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Background: Productivity costs of sexually transmitted infections (STIs) reflect the value of lost time due to STI morbidity and mortality, including time spent traveling to, waiting for, and receiving STI treatment. The purpose of this study was to provide updated estimates of the average lifetime productivity cost for chlamydia, gonorrhea, and syphilis, per incident infection., Methods: We adapted published decision tree models from recent studies of the lifetime medical costs of chlamydia, gonorrhea, and syphilis in the United States. For each possible outcome of infection, we applied productivity costs that we obtained based on published health economic studies. Productivity costs included the value of patient time spent to receive treatment for STIs and for related sequelae such as pelvic inflammatory disease in women. We used a human capital approach and included losses in market (paid) and nonmarket (unpaid) productivity. We conducted 1-way sensitivity analyses and probabilistic sensitivity analyses., Results: The average lifetime productivity cost per infection was $28 for chlamydia in men, $205 for chlamydia in women, $37 for gonorrhea in men, $212 for gonorrhea in women, and $411 for syphilis regardless of sex, in 2023 US dollars. The estimated lifetime productivity cost of these STIs acquired in the United States in 2018 was $795 million., Conclusions: These estimates of the lifetime productivity costs can help in quantifying the overall economic burden of STIs in the United States beyond just the medical cost burden and can inform cost-effectiveness analyses of STI prevention activities., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2024 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Since common diagnostic tests for gonorrhea do not provide information about susceptibility to antibiotics, treatment of gonorrhea remains empiric. Antibiotics used for empiric therapy are usually changed once resistance prevalence exceeds a certain threshold (e.g., 5%). A low switch threshold is intended to increase the probability that an infection is successfully treated with the first-line antibiotic, but it could also increase the pace at which recommendations are switched to newer antibiotics. Little is known about the impact of changing the switch threshold on the incidence of gonorrhea, the rate of treatment failure, and the overall cost and quality-adjusted life-years (QALYs) associated with gonorrhea., Methods and Findings: We developed a transmission model of gonococcal infection with multiple resistant strains to project gonorrhea-associated costs and loss in QALYs under different switch thresholds among men who have sex with men (MSM) in the United States. We accounted for the costs and disutilities associated with symptoms, diagnosis, treatment, and sequelae, and combined costs and QALYs in a measure of net health benefit (NHB). Our results suggest that under a scenario where 3 antibiotics are available over the next 50 years (2 suitable for the first-line therapy of gonorrhea and 1 suitable only for the retreatment of resistant infections), changing the switch threshold between 1% and 10% does not meaningfully impact the annual number of gonorrhea cases, total costs, or total QALY losses associated with gonorrhea. However, if a new antibiotic is to become available in the future, choosing a lower switch threshold could improve the population NHB. If in addition, drug-susceptibility testing (DST) is available to inform retreatment regimens after unsuccessful first-line therapy, setting the switch threshold at 1% to 2% is expected to maximize the population NHB. A limitation of our study is that our analysis only focuses on the MSM population and does not consider the influence of interventions such as vaccine and common use of rapid drugs susceptibility tests to inform first-line therapy., Conclusions: Changing the switch threshold for first-line antibiotics may not substantially change the health and financial outcomes associated with gonorrhea. However, the switch threshold could be reduced when newer antibiotics are expected to become available soon or when in addition to future novel antibiotics, DST is also available to inform retreatment regimens., Competing Interests: T.L.G is employed by CDC; other authors declare no competing interests., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

