The Estimated Lifetime Medical Cost of Syphilis in the United States.

BACKGROUND: The purpose of this study was to estimate the cost of syphilis in the United States, in terms of the average lifetime direct medical cost per infection. METHODS: We used a decision tree model of the natural history of syphilis. The model allowed for numerous possible outcomes of infection, including treatment for syphilis at various stages, inadvertent treatment, and late syphilis outcomes in those who are alive and still infected 30 years after acquisition. Future costs were discounted at 3% annually. Model inputs, such as the cost and probability of each outcome, were based on published sources. The probabilities we applied yielded outcomes consistent with reported cases of syphilis by stage from national surveillance data and number of deaths due to late syphilis from national mortality data. RESULTS: The estimated, discounted lifetime cost per infection was $1190 under base case assumptions (2019 dollars). Treatment costs associated with late syphilis outcomes, such as cardiovascular syphilis, accounted for only $26 of the average lifetime cost per infection. Results were most sensitive to assumptions regarding the treatment cost per case of unknown duration or late syphilis. In the probabilistic sensitivity analyses, the 2.5th and 97.5th percentiles of the 10,000 simulations of the lifetime cost per infection were $729 and $1884, respectively. CONCLUSIONS: Our estimate of the lifetime cost per infection is about 50% higher than in a previous study, a difference due in large part to our higher cost assumptions for benzathine penicillin G.

The Estimated Direct Lifetime Medical Costs of Sexually Transmitted Infections Acquired in the United States in 2018.

BACKGROUND: We estimated the lifetime medical costs attributable to sexually transmitted infections (STIs) acquired in 2018, including sexually acquired human immunodeficiency virus (HIV). METHODS: We estimated the lifetime medical costs of infections acquired in 2018 in the United States for 8 STIs: chlamydia, gonorrhea, trichomoniasis, syphilis, genital herpes, human papillomavirus (HPV), hepatitis B, and HIV. We limited our analysis to lifetime medical costs incurred for treatment of STIs and for treatment of related sequelae; we did not include other costs, such as STI prevention. For each STI, except HPV, we calculated the lifetime medical cost by multiplying the estimated number of incident infections in 2018 by the estimated lifetime cost per infection. For HPV, we calculated the lifetime cost based on the projected lifetime incidence of health outcomes attributed to HPV infections acquired in 2018. Future costs were discounted at 3% annually. RESULTS: Incident STIs in 2018 imposed an estimated $15.9 billion (25th-75th percentile: $14.9-16.9 billion) in discounted, lifetime direct medical costs (2019 US dollars). Most of this cost was due to sexually acquired HIV ($13.7 billion) and HPV ($0.8 billion). STIs in women accounted for about one fourth of the cost of incident STIs when including HIV, but about three fourths when excluding HIV. STIs among 15- to 24-year-olds accounted for $4.2 billion (26%) of the cost of incident STIs. CONCLUSIONS: Incident STIs continue to impose a considerable lifetime medical cost burden in the United States. These results can inform health economic analyses to promote the use of cost-effective STI prevention interventions to reduce this burden.

US Public Sexually Transmitted Disease Clinical Services in an Era of Declining Public Health Funding: 2013-14.

BACKGROUND: We examined the infrastructure for US public sexually transmitted disease (STD) clinical services. METHODS: In 2013 to 2014, we surveyed 331 of 1225 local health departments (LHDs) who either reported providing STD testing/treatment in the 2010 National Profile of Local Health Departments survey or were the 50 local areas with the highest STD cases or rates. The sample was stratified by jurisdiction population size. We examined the primary referral clinics for STDs, the services offered and the impact of budget cuts (limited to government funding only). Data were analyzed using SAS, and analyses were weighted for nonresponse. RESULTS: Twenty-two percent of LHDs cited a specialty STD clinic as their primary referral for STD services; this increased to 53.5% of LHDs when combination STD-family planning clinics were included. The majority of LHDs (62.8%) referred to clinics providing same-day services. Sexually transmitted disease clinics more frequently offered extragenital testing for chlamydia and/or gonorrhea (74.7%) and gonorrhea culture (68.5%) than other clinics (52.9%, 46.2%, respectively; P < 0.05). The majority of LHDs (61.5%) reported recent budget cuts. Of those with decreased budgets, the most common impacts were fewer clinic hours (42.8%; 95% confidence interval [CI], 24.4-61.2), reduced routine screening (40.2%; 95% CI, 21.7-58.8) and reductions in partner services (42.1%; 95% CI, 23.6-60.7). One quarter of those with reduced STD budgets increased fees or copays for clients. CONCLUSIONS: Findings demonstrate gaps and reductions in US public STD services including clinical services that play an important role in reducing disease transmission. Furthermore, STD clinics tended to offer more specialized STD services than other public clinics.

High risk for HIV following syphilis diagnosis among men in Florida, 2000-2011.

