Relative Cost and Infectious Days Averted Associated With Rapid Gonorrhea and Chlamydia Testing Among Men Who Have Sex With Men.

BACKGROUND: Standard-of-care nucleic acid amplification tests (routine NAATs) for Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) can take several days to result and therefore delay treatment. Rapid point-of-care GC/CT NAAT (rapid NAAT) could reduce the time to treatment and therefore onward transmission. This study evaluated the incremental cost per infectious day averted and overall cost of implementation associated with rapid compared with routine NAAT. METHODS: Prospective sexually transmitted infection (STI) treatment data from men who have sex with men and transgender women in San Diego who received rapid NAAT between November 2018 and February 2021 were evaluated. Historical time from testing to treatment for routine NAAT was abstracted from the literature. Costs per test for rapid and routine NAAT were calculated using a micro-costing approach. The incremental cost per infectious day averted comparing rapid to routine NAAT and the costs of rapid GC/CT NAAT implementation in San Diego Public Health STI clinics were calculated. RESULTS: Overall, 2333 individuals underwent rapid NAAT with a median time from sample collection to treatment of 2 days compared with 7 to 14 days for routine NAAT equating to a reduction of 5 to 12 days. The cost of rapid and routine GC/CT NAAT was $57.86 and $18.38 per test, respectively, with a cost-effectiveness of between $2.43 and $5.82 per infectious day averted. The incremental cost of rapid NAAT improved when at least 2000 tests were performed annually. CONCLUSIONS: Although rapid GC/CT NAAT is more expensive than routine testing, the reduction of infectious days between testing and treatment may reduce transmission and provide improved STI treatment services to patients.

Vaccination May Be Economically and Epidemiologically Advantageous Over Frequent Screening for Gonorrhea Prevention.

BACKGROUND: Gonorrhea's rapid development of antimicrobial resistance underscores the importance of new prevention modalities. Recent evidence suggests that a serogroup B meningococcal vaccine may be partially effective against gonococcal infection. However, the viability of vaccination and the role it should play in gonorrhea prevention are an open question. METHODS: We modeled the transmission of gonorrhea over a 10-year period in a heterosexual population to find optimal patterns of year-over-year investment of a fixed budget in vaccination and screening programs. Each year, resources could be allocated to vaccinating people or enrolling them in a quarterly screening program. Stratifying by mode (vaccination vs. screening), sex (male vs. female), and enrollment venue (background screening vs. symptomatic visit), we consider 8 different ways of controlling gonorrhea. We then found the year-over-year pattern of investment among those 8 controls that most reduced the incidence of gonorrhea under different assumptions. A compartmental transmission model was parameterized from existing literature in the US context. RESULTS: Vaccinating men with recent symptomatic infection, which selected for higher sexual activity, was optimal for population-level gonorrhea control. Given a prevention budget of $3 per capita, 9.5% of infections could be averted ($299 per infection averted), decreasing gonorrhea sequelae and associated antimicrobial use by similar percentages. These results were consistent across sensitivity analyses that increased the budget, prioritized incidence or prevalence reductions in women, or lowered screening costs. Under a scenario where only screening was implemented, just 5.5% of infections were averted. CONCLUSIONS: A currently available vaccine, although only modestly effective, may be superior to frequent testing for population-level gonorrhea control.

Cost-effectiveness of two screening strategies for Chlamydia trachomatis and Neisseria gonorrhoeae as part of the PrEP programme in the Netherlands: a modelling study.

OBJECTIVES: Pre-exposure prophylaxis (PrEP) users are routinely tested four times a year (3 monthly) for asymptomatic Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections on three anatomical locations. Given the high costs of this testing to the PrEP programme, we assessed the impact of 3 monthly screening(current practice), compared with 6 monthly on the disease burden. We quantified the difference in impact of these two testing frequencies on the prevalence of CT and NG among all men who have sex with men (MSM) who are at risk of an STI, and explored the cost-effectiveness of 3-monthly screening compared with a baseline scenario of 6-monthly screening. METHODS: A dynamic infection model was developed to simulate the transmission of CT and NG among sexually active MSM (6500 MSM on PrEP and 29 531 MSM not on PrEP), and the impact of two different test frequencies over a 10-year period. The difference in number of averted infections was used to calculate incremental costs and quality-adjusted life-years (QALY) as well as an incremental cost-effectiveness ratio (ICER) from a societal perspective. RESULTS: Compared with 6-monthly screening, 3-monthly screening of PrEP users for CT and NG cost an additional €46.8 million over a period of 10 years. Both screening frequencies would significantly reduce the prevalence of CT and NG, but 3-monthly screening would avert and extra ~18 250 CT and NG infections compared with 6-monthly screening, resulting in a gain of ~81 QALYs. The corresponding ICER was ~€430 000 per QALY gained, which exceeded the cost-effectiveness threshold of €20 000 per QALY. CONCLUSIONS: Three-monthly screening for CT and NG among MSM on PrEP is not cost-effective compared with 6-monthly screening. The ICER becomes more favourable when a smaller fraction of all MSM at risk for an STI are screened. Reducing the screening frequency could be considered when the PrEP programme is established and the prevalence of CT and NG decline.

