoing discussions to strengthen the integration of essential prenatal care services such as syphilis testing with other interventions for preventing mother-to-child transmission of HIV and malaria treatment in Mozambique.7

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Appendix 1
Cost Categories and Definitions
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Syphilis Screening Supply and Equipment Costs
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Immunochromatographic Strip

In Bolivia, the Abbott Determine rapid test was used. The tests were available in kits of 200 provided by Abbott Diagnostics at a cost of $200.00 per kit or $1.00 per test. A less expensive test was used in Mozambique. The ICS rapid test is available in kits of 100 provided by Standard Diagnostics at a cost of $39.00 per kit or $0.39 per test. Both prices include the cost of transportation from the distributor to the port of entry in each country and include insurance. In Bolivia, the prices for gloves, lancets, pipette tips, cotton, alcohol, and biomedical waste containers were obtained from both hospital administration records and from the Population Council project records. In Mozambique, the prices for gloves, lancets, micropipette tubes, cotton, and alcohol were obtained from estimates submitted to the project by local suppliers in Beira. Costs of the biomedical waste container and sterile containers for holding supplies were estimated using data from a U.S.-based company price list.

There are several suppliers of the RPR test kits in Bolivia. Depending on the supplier and brand, the price of the RPR test ranges in price from $0.08 to $0.12 per test for 500 test kits. The cost of the RPR test used in Bolivia averages $0.11 per RPR test. In Mozambique, the RPR test kits are imported from South Africa, where there are also several different suppliers. The test ranges in price from $0.13 to $0.15 per test for 100 and 500 test kits, respectively. The cost used for Mozambique is an average price of $0.15 per RPR test for the 500 test kit.

The RPR also requires test tubes and pipettes for centrifuging the sample and drawing the serum from the test tube onto the RPR cards. In Bolivia, the additional costs for drawing blood include the cost of a 10-mL syringe ($0.13) and a Vacutainer test tube for capturing blood ($0.17). For the RPR in Mozambique, a 3-mL syringe cost $0.11 and a test tube for drawing blood was $0.07. Stockouts of syringes were frequently observed during the project implementation in Mozambique, requiring the use of more expensive medical supplies for drawing blood. However, for this analysis, we assumed that syringes would be used.

Laboratory equipment includes a centrifuge (with a capacity for 10 test tubes), a shaker, and a refrigerator. Because laboratory equipment is used for other activities, a share of the capital costs was allocated to syphilis testing. In Bolivia, 70% of the estimated capital costs for the centrifuge and shaker and 20% for the refrigerator were allocated to syphilis testing. In Mozambique, where there are fewer services offered, 90% of the centrifuge and shaker and 20% for the refrigerator were allocated to syphilis screening. The annual capital costs of smaller equipment were included for a pipette, test tube rack, and timer.

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Syphilis Screening and Treatment Personnel Costs

The cost of health worker, supervisor, and laboratory staff time consists of 2 parts: salary and benefits. In Bolivia, both of these have been estimated from salary data collected from health workers and laboratory technicians. Benefits are estimated as a 13th month bonus to the base salary. In Mozambique, salary and benefits have been estimated from salary data collected from the Ministry of Finance and Planning. Benefits are estimated as a percentage of the base salary for different job levels.

Observational data were used to estimate differences in labor time spent with women to counsel women and collect specimens by venipuncture compared with labor time spent with women to collect specimens by fingerstick. Interviews and observations with laboratory staff were used to estimate labor time of performing the RPR. From these observations, average labor time in minutes and average unit cost per minute were used to estimate total personnel costs for screening, treatment, and laboratory activities. In Bolivia, supervisory staff time was assumed to be approximately 10% and 13% of the time that clinical staff spent with women using the RPR and ICS tests, respectively, in urban hospitals. In rural facilities, it was assumed that the introduction of syphilis testing would require greater supervision. Supervision time was approximately 18% of the time that clinical staff spent with women using the ICS test. In Mozambique, supervisory staff time was assumed to be higher at approximately 25% of the time that clinical staff spent with women to account for their role in providing aggregated data on patient testing and treatment levels at higher administrative departments at the district and provincial level.

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Syphilis Treatment Supply and Costs

For treatment, the price of a 10-mL syringe is $0.13 and $0.15 in Bolivia and Mozambique, respectively. The actual price of the syringe might vary in practice in Mozambique, because patients are often responsible for purchasing their own syringes for treatment. The price of penicillin is $0.62 per dose in Bolivia and $0.49 per dose in Mozambique. In Bolivia, 9 participants with allergies to penicillin were offered an alternative treatment. However, this analysis exclusively considers the cost of the penicillin treatment. Syphilis treatment consists of a nurse’s time to counsel women and to administer a single dose of penicillin. Cited Here...

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References

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*Financial costs include the actual expenditures for all inputs and resources used to deliver the service. Economic costs capture the additional resources that are used to provide services that are not fully captured in budget expense reports (e.g., drugs, devices, or other supplies that have been donated or provided with a large discount, valuation of capital equipment, and so on). Cited Here...

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This article has been cited 3 time(s).

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