May 2002

Estimating the Cost and Effectiveness of
Different STI Management Strategies for
Sex Workers in Madagascar

In Madagascar, the prevalence of sexually transmitted infections (STIs) is a serious public health problem, particularly among sex worker populations. In 2000, Horizons, in partnership with Family Health International (FHI) and the Madagascar Ministry of Health, conducted a study in three cities that found approximately two-thirds of the female sex workers in the sample had an STI, although few were infected with HIV¹. Since the link between the presence of STIs and transmission of HIV has been well established, affordable strategies to manage STIs among sex workers need to be developed.

Study investigators also conducted an assessment of STI management practices in health facilities in two urban areas of Madagascar. They found that health practitioners were using a syndromic approach to manage STIs (that is, treating for STIs if the patient presents with symptoms and signs associated with specific infections). While this approach may be appropriate for the management of certain STIs (such as genital ulcer disease) in the general population, it is less appropriate for sex workers who may have multiple, often asymptomatic infections, all of which may not be captured through this method of diagnosis. If practitioners were to diagnose STIs with laboratory tests, however, medical visits would become prohibitively expensive and time-consuming.

Hence, the researchers proposed examining another method of diagnosing STIs in sex workers. They developed a risk profile for various STIs based on characteristics of women that present with each STI, such as age, number of partners, symptoms, and so on. The investigators hypothesized that a risk assessment tool using these profiles would result in more appropriate and effective STI treatment for sex workers.

This summary presents a cost-effectiveness analysis of different strategies to manage STIs among sex workers in Madagascar.

¹Behets, Frieda et al. “Evidence-based Treatment Guidelines for Sexually Transmitted Infections Developed with and for Female Sex Workers.” Submitted for publication.

• Study Design
• Study Methods
• Key Findings
• Application of Findings
• Conclusion
• PDF format of summary (943 KB)

Study investigators were Rick Homan and Kathleen van Damme of Family Health International; Frieda M.T. Behets and Kristi McClamroch of the University of North Carolina-Chapel Hill; Désiré Rasamilalao, Justin Ranjalahy Rasolofomanana, and Andry Rasamindrakotroka of the Madagascar Ministry of Health; and Johannes van Dam of Horizons/Population Council.

The authors would like to acknowledge the enthusiastic collaboration from the Ministry of Health and various other stakeholders from the public and non-governmental sectors in conducting the research, the collaboration from the women attending the clinics and especially those who collaborated in the final workshop, and last, but not least, the support from the U.S. Agency for International Development, both in Madagascar and in Washington, DC.

About Horizons

Horizons conducts global operations research to improve prevention, care, and support program. Horizons is implemented by the Population Council under a cooperative agreement with the U.S. Agency for International Development. Horizons is implemented by the Population Council in partnership with the International Center for Research on Women (ICRW), the Program for Appropriate Technology in Health (PATH), the International HIV/AIDS Alliance, Tulane University, Family Health International (FHI), and Johns Hopkins University.

Copyright © 2002 The Population Council

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19 Oct 2007