Cost-effectiveness of Sexually Transmitted Infection Screening for Adolescents and Young Adults in the Pediatric Emergency Department.

Importance: Adolescents and young adults compose almost 50% of all diagnosed sexually transmitted infection (STI) cases annually in the US. Given that these individuals frequently access health care through the emergency department (ED), the ED could be a strategic venue for examining the identification and treatment of STIs. Objective: To examine the cost-effectiveness of screening strategies for Chlamydia trachomatis and Neisseria gonorrhoeae (chlamydia and gonorrhea) in adolescents and young adults who seek acute care at pediatric EDs. Design, Setting, and Participants: This economic evaluation is a component of an ongoing, larger multicenter clinical trial at the Pediatric Emergency Care Applied Research Network. A decision analytic model, created using literature-based estimates for the key parameters, was developed to simulate the events and outcomes associated with 3 strategies for screening and testing chlamydial and gonococcal infections in individuals aged 15 to 21 years who sought acute care at pediatric EDs. Data sources included published (from January 1, 1997, to December 31, 2019) English-language articles indexed in MEDLINE, bibliographies in relevant articles, insurance claims data in the MarketScan database, and reimbursement payments from the Centers for Medicare and Medicaid Services. Because the events and outcomes were simulated, a hypothetical population of 10 000 ED visits by adolescents and young adults was used. Interventions: The 3 screening strategies were (1) no screening, (2) targeted screening, and (3) universally offered screening. Targeted screening involved the completion of a sexual health survey, which yielded an estimated STI risk (at risk, high risk, or low risk). Main Outcomes and Measures: Outcome metrics included cost (measured in 2019 US dollars) and the detection and successful treatment of STIs. The incremental cost-effectiveness ratio (ICER) of each strategy was calculated in a base case analysis. The ICER reflects the cost per case detected and successfully treated. Results: A 3.6% prevalence of chlamydia and gonorrhea was applied to a hypothetical population of 10 000 ED visits by adolescents and young adults. Targeted screening resulted in the detection and successful treatment of 95 of 360 STI cases (26.4%) at a cost of $313 063, and universally offered screening identified and treated 112 of 360 STI cases (31.1%) at a cost of $515 503. The ICER for targeted screening vs no screening was $6444, and the ICER for universally offered screening vs targeted screening was $12 139. Conclusions and Relevance: This economic evaluation found that targeted screening and universally offered screening compared with no screening appeared to be cost-effective strategies for identifying and treating chlamydial and gonococcal infections in adolescents and young adults who used the ED for acute care. Universally offered screening was associated with detecting and successfully treating a higher proportion of STIs in this population.

Budgeting for comprehensive sexual and reproductive health and rights under universal health coverage.

Achieving universal health coverage (UHC) for sexual and reproductive health (SRH) requires informed budgeting that is aligned with UHC objectives. We draw data from Adding It Up 2019 (AIU-2019) to provide critical new country-level and regional, intervention-specific costs for the provision of SRH services. AIU-2019 is a cost-outcomes analysis, undertaken from the health system perspective, which estimates the costs and impacts of offering SRH care in low- and middle-income countries. We present direct cost estimates for 109 SRH interventions and find that human resources comprise the largest category of direct SRH service costs and that the most expensive services in the model are largely preventable. We use scenario analysis to explore the synergistic costs and impacts of providing SRH interventions in clusters, focussing on chlamydia and gonorrhoea treatment, provision of safe abortion and post-abortion care services, and safe childbirth services. When costs are considered for the preventive and impacted services in these three clusters, there are cost savings for some of the impacted services in the packages and for the abortion-related package overall. The direct cost estimates from our analysis can be used to guide UHC budgeting and planning efforts. Having these cost estimates and understanding the potential for cost savings when providing comprehensive SRH services are critical for efforts to fulfil the rights and needs of all individuals, including the most marginalised, to access this essential care.

