Costs and health consequences of chlamydia management strategies among pregnant women in sub-Saharan Africa

Objectives: Chlamydia is the most common bacterial sexually transmitted infection worldwide and a major cause of morbidity – particularly among women and neonates. We compared costs and health consequences of using point-of-care (POC) tests with current syndromic management among antenatal care attendees in sub-Saharan Africa. We also compared erythromycin with azithromycin treatment and universal with age-based chlamydia management. Methods: A decision analytic model was developed to compare diagnostic and treatment strategies, using Botswana as a case. Model input was based upon 1) a study of pregnant women in Botswana, 2) literature reviews and 3) expert opinion. We expressed the study outcome in terms of costs (US$), cases cured, magnitude of overtreatment and successful partner treatment. Results: Azithromycin was less costly and more effective than was erythromycin. Compared to syndromic management, testing all attendees on their first visit with a 75% sensitive POC test increased the number of cases cured from 1 500 to 3 500 in a population of 100 000 women, at a cost of US$38 per additional case cured. This cost was lower in high-prevalence populations or if testing was restricted to teenagers. The specific POC tests provided the advantage of substantial reductions in overtreatment with antibiotics and improved partner management. Conclusions: Using POC tests to diagnose chlamydia during antenatal care in sub-Saharan Africa entails greater health benefits than syndromic management does – and at acceptable costs – especially when restricted to younger women. Changes in diagnostic strategy and treatment regimens may improve people’s health and even reduce health care budgets.