Antenatal Syphilis Screening Using Point-Of-Care Testing in Low- and Middle-Income Countries in Asia and Latin America: A Cost-Effectiveness Analysis

Abstract

BackgroundUntreated syphilis in pregnancy is associated with adverse clinical outcomes to the infant. In low- and middle-income countries in Asia and Latin America, 20%-30% of women are not tested for syphilis during pregnancy. We evaluated the cost-effectiveness of increasing the coverage for antenatal syphilis screening in 11 Asian and 20 Latin American countries, using a point-of-care immunochromatographic strip (ICS) test.MethodsThe decision analytical cost-effectiveness models reported incremental costs per disability-adjusted life years (DALYs) averted from the perspectives of the national health care payer. Clinical outcomes were stillbirths, neonatal deaths, and congenital syphilis. DALYs were computed using WHO disability weights. Costs included the ICS test, three injections of benzathine penicillin, and nurse wages. Country-specific inputs included the antenatal prevalence of syphilis and the proportion of women in the antenatal care setting that are screened for syphilis infection as reported in the 2014 WHO baseline report on global sexually transmitted infection surveillance. Country-specific data on the annual number of live births, proportion of women with at least one antenatal care visit, and per capita gross national income were also included in the model.ResultsThe incremental cost/DALY averted of syphilis screening is US$53 (range: US$10-US$332; Prob<1*per capita GDP=99.71%) in Asia and US$60 (range: US$5-US$225; Prob<1*per capita GDP=99.77%) in Latin America. Universal screening may reduce the annual number of stillbirths by 20,344 and 4,270, neonatal deaths by 8,201 and 1,721, cases of congenital syphilis by 10,952 and 2,298, and avert 925,039 and 197,454 DALYs in the aggregate Asian and Latin American panel, respectively.ConclusionAntenatal syphilis screening is highly cost-effective in all the 11 Asian and 20 Latin American countries assessed. Our findings support the decision to expand syphilis screening in countries with currently low screening rates or continue national syphilis screening programs in countries with high rates.

Syphilis

“…Furthermore, studies have shown that prenatal syphilis screening, treatment support testing and treatment during pregnancy are highly cost-effective in most countries regardless of prevalence or availability of resources, and can even be cost-saving in LMICs with syphilis prevalence ≥3% in pregnant women 47–50 . In China, where syphilis and HIV prevalence in pregnant women is low but rising, integration of prenatal syphilis and HIV screening was found to be highly cost-effective 51 .…”

Risk factors for syphilis in women: case-control study

“…Brazil is signatory of international plans for the elimination of syphilis. Recently, the World Health Organization (WHO) has defined, as goals for the certification of elimination of syphilis, the 95% of coverage of prenatal care and screening for syphilis in pregnant women, in order to reach the goal of congenital syphilis of 0.5 cases per 1,000 live births, which has been reached only by Cuba and Chile in the Latin America 12 .…”

“…In the Brazilian scenario, gestational syphilis presents a high magnitude and most cases continue to be diagnosed late, especially in the North and Northeast regions, where difficulties persist in the control of the disease a . The recognition of the complex and dynamic determination of sexually transmitted infections and the deepening of the knowledge on risk factors, in the relation to sociodemographic, behavioral, life condition, and organizational changes in the health system and services, can contribute to the updating of interventions aimed at them 9 , 12 .…”

Management of syphilis in pregnancy: Knowledge and practices of health care providers and barriers to the control of disease in Teresina, Brazil

“…Particularly worrying is the lack of knowledge regarding the rapid syphilis test, recommended by the WHO to improve access to syphilis diagnosis. There is evidence of the cost‐effectiveness of these tests for the treatment of syphilis during pregnancy and reports of high acceptance among professionals and users . The Brazilian MoH established the implementation of RST in PNC in 2011, which may explain the lower familiarity of professionals with these tests, given its more recent deployment.…”