Background: Current clinical care for common bacterial STIs (Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Mycoplasma genitalium (MG)) involves empiric antimicrobial therapy when clients are symptomatic, or if asymptomatic, waiting for laboratory testing and recall if indicated. Near-to-patient testing (NPT) can improve pathogen-specific prescribing and reduce unnecessary or inappropriate antibiotic use in treating sexually transmitted infections (STI) by providing same-day delivery of results and treatment., Methods: We compared the economic cost of NPT to current clinic practice for managing clients with suspected proctitis, non-gonococcal urethritis (NGU), or as an STI contact, from a health provider's perspective. With a microsimulation of 1000 clients, we calculated the cost per client tested and per STI- and pathogen- detected for each testing strategy. Sensitivity analyses were conducted to assess the robustness of the main outcomes. Costs are reported as Australian dollars (2023)., Results: In the standard care arm, cost per client tested for proctitis, NGU in men who have sex with men (MSM) and heterosexual men were the highest at $247.96 (95% Prediction Interval (PI): 246.77-249.15), $204.23 (95% PI: 202.70-205.75) and $195.01 (95% PI: 193.81-196.21) respectively. Comparatively, in the NPT arm, it costs $162.36 (95% PI: 161.43-163.28), $158.39 (95% PI: 157.62-159.15) and $149.17 (95% PI: 148.62-149.73), respectively. Using NPT resulted in cost savings of 34.52%, 22.45% and 23.51%, respectively. Among all the testing strategies, substantial difference in cost per client tested between the standard care arm and the NPT arm was observed for contacts of CT or NG, varying from 27.37% to 35.28%., Conclusion: We found that NPT is cost-saving compared with standard clinical care for individuals with STI symptoms and sexual contacts of CT, NG, and MG., Competing Interests: Declaration of Competing Interest CSB and CKF were supported by an Australian National Health and Medical Research Council Leadership Investigator Grant (GNT1173361 and GNT1172900, respectively). JJO and EPFC are supported by an Australian National Health and Medical Research Council Emerging Leadership Investigator Grant (GNT1193955 and GNT1172873). YZ is supported by an Australian Government Research Training Program (RTP) scholarship. All other authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Standard-of-care nucleic acid amplification tests (routine NAATs) for Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) can take several days to result and therefore delay treatment. Rapid point-of-care GC/CT NAAT (rapid NAAT) could reduce the time to treatment and therefore onward transmission. This study evaluated the incremental cost per infectious day averted and overall cost of implementation associated with rapid compared with routine NAAT., Methods: Prospective sexually transmitted infection (STI) treatment data from men who have sex with men and transgender women in San Diego who received rapid NAAT between November 2018 and February 2021 were evaluated. Historical time from testing to treatment for routine NAAT was abstracted from the literature. Costs per test for rapid and routine NAAT were calculated using a micro-costing approach. The incremental cost per infectious day averted comparing rapid to routine NAAT and the costs of rapid GC/CT NAAT implementation in San Diego Public Health STI clinics were calculated., Results: Overall, 2333 individuals underwent rapid NAAT with a median time from sample collection to treatment of 2 days compared with 7 to 14 days for routine NAAT equating to a reduction of 5 to 12 days. The cost of rapid and routine GC/CT NAAT was $57.86 and $18.38 per test, respectively, with a cost-effectiveness of between $2.43 and $5.82 per infectious day averted. The incremental cost of rapid NAAT improved when at least 2000 tests were performed annually., Conclusions: Although rapid GC/CT NAAT is more expensive than routine testing, the reduction of infectious days between testing and treatment may reduce transmission and provide improved STI treatment services to patients., Competing Interests: Conflict of Interest and Sources of Funding: S.J.L. has received funding from Gilead Sciences paid to her institution and donation of medications from Gilead Sciences. E.W., T.C.S.M., N.K.M., and W.T. have no conflicts of interest to disclose., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Sexually Transmitted Diseases Association.)

