Cost-effectiveness of on-site antenatal screening to prevent congenital syphilis in rural eastern Cape Province, Republic of South Africa.

OBJECTIVES: On-site screening and same-day treatment of maternal syphilis in underresourced settings can avert greater numbers of congenital syphilis cases, but health outcomes and associated costs must be evaluated jointly. METHODS: We used decision analysis to estimate the incremental cost-effectiveness of two on-site antenatal syphilis screening strategies to avert congenital infections-qualitative RPR (on-site RPR) and treponemal immunochromatographic strip assay (on-site ICS)-compared to the current practice (off-site RPR/TPHA). FINDINGS: With antenatal active syphilis prevalence of 6.3%, the incremental cost-effectiveness of on-site ICS in averting congenital infections was estimated to be USD104, averting 82% of cases expected in absence of a program. The incremental cost-effectiveness of off-site RPR/TPHA was USD82 but would avert only 55% of congenital syphilis cases. On-site RPR was dominated by the other screening strategies. CONCLUSIONS: In settings of high maternal syphilis prevalence, on-site antenatal screening with ICS is a cost-effective approach to reduce the incidence of congenital syphilis.

On-site rapid antenatal syphilis screening with an immunochromatographic strip improves case detection and treatment in rural South African clinics.

OBJECTIVES: Congenital syphilis is a significant cause of adverse pregnancy outcomes. In South Africa, rural clinics perform antenatal screening offsite, but unreliable transport and poor client follow up impede effective treatment. We compared 3 syphilis screening strategies at rural clinics: on-site rapid plasma reagin (RPR), on-site treponemal immunochromatographic strip (ICS) test, and the standard practice offsite RPR with Treponema pallidum hemagglutination assay (RPR/TPHA). METHODS: Eight rural clinics performed the on-site RPR and ICS tests and provided immediate treatment. Results were compared with RPR/TPHA at a reference laboratory. Chart reviews at 8 standard practice clinics established diagnosis and treatment rates for offsite RPR/TPHA. FINDINGS: Seventy-nine (6.3%) of 1,250 women screened on-site had active syphilis according to the reference laboratory. The on-site ICS resulted in the highest percentage of pregnant women correctly diagnosed and treated for syphilis (89.4% ICS, 63.9% on-site RPR, 60.8% offsite RPR/TPHA). The on-site RPR had low sensitivity (71.4% for high-titer syphilis). The offsite approach suffered from poor client return rates. One percent of women screened with the ICS may have received penicillin unnecessarily. There were no adverse treatment outcomes. CONCLUSIONS: The on-site ICS test can reduce syphilis-related adverse outcomes of pregnancy through accurate diagnosis and immediate treatment of pregnant women with syphilis.