Date Published: May 29, 2007
Publisher: Public Library of Science
Author(s): Bruce R Schackman, Christopher P Neukermans, Sandy N. Nerette Fontain, Claudine Nolte, Patrice Joseph, Jean W Pape, Daniel W Fitzgerald, Joshua A Salomon
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.
Partial Text: New global initiatives are financing large scale-up programs for the prevention of mother-to-child transmission of HIV in resource-poor countries . However, neonates who avoid HIV infection are still at risk of dying from congenital syphilis—a disease that can largely be prevented with inexpensive penicillin treatment of the pregnant mother if correctly diagnosed . An estimated 1 million pregnancies each year are adversely affected by syphilis due to maternal infection, and about half of these pregnancies end in stillbirth or neonatal death . Children who survive with congenital syphilis can suffer serious long-term adverse effects such as mental retardation, deafness, and blindness [4–6]. Most women in resource-poor countries receive inadequate testing and treatment for syphilis in pregnancy, often because they must walk many hours to the testing site and fail to return for follow-up appointments. Thus, the substantial resources devoted to scaling up prenatal HIV testing and treatment services may not fully achieve the goal of reducing infant mortality unless syphilis screening becomes more widely available.
In an era when substantial resources are going towards the prevention of mother-to-child transmission of HIV, there is an opportunity to integrate these efforts with programs to prevent congenital syphilis [30,31]. New rapid syphilis tests can be included in prenatal HIV testing programs operating in settings without access to same-day laboratory results. The current study demonstrates that such a prenatal syphilis screening strategy in Haiti using new rapid tests that permit same-day diagnosis and treatment have attractive incremental cost-effectiveness ratios when compared with current practice, which relies upon syndromic management or RPR testing with treatment at a follow-up visit. We project that integrating rapid syphilis screening into a scaled-up national program to test pregnant women for HIV in Haiti would prevent over 1,100 cases of congenital syphilis and over 1,200 neonatal deaths or stillbirths annually, mostly in rural areas. The cost-effectiveness of implementing this strategy is approximately $7.00/DALY in rural settings and $10.00/DALY in urban settings. The cost to prevent an adverse outcome of syphilis in pregnancy, including a stillbirth, a neonatal death, or an infant with congenital syphilis, is $108–$218 per adverse outcome in rural settings. The results of our analysis suggest that empirically treating all pregnant women with penicillin may be more cost-effective than the current practice in settings where syphilis testing is not feasible, even though mass treatment campaigns have had mixed success in other settings [32–34]. However, our analysis did not include the potential consequences of widespread antibiotic use in the empiric treatment strategy.