Addressing Neisseria gonorrhoeae Treatment Resistance With the DNA Gyrase A Assay: An Economic Study, United States.

Targeted antibiotics could delay emergence of resistant Neisseria gonorrhoeae. The DNA gyrase subunit A assay predicts susceptibility to ciprofloxacin. A model found that adding a $50 gyrase subunit A test for asymptomatic patients screened for N. gonorrhoeae resulted in cost neutrality. When ciprofloxacin susceptibility was high, a $114 test resulted in savings.

Sexually Transmitted Disease Partner Services Costs, Other Resources, and Strategies Across Jurisdictions to Address Unique Epidemic Characteristics and Increased Incidence.

BACKGROUND: Sexually transmitted disease (STD) partner services (PS) are a core component of STD programs. Data on costs are needed to support PS programming. METHODS: In Washington State STD PS programs, disease intervention specialists (DIS) conduct telephone-based interviews and occasional field visits, offer expedited partner therapy to heterosexuals with gonorrhea or chlamydia, and promote human immunodeficiency virus (HIV) testing, preexposure prophylaxis, and HIV care. We conducted activity-based microcosting of PS, including: observational and self-reported time studies and interviews. We analyzed cost, surveillance, and service delivery data to determine costs per program outcomes. RESULTS: In King, Pierce, and Spokane counties, respectively, DIS allocated 6.5, 6.4, and 28.8 hours per syphilis case and 1.5, 1.6, and 2.9 hours per gonorrhea/chlamydia case, on average. In 2016, each full-time DIS investigated 270, 268, and 61 syphilis and 1177, 1105, and 769 gonorrhea/chlamydia cases. Greater than 80% of syphilis cases in King and Pierce were among men who have sex with men versus 38% in Spokane. Disease intervention specialists spent 12% to 39% of their time actively interviewing cases and notifying partners (clients), and the remaining time locating clients, coordinating and verifying care, and managing case reports. Time spent on expedited partner therapy, HIV testing, and referrals to HIV treatment or preexposure prophylaxis, was minimal (<5 minutes per interview) at locations with resources outside PS staff. Program cost-per-interview ranged from US $527 to US $2210 for syphilis, US $219 to US $484 for gonorrhea, and US $164 to US $547 for chlamydia. DISCUSSION: The STD PS resource needs depended on epidemic characteristics and program models. Integrating HIV prevention objectives minimally impacted PS-specific program costs. Results can inform program planning, future budget impact, and cost-effectiveness analyses.

Assessing the Burden of Chlamydia and Gonorrhea for Deployed and Active Duty Personnel Assigned Outside the USA.

Sexually transmitted infections (STIs) have posed a threat to military service members throughout history, but limited evidence describes current sexually transmitted infection burden for personnel in-theater and stationed abroad. This study assessed chlamydia and gonorrhea rates by unit of country assignment and evaluated the demographic profile of affected personnel during deployment. Chlamydia and gonorrhea cases among active duty personnel were identified from laboratory results and ambulatory encounter records in the Military Health System from fiscal years October 2006 through September 2015; these were linked to personnel and deployment records to ascertain demographic characteristics, unit of country assignment, and if the case was captured during a period of deployment. Case rates were higher for chlamydia (1,321.7 per 100,000) than gonorrhea (222.7 per 100,000). Approximately 2% of both chlamydia and gonorrhea cases were identified during deployment, with significant differences by service, sex, and age. Elevated rates were identified in several countries of unit assignment outside the USA, warranting further assessment to better understand implications of screening programs or increased morbidity. Pertinent limitations for this study potentially underestimate STI cases during deployment, due to incomplete capture of records from shipboard and in-theater facilities.

Prevalence, risk factors, and medical costs of Chlamydia trachomatis infections in Shandong Province, China: a population-based, cross-sectional study.