Background: Gonorrhea's rapid development of antimicrobial resistance underscores the importance of new prevention modalities. Recent evidence suggests that a serogroup B meningococcal vaccine may be partially effective against gonococcal infection. However, the viability of vaccination and the role it should play in gonorrhea prevention are an open question., Methods: We modeled the transmission of gonorrhea over a 10-year period in a heterosexual population to find optimal patterns of year-over-year investment of a fixed budget in vaccination and screening programs. Each year, resources could be allocated to vaccinating people or enrolling them in a quarterly screening program. Stratifying by mode (vaccination vs. screening), sex (male vs. female), and enrollment venue (background screening vs. symptomatic visit), we consider 8 different ways of controlling gonorrhea. We then found the year-over-year pattern of investment among those 8 controls that most reduced the incidence of gonorrhea under different assumptions. A compartmental transmission model was parameterized from existing literature in the US context., Results: Vaccinating men with recent symptomatic infection, which selected for higher sexual activity, was optimal for population-level gonorrhea control. Given a prevention budget of $3 per capita, 9.5% of infections could be averted ($299 per infection averted), decreasing gonorrhea sequelae and associated antimicrobial use by similar percentages. These results were consistent across sensitivity analyses that increased the budget, prioritized incidence or prevalence reductions in women, or lowered screening costs. Under a scenario where only screening was implemented, just 5.5% of infections were averted., Conclusions: A currently available vaccine, although only modestly effective, may be superior to frequent testing for population-level gonorrhea control., Competing Interests: Conflict of interest and Sources of Funding: None declared., (Copyright © 2024 American Sexually Transmitted Diseases Association. All rights reserved.)

Objectives: Pre-exposure prophylaxis (PrEP) users are routinely tested four times a year (3 monthly) for asymptomatic Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections on three anatomical locations. Given the high costs of this testing to the PrEP programme, we assessed the impact of 3 monthly screening(current practice), compared with 6 monthly on the disease burden. We quantified the difference in impact of these two testing frequencies on the prevalence of CT and NG among all men who have sex with men (MSM) who are at risk of an STI, and explored the cost-effectiveness of 3-monthly screening compared with a baseline scenario of 6-monthly screening., Methods: A dynamic infection model was developed to simulate the transmission of CT and NG among sexually active MSM (6500 MSM on PrEP and 29 531 MSM not on PrEP), and the impact of two different test frequencies over a 10-year period. The difference in number of averted infections was used to calculate incremental costs and quality-adjusted life-years (QALY) as well as an incremental cost-effectiveness ratio (ICER) from a societal perspective., Results: Compared with 6-monthly screening, 3-monthly screening of PrEP users for CT and NG cost an additional €46.8 million over a period of 10 years. Both screening frequencies would significantly reduce the prevalence of CT and NG, but 3-monthly screening would avert and extra ~18 250 CT and NG infections compared with 6-monthly screening, resulting in a gain of ~81 QALYs. The corresponding ICER was ~€430 000 per QALY gained, which exceeded the cost-effectiveness threshold of €20 000 per QALY., Conclusions: Three-monthly screening for CT and NG among MSM on PrEP is not cost-effective compared with 6-monthly screening. The ICER becomes more favourable when a smaller fraction of all MSM at risk for an STI are screened. Reducing the screening frequency could be considered when the PrEP programme is established and the prevalence of CT and NG decline., Competing Interests: Competing interests: EH obtained advisory board fees and a research grant from Gilead Sciences; both of which were paid to her institute., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: Adolescents and young adults compose almost 50% of all diagnosed sexually transmitted infection (STI) cases annually in the US. Given that these individuals frequently access health care through the emergency department (ED), the ED could be a strategic venue for examining the identification and treatment of STIs., Objective: To examine the cost-effectiveness of screening strategies for Chlamydia trachomatis and Neisseria gonorrhoeae (chlamydia and gonorrhea) in adolescents and young adults who seek acute care at pediatric EDs., Design, Setting, and Participants: This economic evaluation is a component of an ongoing, larger multicenter clinical trial at the Pediatric Emergency Care Applied Research Network. A decision analytic model, created using literature-based estimates for the key parameters, was developed to simulate the events and outcomes associated with 3 strategies for screening and testing chlamydial and gonococcal infections in individuals aged 15 to 21 years who sought acute care at pediatric EDs. Data sources included published (from January 1, 1997, to December 31, 2019) English-language articles indexed in MEDLINE, bibliographies in relevant articles, insurance claims data in the MarketScan database, and reimbursement payments from the Centers for Medicare and