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The Costs of Treating Curable Sexually Transmitted Infections in Low- and Middle-Income Countries: A Systematic Review
Global Health Sciences Literature Digest
Published November 3, 2006
Journal Article

Terris-Prestholt F, Vyas S, Kumaranayake L, Mayaud P, Watts C. The Costs of Treating Curable Sexually Transmitted Infections in Low- and Middle-Income Countries: A Systematic Review. Sex Transm Dis. 2006 Oct;33(10 Suppl):S153-66.

Objective

To systematically review the costs of providing services for curable and treatable sexually transmitted infections (STIs) in low- and middle-income countries; and to explore the relationship between unit costs and potential moderating variables related to costing methods, impact measures used, mode of service delivery, form of STI management, intervention scale, and study location.

Search Strategy

Between November and December 2005, the authors searched PubMed, conference abstracts, and other grey literature for studies examining the cost of treating curable STIs. A detailed search in PubMed was conducted using the term “cost” and various STI pathogens and syndromes. Only English-language publications that focused on low- or middle-income countries were eligible for inclusion. Articles that had no reference to cost in the title or abstract were excluded, as were articles that focused on the laboratory aspects of diagnosis. No date/time limitation was specified. All papers and abstracts were reviewed independently by two of the authors, and discrepancies were reconciled through discussion with other authors.

Studies

Fifty-three original studies from low-and middle-income countries (as defined by World Bank criteria) were included in this review. Most studies (n=35, 65%) were from sub-Saharan Africa. The non-African studies were from Bangladesh, Bulgaria, Cambodia, China, India, Indonesia, Nicaragua, Peru, Russia, and Thailand.

Participants

Most studies targeted general population or symptomatic males and females. Some studies focused on specific groups, such as commercial sex workers (CSWs), the clients and partners of CSWs, family planning and antenatal clinic attendees, workplace STI screening attendees, voluntary counseling and testing (VCT) attendees, glue sniffers, and transvestites.

Intervention(s)

The included studies covered a range of issues associated with the provision of STI treatment services. Forty-two studies focused on the provision of STI treatment, four estimated the drug costs associated with STI treatment, five focused on patient expenditure, one focused on provider profits, and one discussed the cost of tracing defaulter patients and partners. No studies were found that examined the costs associated with mass treatment of STI.

Outcome Measures

Cost per (unspecified) STI treated was the most common outcome. Of the 53 studies included in this review, 31 (58%) estimated the empirical costs of STI treatment, 34% (n=18) the economic costs, and 17% (n=9) the estimated full costs. To enable comparison and analysis, all costs were converted to constant 2004 US dollars. Studies reported unit costs for 20 different outcomes. In total, the studies provided 117 observations on the costs of STI drugs and 134 observations on the cost per STI treated.

Results

The median cost for drugs was $2.62 and for treatment $17.80. In regression analysis, the cost of outreach services was 51% higher than clinic-based services for symptomatic patients. Unit costs in Africa were 3.34 times the costs of interventions elsewhere. Interventions that used syndromic management protocols to identify STIs were half the cost of using other forms of STI management, such as etiologic diagnosis. The cost per HIV infection averted was $2,299.

Conclusions

The compiled cost data provide an evidence base that can be used to help inform resource planning.

Quality Rating

Using the QUOROM criteria for assessing the quality of systematic reviews, this study was of high quality. The quality of this systematic review was limited in that only English-language articles were searched and key pieces of technical information were missing from the descriptions of the methods used to calculate unit costs, and that when available, methodologies varied significantly. It should also be noted that because studies often reported on the cost per case cured and did not account for the secondary effects of treating STIs on the transmission, the overall cost-effectiveness of these interventions may be underestimated.

In Context

Although several reviews have summarized the evidence of the costs and cost-effectiveness of various forms of HIV prevention, no reviews of the costs of providing services for curable STIs have been published. It has been estimated that in developing countries, STIs, excluding HIV, account for 17% of economic losses caused by ill-health.(1)

Programmatic Implications

Data on intervention costs, such as those presented here, can be used to inform resource decisions. As treatment using syndromic management was shown to reduce unit costs, this approach can be encouraged in low-resource settings. Additionally, although outreach interventions were shown to be more expensive per outcome, their cost-effectiveness would depend on the prevalence of treatable STIs in the target groups.(2,3)

References

  1. World Development Report 1993: Investing in Health. New York: Oxford University Press for the World Bank, 1993. [PDF, 6MB]
  2. Terris-Prestholt F, Watson-Jones D, Mugeye K, Kumaranayake L, Ndeki L, Weiss H, Changalucha J, Todd J, Lisekie F, Gumodoka B, Mabey D, Hayes R. Is antenatal syphilis screening still cost effective in sub-Saharan Africa? Sex Transm Infect. 2003 Oct;79(5):375-81.
  3. Vickerman P, Terris-Prestholt F, Delany S, Kumaranayake L, Rees H, Watts C. Are targeted HIV prevention activities cost-effective in high prevalence settings? Results from a sexually transmitted infection treatment project for sex workers in Johannesburg, South Africa. Sex Transm Dis. 2006 Oct;33(10 Suppl):S122-32.