The impact of antenatal syphilis point of care testing on pregnancy outcomes: A systematic review.

BACKGROUND: Mother-to-child transmission of syphilis remains a leading cause of neonatal death and stillbirth, disproportionally affecting women in low-resource settings where syphilis prevalence rates are high and testing rates low. Recently developed syphilis point-of-care tests (POCTs) are promising alternatives to conventional laboratory screening in low-resource settings as they do not require a laboratory setting, intensive technical training and yield results in 10-15 minutes thereby enabling both diagnosis and treatment in a single visit. Aim of this review was to provide clarity on the benefits of different POCTs and assess whether the implementation of syphilis POCTs is associated with decreased numbers of syphilis-related adverse pregnancy outcomes. METHODS: Following the PRISMA guidelines, three electronic databases (PubMed, Medline (Ovid), Cochrane) were systematically searched for intervention studies and cost-effectiveness analyses investigating the association between antenatal syphilis POCT and pregnancy outcomes such as congenital syphilis, low birth weight, prematurity, miscarriage, stillbirth as well as perinatal, fetal or infant death. RESULTS: Nine out of 278 initially identified articles were included, consisting of two clinical studies and seven modelling studies. Studies compared the effect on pregnancy outcomes of treponemal POCT, non-treponemal POCT and dual POCT to laboratory screening and no screening program. Based on the clinical studies, significantly higher testing and treatment rates, as well as a significant reduction (93%) in adverse pregnancy outcomes was reported for treponemal POCT compared to laboratory screening. Compared to no screening and laboratory screening, modelling studies assumed higher treatment rates for POCT and predicted the most prevented adverse pregnancy outcomes for treponemal POCT, followed by a dual treponemal and non-treponemal POCT strategy. CONCLUSION: Implementation of treponemal POCT in low-resource settings increases syphilis testing and treatment rates and prevents the most syphilis-related adverse pregnancy outcomes compared to no screening, laboratory screening, non-treponemal POCT and dual POCT. Regarding the benefits of dual POCT, more research is needed. Overall, this review provides evidence on the contribution of treponemal POCT to healthier pregnancies and contributes greater clarity on the impact of diverse diagnostic methods available for the detection of syphilis.

Cost-effectiveness of dual maternal HIV and syphilis testing strategies in high and low HIV prevalence countries: a modelling study.

BACKGROUND: Dual HIV and syphilis testing might help to prevent mother-to-child transmission (MTCT) of HIV and syphilis through increased case detection and treatment. We aimed to model and assess the cost-effectiveness of dual testing during antenatal care in four countries with varying HIV and syphilis prevalence. METHODS: In this modelling study, we developed Markov models of HIV and syphilis in pregnant women to estimate costs and infant health outcomes of maternal testing at the first antenatal care visit with individual HIV and syphilis tests (base case) and at the first antenatal care visit with a dual rapid diagnostic test (scenario one). We additionally evaluated retesting during late antenatal care and at delivery with either individual tests (scenario two) or a dual rapid diagnosis test (scenario three). We modelled four countries: South Africa, Kenya, Colombia, and Ukraine. Strategies with an incremental cost-effectiveness ratio (ICER) less than the country-specific cost-effectiveness threshold (US$500 in Kenya, $750 in South Africa, $3000 in Colombia, and $1000 in Ukraine) per disability-adjusted life-year averted were considered cost-effective. FINDINGS: Routinely offering testing at the first antenatal care visit with a dual rapid diagnosis test was cost-saving compared with the base case in all four countries (ICER: -$26 in Kenya,-$559 in South Africa, -$844 in Colombia, and -$454 in Ukraine). Retesting during late antenatal care with a dual rapid diagnostic test (scenario three) was cost-effective compared with scenario one in all four countries (ICER: $270 in Kenya, $260 in South Africa, $2207 in Colombia, and $205 in Ukraine). INTERPRETATION: Incorporating dual rapid diagnostic tests in antenatal care can be cost-saving across countries with varying HIV prevalence. Countries should consider incorporating dual HIV and syphilis rapid diagnostic tests as the first test in antenatal care to support efforts to eliminate MTCT of HIV and syphilis. FUNDING: WHO, US Agency for International Development, and the Bill & Melinda Gates Foundation.