Medicaid Services. Because the events and outcomes were simulated, a hypothetical population of 10 000 ED visits by adolescents and young adults was used., Interventions: The 3 screening strategies were (1) no screening, (2) targeted screening, and (3) universally offered screening. Targeted screening involved the completion of a sexual health survey, which yielded an estimated STI risk (at risk, high risk, or low risk)., Main Outcomes and Measures: Outcome metrics included cost (measured in 2019 US dollars) and the detection and successful treatment of STIs. The incremental cost-effectiveness ratio (ICER) of each strategy was calculated in a base case analysis. The ICER reflects the cost per case detected and successfully treated., Results: A 3.6% prevalence of chlamydia and gonorrhea was applied to a hypothetical population of 10 000 ED visits by adolescents and young adults. Targeted screening resulted in the detection and successful treatment of 95 of 360 STI cases (26.4%) at a cost of $313 063, and universally offered screening identified and treated 112 of 360 STI cases (31.1%) at a cost of $515 503. The ICER for targeted screening vs no screening was $6444, and the ICER for universally offered screening vs targeted screening was $12 139., Conclusions and Relevance: This economic evaluation found that targeted screening and universally offered screening compared with no screening appeared to be cost-effective strategies for identifying and treating chlamydial and gonococcal infections in adolescents and young adults who used the ED for acute care. Universally offered screening was associated with detecting and successfully treating a higher proportion of STIs in this population.

Achieving universal health coverage (UHC) for sexual and reproductive health (SRH) requires informed budgeting that is aligned with UHC objectives. We draw data from Adding It Up 2019 (AIU-2019) to provide critical new country-level and regional, intervention-specific costs for the provision of SRH services. AIU-2019 is a cost-outcomes analysis, undertaken from the health system perspective, which estimates the costs and impacts of offering SRH care in low- and middle-income countries. We present direct cost estimates for 109 SRH interventions and find that human resources comprise the largest category of direct SRH service costs and that the most expensive services in the model are largely preventable. We use scenario analysis to explore the synergistic costs and impacts of providing SRH interventions in clusters, focussing on chlamydia and gonorrhoea treatment, provision of safe abortion and post-abortion care services, and safe childbirth services. When costs are considered for the preventive and impacted services in these three clusters, there are cost savings for some of the impacted services in the packages and for the abortion-related package overall. The direct cost estimates from our analysis can be used to guide UHC budgeting and planning efforts. Having these cost estimates and understanding the potential for cost savings when providing comprehensive SRH services are critical for efforts to fulfil the rights and needs of all individuals, including the most marginalised, to access this essential care.

Targeted antibiotics could delay emergence of resistant Neisseria gonorrhoeae. The DNA gyrase subunit A assay predicts susceptibility to ciprofloxacin. A model found that adding a $50 gyrase subunit A test for asymptomatic patients screened for N. gonorrhoeae resulted in cost neutrality. When ciprofloxacin susceptibility was high, a $114 test resulted in savings.

Background: Sexually transmitted disease (STD) partner services (PS) are a core component of STD programs. Data on costs are needed to support PS programming., Methods: In Washington State STD PS programs, disease intervention specialists (DIS) conduct telephone-based interviews and occasional field visits, offer expedited partner therapy to heterosexuals with gonorrhea or chlamydia, and promote human immunodeficiency virus (HIV) testing, preexposure prophylaxis, and HIV care. We conducted activity-based microcosting of PS, including: observational and self-reported time studies and interviews. We analyzed cost, surveillance, and service delivery data to determine costs per program outcomes., Results: In King, Pierce, and Spokane counties, respectively, DIS allocated 6.5, 6.4, and 28.8 hours per syphilis case and 1.5, 1.6, and 2.9 hours per gonorrhea/chlamydia case, on average. In 2016, each full-time DIS investigated 270, 268, and 61 syphilis and 1177, 1105, and 769 gonorrhea/chlamydia cases. Greater than 80% of syphilis cases in King and Pierce were among men who have sex with men versus 38% in Spokane. Disease intervention specialists spent 12% to 39% of their time actively interviewing cases and notifying partners (clients), and the remaining time locating clients, coordinating and verifying care, and managing case reports. Time spent on expedited partner therapy, HIV testing, and referrals to HIV treatment or preexposure prophylaxis, was minimal (<5 minutes per interview) at locations with resources outside PS staff. Program cost-per-interview ranged from US $527 to US $2210 for syphilis, US $219 to US $484 for gonorrhea, and US $164 to US $547 for chlamydia., Discussion: The STD PS resource needs depended on epidemic characteristics and program models. Integrating HIV prevention objectives minimally impacted PS-specific program costs. Results can inform program planning, future budget impact, and cost-effectiveness analyses.

