title: Finding a needle in the haystack: the costs and cost-effectiveness of syphilis diagnosis and treatment during pregnancy to prevent congenital syphilis in Kalomo District of Zambia.
abstract: BACKGROUND
  In March 2012, The Elizabeth Glaser Pediatric AIDS Foundation trained maternal and child health workers in Southern Province of Zambia to use a new rapid syphilis test (RST) during routine antenatal care. A recent study by Bonawitz et al. (2014) evaluated the impact of this roll out in Kalomo District. This paper estimates the costs and cost-effectiveness from the provider's perspective under the actual conditions observed during the first year of the RST roll out.
  
  
  METHODS
  Information on materials used and costs were extracted from program records. A decision-analytic model was used to evaluate the costs (2012 USD) and cost-effectiveness. Basic parameters needed for the model were based on the results from the evaluation study.
  
  
  RESULTS
  During the evaluation study, 62% of patients received a RST, and 2.8% of patients tested were positive (and 10.4% of these were treated). Even with very high RST sensitivity and specificity (98%), true prevalence of active syphilis would be substantially less (estimated at <0.7%). For 1,000 new ANC patients, costs of screening and treatment were estimated at $2,136, and the cost per avoided disability-adjusted-life year lost (DALY) was estimated at $628. Costs change little if all positives are treated (because prevalence is low and treatment costs are small), but the cost-per-DALY avoided falls to just $66. With full adherence to guidelines, costs increase to $3,174 per 1,000 patients and the cost-per-DALY avoided falls to $60.
  
  
  CONCLUSIONS
  Screening for syphilis is only useful for reducing adverse birth outcomes if patients testing positive are actually treated. Even with very low prevalence of syphilis (a needle in the haystack), cost effectiveness improves dramatically if those found positive are treated; additional treatment costs little but DALYs avoided are substantial. Without treatment, the needle is essentially found and thrown back into the haystack.
authors.affiliation: Center for Global Health and Development, Boston University, Boston, MA, United States of America.
authors.forename: Bruce A
authors.initials: BA
authors.lastname: Larson
authors.affiliation: Zambia Center for Applied Health Research and Development, Lusaka, Zambia.
authors.forename: Deophine
authors.initials: D
authors.lastname: Lembela-Bwalya
authors.affiliation: Center for Global Health and Development, Boston University, Boston, MA, United States of America; Department of Pediatrics, Boston Medical Center, Boston, MA, United States of America.
authors.forename: Rachael
authors.initials: R
authors.lastname: Bonawitz
authors.affiliation: Center for Global Health and Development, Boston University, Boston, MA, United States of America.
authors.forename: Emily E
authors.initials: EE
authors.lastname: Hammond
authors.affiliation: Center for Global Health and Development, Boston University, Boston, MA, United States of America.
authors.forename: Donald M
authors.initials: DM
authors.lastname: Thea
authors.affiliation: Center for Global Health and Development, Boston University, Boston, MA, United States of America; Department of Pediatrics, Boston Medical Center, Boston, MA, United States of America.
authors.forename: Julie
authors.initials: J
authors.lastname: Herlihy
mesh_terms: D000328:Adult; D002648:Child; D003362:Cost-Benefit Analysis; D005260:Female; D017048:Health Care Costs; D006801:Humans; D008403:Mass Screening; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000175:diagnosis* / Q000453:epidemiology / Q000382:microbiology; D011296:Prenatal Diagnosis; D013588:Syphilis Serodiagnosis / Q000191:economics; D013590:Syphilis, Congenital / Q000175:diagnosis* / Q000453:epidemiology / Q000382:microbiology; D015024:Zambia