BACKGROUND: A population-based study of Chlamydia trachomatis (CT) infections is essential in designing a specific control program; however, no large investigation of CT infections among the general population in mainland China has been conducted since 2000. We aimed to determine the prevalence, risk factors, and associated medical costs of CT among residents, 18-49 years of age, in Shandong, China. METHODS: From May to August 2016, a multistage probability sampling survey involving 8074 individuals was distributed. Data were collected via face-to-face interviews, followed by self-administered questionnaire surveys. First-void urines were collected and tested for CT and Neisseria gonorrhoeae (NG) using nucleic acid amplification. RESULTS: The weighted prevalence of CT infection was 2.3% (95% confidence interval [CI], 1.5-3.2) in females and 2.7% (1.6-3.8) in males. Women, 30-34 years of age, had the highest prevalence of CT infections (3.5%, 2.6-4.4), while the highest prevalence of CT infections in males was in those 18-24 years of age (4.3%, 0.0-8.8). Neisseria gonorrhoeae infection had a prevalence of 0.1% (0.0-0.3) in women and 0.03% (0.0-0.1) in men. Risk factors for CT infections among females included being unmarried, divorced, or widowed (odds ratio [OR], 95% CI 3.57, 1.54-8.24) and having two or more lifetime sex partners (3.72, 1.14-12.16). Among males, first intercourse before 20 years of age (1.83, 1.10-3.02) and having two or more lifetime sex partners (1.85, 1.14-3.02) were associated with CT infections. The estimated lifetime cost of CT infections in patients 18-49 years of age in Shandong was 273 million (range, 172-374 million) China Renminbi in 2016. CONCLUSIONS: This study demonstrated a high burden of CT infections among females < 35 years of age and males < 25 years of age in Shandong. Thus, a CT infection control program should focus on this population, as well as others with identified risk factors.

Modelling-based evaluation of the costs, benefits and cost-effectiveness of multipathogen point-of-care tests for sexually transmitted infections in symptomatic genitourinary medicine clinic attendees.

OBJECTIVES: To quantify the costs, benefits and cost-effectiveness of three multipathogen point-of-care (POC) testing strategies for detecting common sexually transmitted infections (STIs) compared with standard laboratory testing. DESIGN: Modelling study. SETTING: Genitourinary medicine (GUM) services in England. POPULATION: A hypothetical cohort of 965 988 people, representing the annual number attending GUM services symptomatic of lower genitourinary tract infection. INTERVENTIONS: The decision tree model considered costs and reimbursement to GUM services associated with diagnosing and managing STIs. Three strategies using hypothetical point-of-care tests (POCTs) were compared with standard care (SC) using laboratory-based testing. The strategies were: A) dual POCT for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG); B) triplex POCT for CT-NG and Mycoplasma genitalium (MG); C) quadruplex POCT for CT-NG-MG and Trichomonas vaginalis (TV). Data came from published literature and unpublished estimates. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes were total costs and benefits (quality-adjusted life years (QALYs)) for each strategy (2016 GB, £) and associated incremental cost-effectiveness ratios (ICERs) between each of the POC strategies and SC. Secondary outcomes were inappropriate treatment of STIs, onward STI transmission, pelvic inflammatory disease in women, time to cure and total attendances. RESULTS: In the base-case analysis, POC strategy C, a quadruplex POCT, was the most cost-effective relative to the other strategies, with an ICER of £36 585 per QALY gained compared with SC when using microcosting, and cost-savings of £26 451 382 when using tariff costing. POC strategy C also generated the most benefits, with 240 467 fewer clinic attendances, 808 fewer onward STI transmissions and 235 135 averted inappropriate treatments compared with SC. CONCLUSIONS: Many benefits can be achieved by using multipathogen POCTs to improve STI diagnosis and management. Further evidence is needed on the underlying prevalence of STIs and SC delivery in the UK to reduce uncertainty in economic analyses.

Impact of point-of-care management on the transmission of anogenital gonococcal infections among men who have sex with men in Amsterdam: a mathematical modelling and cost-effectiveness study.

OBJECTIVE: Point-of-care (POC) management may avert ongoing transmissions occurring between testing and treatment or due to loss to follow-up. We modelled the impact of POC management of anogenital gonorrhoea (with light microscopic evaluation of Gram stained smears) among men who have sex with men (MSM) on gonorrhoea prevalence and testing and treatment costs. METHODS: Data concerning costs and sexual behaviour were collected from the STI clinic of Amsterdam. With a deterministic model for gonorrhoea transmission, we calculated the prevalence of gonorrhoea in MSM in Amsterdam and the numbers of consultations at our clinic over 5 years, in three testing scenarios: POC for symptomatic MSM only (currently routine), POC for all MSM and no POC for MSM. RESULTS: Among MSM, 34.7% (109/314) had sexual contacts in the period between testing and treatment, of whom 22.9% (25/109) had unprotected anal intercourse. Expanding POC testing from symptomatic MSM to all MSM could result in an 11% decrease (IQR, 8%-15%) in gonorrhoea prevalence after 5 years and a cost increase of 8.6% (€2.40) per consultation and €86 118 overall (+8.3%). Switching from POC testing of symptomatic MSM to no POC testing could save €1.83 per consultation (6.5%) and €54 044 (-5.2%) after 5 years with a 60% (IQR, 26%-127%) gonorrhoea prevalence increase. Overtreatment was 2.1% (30/1411) with POC for symptomatic MSM only and 4.1% (68/1675) with POC for all MSM. CONCLUSIONS: In the Amsterdam setting, possible abandonment of POC testing of symptomatic MSM because of budget cuts could result in a considerable increase in gonorrhoea prevalence against a reduction in costs per consultation. Expanding POC testing to all MSM could result in a modest reduction in prevalence and a cost increase. While the costs and outcomes depend on specific local characteristics, the developed framework of this study is useful to evaluate POC management in other settings.