OBJECTIVE: Multiple interventions have been shown to reduce the risk of HIV acquisition, including preexposure prophylaxis with antiretroviral medications, but high costs require targeting interventions to people at the highest risk. We identified the risk of HIV following a syphilis diagnosis for men in Florida. METHODS: We analyzed surveillance records of 13- to 59-year-old men in Florida who were reported as having syphilis from January 1, 2000, to December 31, 2009. We excluded men who had HIV infection reported before their syphilis diagnosis (and within 60 days after), then searched the database to see if the remaining men were reported as having HIV infection by December 31, 2011. RESULTS: Of the 9,512 men with syphilis we followed, 1,323 were subsequently diagnosed as having HIV infection 60-3,753 days after their syphilis diagnosis. The risk of a subsequent diagnosis of HIV infection was 3.6% in the first year after syphilis was diagnosed and reached 17.5% 10 years after a syphilis diagnosis. The risk of HIV was higher for non-Hispanic white men (3.4% per year) than for non-Hispanic black men (1.8% per year). The likelihood of developing HIV was slightly lower for men diagnosed with syphilis in 2000 and 2001 compared with subsequent years. Of men diagnosed with syphilis in 2003, 21.5% were reported as having a new HIV diagnosis by December 31, 2011. CONCLUSION: Men who acquire syphilis are at very high risk of HIV infection.

Needle in a haystack: the yield of syphilis outreach screening at 5 US sites-2000 to 2007.

BACKGROUND: Screening for syphilis has been performed for decades, but it is unclear if the practice yields many cases at acceptable cost, and if so, at which venues. We attempted a retrospective study to determine the costs, yield, and feasibility of analyzing health department-funded syphilis outreach screening in 5 diverse US sites with significant disease burdens. METHODS: Data (venue, costs, number of tests, reactive tests, new diagnoses) from 2000 to 2007 were collected for screening efforts funded by public health departments from Philadelphia; New York City; Washington, District of Columbia; Maricopa County, Arizona (Phoenix); and the state of Florida. Crude cost per new case was calculated. RESULTS: Screening was conducted in multiple venues including jails, shelters, clubs, bars, and mobile vans. Over the study period, approximately 926 258 tests were performed and 4671 new syphilis cases were confirmed, of which 225 were primary and secondary, and 688 were early latent or high-titer late latent. Jail intake screening consistently identified the largest numbers of new cases (including 67.6% of early and high-titer late-latent cases) at a cost per case ranging from $144 to $3454. Data quality from other venues varied greatly between sites and was often poor. CONCLUSIONS: Though the yield of jail intake screening was good, poor data quality, particularly cost data, precluded accurate cost/yield comparisons at other venues. Few cases of infectious syphilis were identified through outreach screening at any venue. Health departments should routinely collect all cost and testing data for screening efforts so that their yield can be evaluated.

Serologic testing for syphilis in the United States: a cost-effectiveness analysis of two screening algorithms.

BACKGROUND: The introduction of automated treponemal enzyme immunoassays and chemiluminescence assays (EIA/CA) tests has led some laboratories in the United States to use new syphilis screening algorithms that start with a treponemal test. We compared the economic and health outcomes of this new algorithm with the standard algorithm from the perspective of the United States health system. METHODS: We used a cohort decision analysis to estimate the expected costs and effects (including follow-ups and overtreatment) of the 2 algorithms from a health-care system perspective. In the standard algorithm, rapid plasma reagin (RPR) is followed (if reactive) by EIA/CA (Nontreponemal-First). In the new algorithm, EIA/CA is followed (if reactive) by RPR. If the RPR is negative, Treponema pallidum passive particle agglutination assay (TP-PA) test is used (Treponemal-First). RESULTS: For a cohort of 200,000 individuals (1000 current infections and 10,000 previous infections), the net costs were $1.6 m (Treponemal-First) and $1.4 m (Nontreponemal-First). The Treponemal-First option treated 118 more cases (986 vs. 868) but resulted in a substantially higher number of follow-ups (11,450 vs. 3756) and overtreatment (964 vs. 38). Treating the additional 118 cases might prevent 1 case of tertiary syphilis. The estimated cost-effectiveness ratios were $1671 (Treponemal-First) and $1621 (Nontreponemal-First) per case treated. The overtreatment was a function of the specificity of the EIA/CA and the lack of independence of EIA/CA and TP-PA. CONCLUSION: The Treponemal-First option costs slightly more and results in more unnecessary treatment.

Dilemmas in the management of syphilis: a survey of infectious diseases experts.

We surveyed infectious diseases consultants to determine how they manage syphilis when there are insufficient data to guide management or when guidelines cannot be followed because of a lack of available definitive diagnostic tests. Most providers did not have access to dark-field microscopy. We found variation in management of syphilis, especially for patients with human immunodeficiency virus infection.