Clinical characteristics and outcomes for paediatric patients admitted with congenital or acquired syphilis: a population-based cohort study.

OBJECTIVES: Paediatric congenital and acquired syphilis cases have been increasing since 2012 in the USA. Potential differences in associated hospitalisation trends and healthcare utilisation between the two syphilis entities have not yet been assessed. We sought to compare these entities and describe their clinical characteristics, distribution and impact in the USA. METHODS: We conducted a population-based cohort study using the 2016 Kids' Inpatient Database (KID) to identify and characterise syphilis-associated hospitalisations among paediatric patients (age 0-21 years) in the USA during the year of 2016. Length of stay and hospitalisation costs for patients with congenital and acquired syphilis were compared in multivariable models. RESULTS: A total of 1226 hospitalisations with the diagnosis of syphilis were identified. Of these patients, 958 had congenital syphilis and 268 were acquired cases. The mean cost of care for congenital syphilis was $23 644 (SD=1727), while the treatment of a patient with acquired syphilis on average cost $10 749 (SD=1966). Mean length of stay was 8 days greater and mean total costs were $12 895 (US dollars) higher in the congenital syphilis cohort compared with the acquired syphilis cohort. In congenital syphilis, there were greater frequency of cases in the Southern and Western regions of the USA (p<0.001). CONCLUSION: Congenital syphilis was associated with greater healthcare-related expenditure than acquired syphilis in paediatric patients. In addition to improving patient outcomes, congenital syphilis prevention efforts may significantly reduce healthcare utilisation burden and cost.

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.

Repeat Screening for Syphilis in the Third Trimester of Pregnancy: A Cost-Effectiveness Analysis.

OBJECTIVE: To estimate the cost-effectiveness of screening all women during the first and third trimesters compared with screening just once during pregnancy. METHODS: We used a theoretical cohort of 3.9 million women in the United States to model syphilis screening approaches in pregnancy, particularly comparing one-time screening with repeat third-trimester screening. Outcomes of syphilis infection included in the model were congenital syphilis, intrauterine fetal demise, neonatal death, and total quality-adjusted life-years (QALYs). Probabilities, utilities, and costs were obtained from the literature, and a cost-effectiveness threshold was set at $100,000 per QALY. A societal perspective was assumed. RESULTS: Our model demonstrated that repeat screening in the third trimester for syphilis in pregnancy will result in fewer maternal and neonatal adverse outcomes and higher QALYs when compared with screening once in the first trimester. Specifically, we demonstrated that repeat screening results in 41 fewer neonates with evidence of congenital syphilis, 73 fewer cases of intrauterine fetal demise, 27 fewer neonatal and infant deaths, in addition to a cost savings of $52 million and 4,000 additional QALYs. CONCLUSION: Using our baseline assumptions, our data support that in pregnancy, repeat screening for syphilis is superior to single screening during the first trimester and is both cost-effective and results in improvement in maternal and neonatal outcomes. When screening policies are being created for pregnant women, the cost-effectiveness of repeat screening for syphilis should be considered.

Reverse syphilis screening algorithm fails to demonstrate cost effectiveness in persons living with HIV.

Although the reverse syphilis screening algorithm is more efficient than the traditional algorithm, it may lead to exorbitant costs for health systems serving persons living with HIV needing annual syphilis screening. Alternatively, the traditional screening algorithm is cost saving in many scenarios.

Monetary incentives for provision of syphilis screening, Yunnan, China.

