Cost-Effectiveness of Rapid Syphilis Screening in Prenatal HIV Testing Programs in Haiti

Abstract

BackgroundNew rapid syphilis tests permit simple and immediate diagnosis and treatment at a single clinic visit. We compared the cost-effectiveness, projected health outcomes, and annual cost of screening pregnant women using a rapid syphilis test as part of scaled-up prenatal testing to prevent mother-to-child HIV transmission in Haiti.Methods and FindingsA decision analytic model simulated health outcomes and costs separately for pregnant women in rural and urban areas. We compared syphilis syndromic surveillance (rural standard of care), rapid plasma reagin test with results and treatment at 1-wk follow-up (urban standard of care), and a new rapid test with immediate results and treatment. Test performance data were from a World Health Organization–Special Programme for Research and Training in Tropical Diseases field trial conducted at the GHESKIO Center Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes in Port-au-Prince. Health outcomes were projected using historical data on prenatal syphilis treatment efficacy and included disability-adjusted life years (DALYs) of newborns, congenital syphilis cases, neonatal deaths, and stillbirths. Cost-effectiveness ratios are in US dollars/DALY from a societal perspective; annual costs are in US dollars from a payer perspective. Rapid testing with immediate treatment has a cost-effectiveness ratio of $6.83/DALY in rural settings and $9.95/DALY in urban settings. Results are sensitive to regional syphilis prevalence, rapid test sensitivity, and the return rate for follow-up visits. Integrating rapid syphilis testing into a scaled-up national HIV testing and prenatal care program would prevent 1,125 congenital syphilis cases and 1,223 stillbirths or neonatal deaths annually at a cost of $525,000.ConclusionsIn Haiti, integrating a new rapid syphilis test into prenatal care and HIV testing would prevent congenital syphilis cases and stillbirths, and is cost-effective. A similar approach may be beneficial in other resource-poor countries that are scaling up prenatal HIV testing.

Maternal and congenital syphilis in rural Haiti

“…Rapid point-of-care syphilis testing during pregnancy has been studied in Haiti and has been shown to be very cost-effective (10). The HHF treatment regimen at the time of this study was two doses of benzathine penicillin, 2.4 million units intramuscularly, given 8 days apart (see below for current treatment regimen).…”

“…associated with congenital syphilis (9,10). Both the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) strongly recommend that all pregnant women, regardless of where they live, be tested for syphilis in the early stages of pregnancy or on the first prenatal visit (11,12).…”

Scaling up syphilis testing in China: implementation beyond the clinic

“…Cost-effectiveness analyses of antenatal syphilis screening have been conducted in several countries, 34,37,44,45 including China. 37 Preliminary data from both national government programmes and WHO pilot programmes suggest that routine syphilis screening for pregnant women is feasible, but more work and operational research are needed to ensure sustainability, especially as international programmes are completed and routine services resume.…”

“…[34][35][36][37] The largest Chinese experience with syphilis screening tested nearly half a million pregnant women at antenatal clinics in a city over a three-year period, using government funded syphilis tests. They found 0.5% of women had a positive rapid plasma reagin (RPR) and Treponema pallidum particle agglutination assay (TPPA), and thus successfully treated 1855 pregnant women with syphilis infection.…”

The role of Point-of-Care testing in the diagnosis of syphilis

“…Nowadays, antenatal screening and treatment of maternal syphilis are cost-effective health interventions [62], even under low prevalence of infection of 1 and 2 %, as shown by Kashiap et al (2015) [45] and Mallma et al (2015) [46], especially when using POCTT.…”