Sexually transmitted infections (STIs) have posed a threat to military service members throughout history, but limited evidence describes current sexually transmitted infection burden for personnel in-theater and stationed abroad. This study assessed chlamydia and gonorrhea rates by unit of country assignment and evaluated the demographic profile of affected personnel during deployment. Chlamydia and gonorrhea cases among active duty personnel were identified from laboratory results and ambulatory encounter records in the Military Health System from fiscal years October 2006 through September 2015; these were linked to personnel and deployment records to ascertain demographic characteristics, unit of country assignment, and if the case was captured during a period of deployment. Case rates were higher for chlamydia (1,321.7 per 100,000) than gonorrhea (222.7 per 100,000). Approximately 2% of both chlamydia and gonorrhea cases were identified during deployment, with significant differences by service, sex, and age. Elevated rates were identified in several countries of unit assignment outside the USA, warranting further assessment to better understand implications of screening programs or increased morbidity. Pertinent limitations for this study potentially underestimate STI cases during deployment, due to incomplete capture of records from shipboard and in-theater facilities., (© Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: A population-based study of Chlamydia trachomatis (CT) infections is essential in designing a specific control program; however, no large investigation of CT infections among the general population in mainland China has been conducted since 2000. We aimed to determine the prevalence, risk factors, and associated medical costs of CT among residents, 18-49 years of age, in Shandong, China., Methods: From May to August 2016, a multistage probability sampling survey involving 8074 individuals was distributed. Data were collected via face-to-face interviews, followed by self-administered questionnaire surveys. First-void urines were collected and tested for CT and Neisseria gonorrhoeae (NG) using nucleic acid amplification., Results: The weighted prevalence of CT infection was 2.3% (95% confidence interval [CI], 1.5-3.2) in females and 2.7% (1.6-3.8) in males. Women, 30-34 years of age, had the highest prevalence of CT infections (3.5%, 2.6-4.4), while the highest prevalence of CT infections in males was in those 18-24 years of age (4.3%, 0.0-8.8). Neisseria gonorrhoeae infection had a prevalence of 0.1% (0.0-0.3) in women and 0.03% (0.0-0.1) in men. Risk factors for CT infections among females included being unmarried, divorced, or widowed (odds ratio [OR], 95% CI 3.57, 1.54-8.24) and having two or more lifetime sex partners (3.72, 1.14-12.16). Among males, first intercourse before 20 years of age (1.83, 1.10-3.02) and having two or more lifetime sex partners (1.85, 1.14-3.02) were associated with CT infections. The estimated lifetime cost of CT infections in patients 18-49 years of age in Shandong was 273 million (range, 172-374 million) China Renminbi in 2016., Conclusions: This study demonstrated a high burden of CT infections among females < 35 years of age and males < 25 years of age in Shandong. Thus, a CT infection control program should focus on this population, as well as others with identified risk factors.