PROBLEM: Early detection of syphilis-infected people followed by effective treatment is essential for syphilis prevention and control. APPROACH: Starting in 2010 the local health authority in Yunnan province, China, developed a network of 670 service sites for syphilis testing, diagnosis and treatment or for testing-only with referral for further diagnosis and treatment. Point-of-care tests for syphilis and syphilis interventions were integrated into the existing human immunodeficiency virus (HIV) prevention and control programme. To improve the syphilis services, a pay-for-performance scheme was introduced in which providers were paid for testing and treating patients. LOCAL SETTING: Yunnan province is the region hardest hit by HIV infection and disproportionately burdened with syphilis cases in China. RELEVANT CHANGES: The proportion of attendees at voluntary counselling and testing clinics who were tested for syphilis increased from 46.2% (32 877/71 162) in 2010 to 98.2% (68 012/69 259) in 2015. Syphilis-infected cases treated with the recommended therapy increased from 26.6% (264/993) in 2010 to 82.5% (453/549) in 2015 at designated testing, diagnosis and treatment sites. LESSONS LEARNT: The strategy greatly increased the uptake of syphilis testing and treatment among people at risk. Introduction of point-of-care tests for syphilis increased coverage of the testing services. Introduction of a pay-for-performance scheme seemed to motivate health-care providers to undertake syphilis intervention services.

The Annual Economic Burden of Syphilis: An Estimation of Direct, Productivity, and Intangible Costs for Syphilis in Guangdong Initiative for Comprehensive Control of Syphilis Sites.

BACKGROUND: Syphilis has continuously posed a great challenge to China. However, very little data existed regarding the cost of syphilis. Taking Guangdong Initiative for Comprehensive Control of Syphilis area as the research site, we aimed to comprehensively measure the annual economic burden of syphilis from a societal perspective. METHODS: Newly diagnosed and follow-up outpatient cases were investigated by questionnaire. Reported tertiary syphilis cases and medical institutions cost were both collected. The direct economic burden was measured by the bottom-up approach, the productivity cost by the human capital method, and the intangible burden by the contingency valuation method. RESULTS: Three hundred five valid early syphilis cases and 13 valid tertiary syphilis cases were collected in the investigation to estimate the personal average cost. The total economic burden of syphilis was US $729,096.85 in Guangdong Initiative for Comprehensive Control of Syphilis sites in the year of 2014, with medical institutions cost accounting for 73.23% of the total. Household average direct cost of early syphilis was US $23.74. Average hospitalization cost of tertiary syphilis was US $2,749.93. Of the cost to medical institutions, screening and testing comprised the largest proportion (26%), followed by intervention and case management (22%) and operational cost (21%). Household average productivity cost of early syphilis was US $61.19. Household intangible cost of syphilis was US $15,810.54. CONCLUSIONS: Syphilis caused a substantial economic burden on patients, their families, and society in Guangdong. Household productivity and intangible costs both shared positive relationships with local economic levels. Strengthening the prevention and effective treatment of early syphilis could greatly help to lower the economic burden of syphilis.

Provider Adherence to Syphilis Testing Recommendations for Women Delivering a Stillbirth.

OBJECTIVE: To assess overall adherence to Centers for Disease Control and Prevention and American College of Obstetrics and Gynecology recommended guidelines for syphilis testing among women who delivered a stillbirth and compare it with other tests recommended for stillbirth evaluation. METHODS: We used MarketScan claims data with 40 million commercially insured and 8 million Medicaid enrollees annually to estimate prenatal care and follow-up testing among women who had stillbirths between January 1, 2013, and December 24, 2013. Stillbirth was identified if women had any International Classification of Disease, Ninth Revision codes related to a stillbirth outcome. Among women with stillbirths, we estimated the proportions of women who received prenatal care and prenatal syphilis testing within 280 days before stillbirth, and testing at the time of stillbirth (syphilis testing, complete blood count, placental examination and autopsy) using Physician's Current Procedural Terminology codes. RESULTS: We identified 3672 Medicaid-insured women and 6023 commercially insured women with stillbirths in 2013. Approximately, 61.7% of Medicaid-insured women and 66.0% of commercially insured women had claims data indicating prenatal syphilis testing. At the time of stillbirth, Medicaid-insured and commercially insured women had similar rates of syphilis testing (6.5% vs 9.3%), placental examination (61.6% vs 57.8%), and complete blood count (31.9% vs 37.6%). Autopsies were too infrequent to be reported. Approximately, 34.6% of Medicaid-insured women and 29.7% of commercially insured women had no syphilis testing either prenatally or at the time of stillbirth. CONCLUSIONS: Syphilis testing among women after stillbirth was less than 10%, illustrating limited adherence to Centers for Disease Control and Prevention and American College of Obstetrics and Gynecology recommendations. Such low prenatal and delivery syphilis testing rates may impact the number of stillbirth cases identified as congenital syphilis cases and reported to the national surveillance system. Our results emphasize the need to improve syphilis testing to improve diagnosis of syphilitic stillbirths, identify women with syphilis infection, and provide treatment to these women to avoid syphilis-related adverse outcomes.

