Microscopic examination of Gram-stained smears for anogenital gonorrhoea in men who have sex with men is cost-effective: evidence from a modelling study.

OBJECTIVE: To assess the cost-effectiveness of three testing strategies with or without light microscopic Gram-stained smear (GSS) evaluation for the detection of anogenital gonorrhoea among men who have sex with men (MSM) at the Amsterdam STI clinic using a healthcare payer perspective. METHODS: Three testing strategies for MSM were compared: (1) GSS in symptomatic MSM only (currently practised strategy), (2) no GSS and (3) GSS in symptomatic and asymptomatic MSM. The three testing protocols include testing with nucleic acid amplification test to verify the GSS results in (1) and (3), or as the only test in (2). A transmission model was employed to calculate the influence of the testing strategies on the prevalence of anogenital gonorrhoea over 10 years. An economic model combined cost data on medical consultations, tests and treatment and utility data to estimate the number of epididymitis cases and quality-adjusted life years (QALY) associated with gonorrhoea. Incremental cost-effectiveness ratios (ICERs) for the testing scenarios were estimated. Uncertainty and sensitivity analyses were performed. RESULTS: No GSS testing compared with GSS in symptomatic MSM only (current strategy) resulted in nine extra epididymitis cases (95% uncertainty interval (UI): 2-22), 72 QALYs lost (95% UI: 59-187) and €7300 additional costs (95% UI: -€185 000 (i.e.cost-saving) to €407 000) over 10 years. GSS testing in both symptomatic and asymptomatic MSM compared with GSS in symptomatic MSM only resulted in one prevented epididymitis case (95% UI: 0-2), 1.1 QALY gained (95% UI: 0.1-3.3), €148 000 additional costs (95% UI: €86 000 to-€217 000) and an ICER of €177 000 (95% UI: €67 000-to €705 000) per QALY gained over 10 years. The results were robust in sensitivity analyses. CONCLUSIONS: GSS for symptomatic MSM only is cost-effective compared with no GSS for MSM and with GSS for both symptomatic and asymptomatic MSM.

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.

Leucocyte esterase dip-stick test as a point-of-care diagnostic for urogenital chlamydia in male patients: A multi-center evaluation in two STI outpatient clinics in Paramaribo and Amsterdam.

BACKGROUND: Point-of-care (POC) tests are an important strategy to address the epidemic of sexually transmitted infections (STIs). The leucocyte esterase test (LET) can be used as a POC test for chlamydia. The aim of this study was to determine the diagnostic accuracy of the LET to detect urogenital chlamydia among men at STI clinics in Paramaribo, Suriname and Amsterdam, the Netherlands. METHODS: Recruitment of patients took place in 2008-2010 in Suriname and in 2009-2010 in the Netherlands. Urine of patients was examined with the LET. The reference test was a nucleic acid amplification test (NAAT). RESULTS: We included 412 patients in Suriname and 645 in the Netherlands. Prevalence of chlamydia in Suriname and the Netherlands was respectively 22.8 and 13.6 %. The sensitivity of the LET was 92.6 % (95 % CI = 85.3-97.0) and 77.3 % (95 % CI = 67.1-85.5) respectively, the specificity was 38.1 % (95 % CI = 32.7-43.6 %) and 58.1 % (95 % CI = 53.9-62.3) respectively. The positive predictive value was 30.6 % (95 % CI = 27.3-36.4) and 22.6 % (95 % CI = 18.0-27.7) respectively and the negative predictive value was 94.5 % (95 % CI = 89.1-97.8) and 94.2 % (95 % CI = 91.1-96.4) respectively. The kappa was respectively 0.179 and 0.176. CONCLUSIONS: To diagnose urogenital chlamydia in men the LET performs poorly. It has a high negative but low positive predictive value. If the LET result is negative, chlamydia is accurately excluded, yet a positive result has a low predictive value. Whether the advantages of direct management based on LET outweigh the disadvantages of overtreatment is a subject for further studies.