The impact of HIV infection and socioeconomic factors on the incidence of gonorrhea: A county-level, US-wide analysis.

BACKGROUND: Gonorrhea is the second most commonly reported identifiable disease in the United States (U.S.). Importantly, more than 25% of gonorrheal infections demonstrate antibiotic resistance, leading the Centers for Disease Control and Prevention (CDC) to classify gonorrhea as an "urgent threat". METHODS: We examined the association of gonorrhea infection rates with the incidence of HIV and socioeconomic factors. A county-level multivariable model was then constructed. RESULTS: Multivariable analysis demonstrated that HIV incidence [Coefficient (Coeff): 1.26, 95% Confidence Interval (CI): 0.86, 1.66, P<0.001] exhibited the most powerful independent association with the incidence of gonorrhea and predicted 40% of the observed variation in gonorrhea infection rates. Sociodemographic factors like county urban ranking (Coeff: 0.12, 95% CI: 0.03, 0.20, P = 0.005), percentage of women (Coeff: 0.41, 95% CI: 0.28, 0.53, P<0.001) and percentage of individuals under the poverty line (Coeff: 0.45, 95% CI: 0.32, 0.57, P<0.001) exerted a secondary impact. A regression model that incorporated these variables predicted 56% of the observed variation in gonorrhea incidence (Pmodel<0.001, R2 model = 0.56). CONCLUSIONS: Gonorrhea and HIV infection exhibited a powerful correlation thus emphasizing the benefits of comprehensive screening for sexually transmitted infections (STIs) and the value of pre-exposure prophylaxis for HIV among patients visiting an STI clinic. Furthermore, sociodemographic factors also impacted gonorrhea incidence, thus suggesting another possible focus for public health initiatives.

Cost Analysis and Performance Assessment of Partner Services for Human Immunodeficiency Virus and Sexually Transmitted Diseases, New York State, 2014.

OBJECTIVE: To estimate the programmatic costs of partner services for HIV, syphilis, gonorrhea, and chlamydial infection. STUDY SETTING: New York State and local health departments conducting partner services activities in 2014. STUDY DESIGN: A cost analysis estimated, from the state perspective, total program costs and cost per case assignment, patient interview, partner notification, and disease-specific key performance indicator. DATA COLLECTION: Data came from contracts, a time study of staff effort, and statewide surveillance systems. PRINCIPAL FINDINGS: Disease-specific costs per case assignment (mean: $580; range: $502-$1,111), patient interview ($703; $608-$1,609), partner notification ($1,169; $950-$1,936), and key performance indicator ($2,697; $1,666-$20,255) varied across diseases. Most costs (79 percent) were devoted to gonorrhea and chlamydial infection investigations. CONCLUSIONS: Cost analysis complements cost-effectiveness analysis in evaluating program performance and guiding improvements.

Impact of Eligibility Criteria on Participant Enrollment for a Randomized Clinical Trial of Gonorrhea Treatment.

BACKGROUND: High rates of failure to qualify for clinical trial participation increase time and cost required for study completion. Identification of remediable reasons for prescreen failure can help reduce prescreen failure rates and improve study cost effectiveness. METHODS: Reasons for prescreen failure to qualify for participation in a phase 2 randomized clinical trial of treatment of uncomplicated urogenital gonorrhea were collected from prescreening logs. Reasons were categorized based on whether the reason was that the subject failed to meet eligibility criteria or declined participation. Subjects who failed prescreening but could have been enrolled under protocol amendments were used to estimate potential cost savings had enrollment completed sooner. RESULTS: Over 88% (1373/1554) of potential study candidates were not enrolled. The majority (68.8%) of nonenrolled subjects failed prescreening due to not meeting eligibility criteria, whereas 31.0% declined to participate. The most common reasons for failure to qualify were having only nonurogenital gonorrhea (16.4%), limited time (13.1%), and being on antiretroviral therapy (7.5%). Potential cost savings if protocol amendments affecting eligibility had been instituted earlier were estimated at US $127,500. CONCLUSIONS: Careful attention to reasons for prescreen failure can inform clinical trial protocol development to address trial design features that may impact successful enrollment. More efficient subject enrollment can result in substantial cost savings.