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.

Laboratory Evaluation of a Smartphone-Based Electronic Reader of Rapid Dual Point-of-Care Tests for Antibodies to Human Immunodeficiency Virus and Treponema pallidum Infections.

BACKGROUND: Dual point-of-care tests for antibodies to human immunodeficiency virus (HIV) and Treponema pallidum allow for same-day testing and treatment and have been demonstrated to be cost-effective in preventing the adverse outcomes of HIV infection and syphilis. By recording and transmitting data as they are collected, electronic readers address challenges related to the decentralization of point-of-care testing. METHODS: We evaluated a smartphone-based electronic reader using 201 sera tested with 2 dual rapid tests for detection of antibodies to HIV and T. pallidum in Los Angeles, USA, and Lima, Peru. Tests were read both visually and with the electronic reader. Enzyme immunoassay followed by Western blot and T. pallidum particle agglutination were the reference tests for HIV and T. pallidum, respectively. RESULTS: The sensitivities of the 2 rapid tests for detection of HIV were 94.1% and 97.0% for electronic readings. Both tests had a specificity of 100% for detection of HIV by electronic reading. The sensitivities of the 2 rapid tests for detection of T. pallidum were 86.5% and 92.4% for electronic readings. The specificities for detection of T. pallidum were 99.1% and 99.0% by electronic reading. There were no significant differences between the accuracies of visual and electronic readings, and the performance did not differ between the 2 study sites. CONCLUSIONS: Our results show the electronic reader to be a promising option for increasing the use of point-of-care testing programs.

A comparative analysis of costs of single and dual rapid HIV and syphilis diagnostics: results from a randomised controlled trial in Colombia.

BACKGROUND: HIV and congenital syphilis are major public health burdens contributing to substantial perinatal morbidity and mortality globally. Although studies have reported on the costs and cost-effectiveness of rapid diagnostic tests (RDTs) for syphilis screening within antenatal care in a number of resource-constrained settings, empirical evidence on country-specific cost and estimates of single RDTs compared with dual RDTs for HIV and syphilis are limited. METHODS: A cluster randomised controlled study design was used to compare the incremental costs of two testing algorithms: (1) single RDTs for HIV and syphilis and (2) dual RDTs for HIV and syphilis, in 12 health facilities in Bogota and Cali, Colombia. The costs of single HIV and syphilis RDTs and dual HIV and syphilis RDTs were collected from each of the health facilities. The economic costs per woman tested for HIV and syphilis and costs per woman treated for syphilis defined as the total costs required to test and treat one woman for syphilis were estimated. RESULTS: A total of 2214 women were tested in the study facilities. Cost per pregnant woman tested and cost per woman treated for syphilis were US$10.26 and US$607.99, respectively in the single RDT arm. For the dual RDTs, the cost per pregnant woman tested for HIV and syphilis and cost per woman treated for syphilis were US$15.89 and US$1859.26, respectively. Overall costs per woman tested for HIV and syphilis and cost per woman treated for syphilis were lower in Cali compared with Bogota across both intervention arms. Staff costs accounted for the largest proportion of costs while treatment costs comprised <1% of the preventive programme. CONCLUSIONS: Findings show lower average costs for single RDTs compared with dual RDTs with costs sensitive to personnel costs and the scale of output at the health facilities. TRIAL REGISTRATION NUMBER: NCT02454816; results.

