Costs for Scenarios 1 and 2.

<p>DOMC = Division of Malaria Control; HW = health worker; DHMT = District Health Management Team.</p

Cost-effectiveness and sensitivity analyses.

<p>Cost-effectiveness and sensitivity analyses.</p

Costs for national scale-up (Scenario 3).

<p>DOMC = Division of Malaria Control; HW = health worker.</p

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

<div><p>Background</p><p>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.</p><p>Methods</p><p>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.</p><p>Results</p><p>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.</p><p>Conclusions</p><p>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.</p></div

Material costs per dose of penicillin (ZMW and US$ 2012).

<p>Material costs per dose of penicillin (ZMW and US$ 2012).</p

Costs (USD 2012) and Cost Effectiveness (cost-per DALY avoided) per 1000 new ANC patients.

<p>Costs (USD 2012) and Cost Effectiveness (cost-per DALY avoided) per 1000 new ANC patients.</p

Training costs per health worker (monthly equivalent costs ZMW and US$ 2012).

<p>Training costs per health worker (monthly equivalent costs ZMW and US$ 2012).</p

Costs per 1,000 patients presenting for antenatal care and patient management as observed during evaluation study (Scenario ES).

<p>Costs per 1,000 patients presenting for antenatal care and patient management as observed during evaluation study (Scenario ES).</p

Material costs per RST and per RPR test (ZMW and US$ 2012).

<p>Material costs per RST and per RPR test (ZMW and US$ 2012).</p

Detailed assumptions used for base case costing and cost-effectiveness analysis (scenario ES^*).

<p>*The base case scenario, called Scenario ES, is the full set of information that is used to estimate costs per 1,000 new ANC patients and cost effectiveness. Information in Scenario is based on prevalence and patient management as observed during the evaluation study (a 12 month period following RST training and the roll out in Kalomo District) and information on costs as presented in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0113868#pone-0113868-t001" target="_blank">Tables 1</a>–<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0113868#pone-0113868-t003" target="_blank">3</a> and additional information as needed. Sources for all information are provided in the table.</p><p>**Nurse level MS08 on government salary scale, ZMW 32,451 annual salary and all benefits, 220 working days per year, 8 hours per day.</p><p>***With 2.8% testing positive during the evaluation study, we identified the combination of true prevalence, sensitivity, and specificity that are consistent with the 2.8% testing positive.</p><p>Detailed assumptions used for base case costing and cost-effectiveness analysis (scenario ES^{<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0113868#nt101" target="_blank">*</a>}).</p