May 2002

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

Key Findings

A combination of syndromic management and risk assessment can be a cost-effective method for decision-making. Table 1 shows the incremental costs and effectiveness of using three methods to diagnose and manage cervical infections (gonorrhea and/or chlamydia): syndromic management, syndromic management with risk assessment, and laboratory evaluation and risk assessment. The cost of decreasing the prevalence of cervical infection by one percent using a risk assessment is almost one-fourth the cost of using a combination of risk assessment and a laboratory test. The use of laboratory diagnosis increases the annual cost of STI management on the basis of a risk assessment by 300 percent, although the effectiveness is about the same. Even more dramatic results were found for the treatment of trichomoniasis and bacterial vaginosis, since using laboratory results for follow-up assessments for these conditions increases annual costs per sex worker by 488 percent.

Frequent follow-up visits would result in higher costs without a reduction in STI prevalence. The investigators estimated the costs and effectiveness of requiring follow-up visits every 30 days compared to every 90 days. In all cases, the more frequent follow-up resulted in higher costs per sex worker, ranging from 11.8 percent higher for syphilis to 62 percent higher for cervical infections. Surprisingly, the prevalence after 12 months of follow-up was predicted to be higher (range: .4 percent higher for cervical infection to 10.8 percent higher for trichomoniasis and bacterial vaginosis) among sex workers seen more frequently than those seen less often. This happens because more sex workers may be lost to follow-up when asked to return more frequently. While initially there may be a performance advantage to more frequent assessment, as sex workers stop returning this early advantage is lost, as seen in Figure 1.

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19 Oct 2007