Disparities in HIV and syphilis prevalence and risk factors between older male clients with and without steady sex partners in southwestern rural China.

BACKGROUND: Heterosexual intercourse accounted for 93% of reported HIV cases in Guangxi, and Guangxi had 10% of China's total number of reported HIV cases. Older men are particularly vulnerable to STIs, for example, 46% of Guangxi's HIV cases were men over 50 years of age. As this is an under-studied population in China, effective prevention and control policies have yet to be developed. Thus, the aim of this study was to use a large-scale cross-sectional survey to understand the demographic and behavior factors associated with HIV and syphilis infections among older male clients of female sex workers (FSWs) in a high epidemic area of rural Guangxi, China. METHODS: A large-scale cross-sectional survey was conducted in 2012 among older male clients of FSWs in low-cost commercial sex venues. Questionnaire interviews were administered to collect sociodemographic and sexual behavior information. Blood samples were collected for HIV and syphilis infection tests. RESULTS: Of the 3485 participants, 2509 (72.0%) clients had a steady sex partner and 976 (28.0%) clients had no steady sex partner. The overall prevalence of HIV and syphilis infection were 3.0% and 3.2%, respectively. Compared to those with a steady sex partner, clients with no steady partner had higher odds of HIV infection (AOR: 1.90, 95% CI: 1.27-2.86), syphilis infection (AOR: 1.53, 95% CI: 1.02-2.30), and having factors associated with HIV or syphilis infection, including non-commercial casual sex encounters in last month (AOR: 3.29, 95% CI: 2.42-4.46), >10 years of commercial sex history (AOR: 1.31, 95% CI: 1.12-1.53), >2 incidents of commercial sex in last month (AOR: 1.53, 95% CI: 1.19-1.96), and aphrodisiac use in last month (AOR: 1.40, 95% CI: 1.16-1.70). Clients with no steady partner had lower odds of having heterosexual intercourse (AOR: 0.66, 95% CI: 0.56-0.79), awareness and knowledge of HIV/AIDS (AOR: 0.75, 95% CI: 0.64-0.88), and having had HIV tests (AOR: 0.65, 95% CI: 0.44-0.98). CONCLUSION: Older male clients of low-cost commercial sex venues in rural southwestern China are at high risk for HIV and syphilis infection, especially those with no steady sex partner. Improved interventions are urgently needed for this neglected risk population.

The Cost-Effectiveness of Syphilis Screening Among Men Who Have Sex With Men: An Exploratory Modeling Analysis.

We adapted a published model to estimate the costs and benefits of screening men who have sex with men for syphilis, including the benefits of preventing syphilis-attributable human immunodeficiency virus. The cost per quality-adjusted life year gained by screening was

Cost-effectiveness of HIV and syphilis antenatal screening: a modelling study.