Objectives: To quantify the costs, benefits and cost-effectiveness of three multipathogen point-of-care (POC) testing strategies for detecting common sexually transmitted infections (STIs) compared with standard laboratory testing., Design: Modelling study., Setting: Genitourinary medicine (GUM) services in England., Population: A hypothetical cohort of 965 988 people, representing the annual number attending GUM services symptomatic of lower genitourinary tract infection., Interventions: The decision tree model considered costs and reimbursement to GUM services associated with diagnosing and managing STIs. Three strategies using hypothetical point-of-care tests (POCTs) were compared with standard care (SC) using laboratory-based testing. The strategies were: A) dual POCT for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG); B) triplex POCT for CT-NG and Mycoplasma genitalium (MG); C) quadruplex POCT for CT-NG-MG and Trichomonas vaginalis (TV). Data came from published literature and unpublished estimates., Primary and Secondary Outcome Measures: Primary outcomes were total costs and benefits (quality-adjusted life years (QALYs)) for each strategy (2016 GB, £) and associated incremental cost-effectiveness ratios (ICERs) between each of the POC strategies and SC. Secondary outcomes were inappropriate treatment of STIs, onward STI transmission, pelvic inflammatory disease in women, time to cure and total attendances., Results: In the base-case analysis, POC strategy C, a quadruplex POCT, was the most cost-effective relative to the other strategies, with an ICER of £36 585 per QALY gained compared with SC when using microcosting, and cost-savings of £26 451 382 when using tariff costing. POC strategy C also generated the most benefits, with 240 467 fewer clinic attendances, 808 fewer onward STI transmissions and 235 135 averted inappropriate treatments compared with SC., Conclusions: Many benefits can be achieved by using multipathogen POCTs to improve STI diagnosis and management. Further evidence is needed on the underlying prevalence of STIs and SC delivery in the UK to reduce uncertainty in economic analyses., Competing Interests: Competing interests: All authors have completed the Unified Competing Interest Form and declare financial support from Innovate UK; EJA, SEH, MJH are employees of Aquarius Population Health (APH), which reports grants from Innovate UK grant to Atlas Genetics, during the conduct of the study; other from Cepheid, St Georges University of London, Enigma Diagnostics and AstraZeneca, on STI and POC research outside the submitted work; RMB is a Lecturer and Programme Director of Economics at St. Angela’s College Sligo/NUI Galway and an academic staff member of the Health Economics and Policy Analysis Centre (HEPAC) at NUI Galway, providing health economic support to Aquarius Population Health on an ad hoc consultancy basis. STS, EH-E, SSF are members of the Applied Diagnostic Research and Evaluation Unit at St George’s, University of London, which has received funding from Atlas Genetics, Alere, Cepheid, SpeeDx and Sekisui. STS has received NIHR funding to develop a POCT with Atlas., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Point-of-care (POC) management may avert ongoing transmissions occurring between testing and treatment or due to loss to follow-up. We modelled the impact of POC management of anogenital gonorrhoea (with light microscopic evaluation of Gram stained smears) among men who have sex with men (MSM) on gonorrhoea prevalence and testing and treatment costs., Methods: Data concerning costs and sexual behaviour were collected from the STI clinic of Amsterdam. With a deterministic model for gonorrhoea transmission, we calculated the prevalence of gonorrhoea in MSM in Amsterdam and the numbers of consultations at our clinic over 5 years, in three testing scenarios: POC for symptomatic MSM only (currently routine), POC for all MSM and no POC for MSM., Results: Among MSM, 34.7% (109/314) had sexual contacts in the period between testing and treatment, of whom 22.9% (25/109) had unprotected anal intercourse. Expanding POC testing from symptomatic MSM to all MSM could result in an 11% decrease (IQR, 8%-15%) in gonorrhoea prevalence after 5 years and a cost increase of 8.6% (€2.40) per consultation and €86 118 overall (+8.3%). Switching from POC testing of symptomatic MSM to no POC testing could save €1.83 per consultation (6.5%) and €54 044 (-5.2%) after 5 years with a 60% (IQR, 26%-127%) gonorrhoea prevalence increase. Overtreatment was 2.1% (30/1411) with POC for symptomatic MSM only and 4.1% (68/1675) with POC for all MSM., Conclusions: In the Amsterdam setting, possible abandonment of POC testing of symptomatic MSM because of budget cuts could result in a considerable increase in gonorrhoea prevalence against a reduction in costs per consultation. Expanding POC testing to all MSM could result in a modest reduction in prevalence and a cost increase. While the costs and outcomes depend on specific local characteristics, the developed framework of this study is useful to evaluate POC management in other settings., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Competing Interests: Competing interests: None declared.