Gentamicin versus ceftriaxone for the treatment of gonorrhoea (G-TOG trial): study protocol for a randomised trial.

BACKGROUND: Gonorrhoea is a common sexually transmitted infection which causes genital pain and discomfort; in women it can also lead to pelvic inflammatory disease and infertility, and in men to epididymo-orchitis. Current treatment is with ceftriaxone, but there is increasing evidence of antimicrobial resistance which is reducing its effectiveness against gonorrhoea. A small, but increasing, number of patients have already been found to have highly resistant strains of gonorrhoea which has been associated with clinical failure. This trial aims to determine whether gentamicin is not clinically worse than ceftriaxone in the treatment of gonorrhoea. METHODS/DESIGN: This is a blinded, two-arm, multicentre, noninferiority randomised trial. Patients are eligible if they are aged 16-70 years with a diagnosis of genital, pharyngeal and/or rectal gonorrhoea. Exclusion criteria are: known concurrent sexually transmitted infection(s) (excluding chlamydia); bacterial vaginosis and/or Trichomonas vaginalis infection; contraindications or an allergy to gentamicin, ceftriaxone, azithromycin or lidocaine; pregnancy or breastfeeding; complicated gonorrhoeal infection; weight under 40 kg; use of ceftriaxone, gentamicin or azithromycin within the preceding 28 days. Randomisation is to receive a single intramuscular injection of either gentamicin or ceftriaxone, all participants receive 1 g oral azithromycin as standard treatment. The estimated sample size is 720 participants (noninferiority limit 5%). The primary outcome is clearance of Neisseria gonorrhoeae at all infected sites by a negative Nucleic Acid Amplification Test, 2 weeks post treatment. Secondary outcomes include clinical resolution of symptoms, frequency of adverse events, tolerability of therapy, relationship between clinical effectiveness and antibiotic minimum inhibitory concentration for N. gonorrhoeae, and cost-effectiveness. DISCUSSION: The options for future treatment of gonorrhoea are limited. Results from this randomised trial will demonstrate whether gentamicin is not clinically worse than ceftriaxone for the treatment of gonorrhoea. This will inform clinical practice and policy for the treatment of gonorrhoea when current therapy with cephalosporins is no longer effective, or is contraindicated. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number - ISRCTN51783227 , Registered on 18 September 2014. Current protocol version 2.0 17 June 2015.

Cost-Effectiveness of Dual Antimicrobial Therapy for Gonococcal Infections Among Men Who Have Sex With Men in the Netherlands.

BACKGROUND: In response to the rising threat of resistance to first-line antibiotics for gonorrhea, international guidelines recommend dual antimicrobial therapy. However, some countries continue to recommend monotherapy. We assess the cost-effectiveness of dual therapy with ceftriaxone and azithromycin compared with monotherapy with ceftriaxone, for control of gonorrhea among men who have sex with men in the Netherlands. METHODS: We developed a transmission model and calculated the numbers of new gonorrhea infections, consultations at health care specialists, tests, and antibiotic doses. With these numbers, we calculated costs and quality-adjusted life-years (QALY) with each treatment; and the incremental cost-effectiveness ratio (ICER) of dual therapy compared to monotherapy. The impact of gonorrhea on human immunodeficiency virus transmission was not included in the model. RESULTS: In the absence of initial resistance, dual therapy can delay the spread of ceftriaxone resistance by at least 15 years, compared to monotherapy. In the beginning, when there is no resistance, dual therapy results in high additional costs, without any QALY gains. When resistance spreads over time, the additional costs of dual therapy decline, the gained QALYs increase, the ICER drops off and, after 50 years, falls below &OV0556;20,000 per QALY gained. If azithromycin resistance is initially prevalent, resistance to the first-line treatment rises almost equally fast with both treatment strategies and the ICER remains extremely high. CONCLUSIONS: Compared with ceftriaxone monotherapy, dual therapy with ceftriaxone and azithromycin can considerably delay the spread of ceftriaxone resistance, but may only be cost-effective in the long run and in the absence of initial resistance.