OBJECTIVES: The WHO called for the elimination of maternal-to-child transmission (MTCT) of HIV and syphilis, a harmonised approach for the improvement of health outcomes for mothers and children. Testing early in pregnancy, treating seropositive pregnant women and preventing syphilis reinfection can prevent MTCT of HIV and syphilis. We assessed the health and economic outcomes of a dual testing strategy in a simulated cohort of 100 000 antenatal care patients in Malawi. METHODS: We compared four screening algorithms: (1) HIV rapid test only, (2) dual HIV and syphilis rapid tests, (3) single rapid tests for HIV and syphilis and (4) HIV rapid and syphilis laboratory tests. We calculated the expected number of adverse pregnancy outcomes, the expected costs and the expected newborn disability-adjusted life years (DALYs) for each screening algorithm. The estimated costs and DALYs for each screening algorithm were assessed from a societal perspective using Markov progression models. Additionally, we conducted a Monte Carlo multiway sensitivity analysis, allowing for ranges of inputs. RESULTS: Our cohort decision model predicted the lowest number of adverse pregnancy outcomes in the dual HIV and syphilis rapid test strategy. Additionally, from the societal perspective, the costs of prevention and care using a dual HIV and syphilis rapid testing strategy was both the least costly ($226.92 per pregnancy) and resulted in the fewest DALYs (116 639) per 100 000 pregnancies. In the Monte Carlo simulation the dual HIV and syphilis algorithm was always cost saving and almost always reduced DALYs compared with HIV testing alone. CONCLUSIONS: The results of the cost-effectiveness analysis showed that a dual HIV and syphilis test was cost saving compared with all other screening strategies. Updating existing prevention of mother-to-child HIV transmission programmes in Malawi and similar countries to include dual rapid testing for HIV and syphilis is likely to be advantageous.

Cost-effectiveness of enhanced syphilis screening among HIV-positive men who have sex with men: a microsimulation model.

BACKGROUND: Syphilis co-infection risk has increased substantially among HIV-infected men who have sex with men (MSM). Frequent screening for syphilis and treatment of men who test positive might be a practical means of controlling the risk of infection and disease sequelae in this population. PURPOSE: We evaluated the cost-effectiveness of strategies that increased the frequency and population coverage of syphilis screening in HIV-infected MSM receiving HIV care, relative to current standard of care. METHODS: We developed a state-transition microsimulation model of syphilis natural history and medical care in HIV-infected MSM receiving care for HIV. We performed Monte Carlo simulations using input data derived from a large observational cohort in Ontario, Canada, and from published biomedical literature. Simulations compared usual care (57% of the population screened annually) to different combinations of more frequent (3- or 6-monthly) screening and higher coverage (100% screened). We estimated expected disease-specific outcomes, quality-adjusted survival, costs, and cost-effectiveness associated with each strategy from the perspective of a public health care payer. RESULTS: Usual care was more costly and less effective than strategies with more frequent or higher coverage screening. Higher coverage strategies (with screening frequency of 3 or 6 months) were expected to be cost-effective based on usually cited willingness-to-pay thresholds. These findings were robust in the face of probabilistic sensitivity analyses, alternate cost-effectiveness thresholds, and alternate assumptions about duration of risk, program characteristics, and management of underlying HIV. CONCLUSIONS: We project that higher coverage and more frequent syphilis screening of HIV-infected MSM would be a highly cost-effective health intervention, with many potentially viable screening strategies projected to both save costs and improve health when compared to usual care. The baseline requirement for regular blood testing in this group (i.e., for viral load monitoring) makes intensification of syphilis screening appear readily practicable.

Insurance among patients seeking care at a municipal sexually transmitted disease clinic: implications for health care reform in the United States.

INTRODUCTION: Limited data exist on insured patients who receive care at publically funded sexually transmitted disease (STD) clinics, despite having access to a primary care provider. In this analysis, we compare patients with and without health insurance who sought services at City Clinic, the San Francisco municipal STD clinic. METHODS: We analyzed San Francisco City Clinic patients between August 1, 2011, and December 31, 2012. Insurance was self-reported and included both private and public insurance. Variables from the clinic electronic medical record were examined and included basic demographic and risk behavior questions, as well as positivity among patients tested for chlamydial and gonoccocal infection. We compared the characteristics of insured and uninsured patients using χ test. RESULTS: There were 13,104 patients in this analysis, of whom 4981 (38%) were categorized as insured and 8123 (62%) as uninsured. Overall, insured patients were older, more likely to be male, more likely to be white, and less likely to be Hispanic compared with uninsured patients (all P < 0.05). In addition, insured patients were more likely to be among men who have sex with men and among HIV-infected individuals compared with uninsured patients (all P < 0.0001). Insured patients were less likely to have a diagnosis of chlamydia at any site or a diagnosis of rectal gonorrhea. CONCLUSIONS: In our municipal STD clinic, more than one-third of patients report currently having insurance, yet still choose to seek care at the STD clinic. The different characteristics between insured and uninsured patients may reflect reasons other than affordability; therefore, STD clinics remain an important source of care for at-risk populations. These data suggest that the expansion of access to insurance may not result in a reduced need for categorical STD services. Maintaining access to high-quality sexual health services should remain a priority in the era of expanded health care access.

Cost-effectiveness of integrated routine offering of prenatal HIV and syphilis screening in China.

BACKGROUND: In China, recent rises in syphilis and HIV cases have increased the focus on preventing mother-to-child transmission of these infections. We assess the health and economic outcomes of different strategies of prenatal HIV and syphilis screening from the local health department's perspective. METHODS: A Markov cohort decision analysis model was used to estimate the health and economic outcomes of pregnancy using disease prevalence and cost data from local sources and, if unavailable, from published literature. Adverse pregnancy outcomes included induced abortion, stillbirth, low birth weight, neonatal death, congenital syphilis in live-born infants, and perinatal HIV infection. We examined 4 screening strategies: no screening, screening for HIV only, for syphilis only, and for both HIV and syphilis. We estimated disability-adjusted life years (DALYs) for each health outcome using life expectancies and infections for mothers and newborns. RESULTS: For a simulated cohort of 10,000 pregnant women (0.07% prevalence for HIV and 0.25% for syphilis; 10% of HIV-positives were coinfected with syphilis), the estimated costs per DALY prevented were as follows: syphilis-only, $168; HIV-and-syphilis, $359; and HIV-only, $5636. The estimated incremental cost-effectiveness ratio if an existing HIV-only strategy added syphilis screening (i.e., move from the HIV-only strategy to the HIV-and-syphilis strategy) was $140 per additional DALY prevented. CONCLUSIONS: Given the increasing prevalence of syphilis and HIV among pregnant women in China, prenatal HIV screening programs that also include syphilis screening are likely to be substantially more cost-effective than HIV screening alone and prevent many more adverse pregnancy outcomes.

Cost and clinical utility of repeated syphilis screening in the third trimester in a high-risk population.

OBJECTIVE: We sought to determine the clinical utility and cost of repeating syphilis testing in the third trimester of pregnancy in a high-risk urban population. STUDY DESIGN: A retrospective cohort analysis was performed for patients delivering from January 1993 through December 2009 with at least 1 venereal disease research laboratory (VDRL) test sent during pregnancy. Chart review was performed for patients with confirmed syphilis to determine the temporal relationship of syphilis diagnosis to the pregnancy. For patients who seroconverted during pregnancy (no antecedent history or treatment for syphilis), newborn charts were reviewed. The costs of treating seropositive neonates and the costs of implementing additional third-trimester syphilis screening were then compared. RESULTS: In the 17-year cohort, 58,569 deliveries were available for analysis. In all, 113 new cases of syphilis occurred (192.9/100,000 deliveries). There were 17 detected seroconversions; 10 were not rescreened in the third trimester and tested positive at delivery. These 10 patients may have benefitted from implementing uniform VDRL testing at 28-32 weeks' gestation. All newborns were asymptomatic with a negative workup and received empiric penicillin therapy. Based on 2011 hospital charges, the cost of evaluating and treating a neonate for syphilis is $11,079. Implementing an additional VDRL screen at 28-32 weeks' gestation for each pregnant patient during the 17 years studied would cost $1,991,346. An 18-fold increase in syphilis prevalence (3500/100,000 [3.5%] deliveries) would be required for the cost of implementation of universal early third-trimester screening to be equal to the potential health care charges saved by detecting maternal seroconversion and obviating the need for neonatal therapy. CONCLUSION: In this high-risk population, additional syphilis screening in the third trimester is costly and is not clinically helpful in detecting maternal seroconversion.