Objective: To estimate the programmatic costs of partner services for HIV, syphilis, gonorrhea, and chlamydial infection., Study Setting: New York State and local health departments conducting partner services activities in 2014., Study Design: A cost analysis estimated, from the state perspective, total program costs and cost per case assignment, patient interview, partner notification, and disease-specific key performance indicator., Data Collection: Data came from contracts, a time study of staff effort, and statewide surveillance systems., Principal Findings: Disease-specific costs per case assignment (mean: $580; range: $502-$1,111), patient interview ($703; $608-$1,609), partner notification ($1,169; $950-$1,936), and key performance indicator ($2,697; $1,666-$20,255) varied across diseases. Most costs (79 percent) were devoted to gonorrhea and chlamydial infection investigations., Conclusions: Cost analysis complements cost-effectiveness analysis in evaluating program performance and guiding improvements., (© Health Research and Educational Trust.)

Background: Gonorrhea is the second most commonly reported identifiable disease in the United States (U.S.). Importantly, more than 25% of gonorrheal infections demonstrate antibiotic resistance, leading the Centers for Disease Control and Prevention (CDC) to classify gonorrhea as an "urgent threat"., Methods: We examined the association of gonorrhea infection rates with the incidence of HIV and socioeconomic factors. A county-level multivariable model was then constructed., Results: Multivariable analysis demonstrated that HIV incidence [Coefficient (Coeff): 1.26, 95% Confidence Interval (CI): 0.86, 1.66, P<0.001] exhibited the most powerful independent association with the incidence of gonorrhea and predicted 40% of the observed variation in gonorrhea infection rates. Sociodemographic factors like county urban ranking (Coeff: 0.12, 95% CI: 0.03, 0.20, P = 0.005), percentage of women (Coeff: 0.41, 95% CI: 0.28, 0.53, P<0.001) and percentage of individuals under the poverty line (Coeff: 0.45, 95% CI: 0.32, 0.57, P<0.001) exerted a secondary impact. A regression model that incorporated these variables predicted 56% of the observed variation in gonorrhea incidence (Pmodel<0.001, R2 model = 0.56)., Conclusions: Gonorrhea and HIV infection exhibited a powerful correlation thus emphasizing the benefits of comprehensive screening for sexually transmitted infections (STIs) and the value of pre-exposure prophylaxis for HIV among patients visiting an STI clinic. Furthermore, sociodemographic factors also impacted gonorrhea incidence, thus suggesting another possible focus for public health initiatives.

Background: High rates of failure to qualify for clinical trial participation increase time and cost required for study completion. Identification of remediable reasons for prescreen failure can help reduce prescreen failure rates and improve study cost effectiveness., Methods: Reasons for prescreen failure to qualify for participation in a phase 2 randomized clinical trial of treatment of uncomplicated urogenital gonorrhea were collected from prescreening logs. Reasons were categorized based on whether the reason was that the subject failed to meet eligibility criteria or declined participation. Subjects who failed prescreening but could have been enrolled under protocol amendments were used to estimate potential cost savings had enrollment completed sooner., Results: Over 88% (1373/1554) of potential study candidates were not enrolled. The majority (68.8%) of nonenrolled subjects failed prescreening due to not meeting eligibility criteria, whereas 31.0% declined to participate. The most common reasons for failure to qualify were having only nonurogenital gonorrhea (16.4%), limited time (13.1%), and being on antiretroviral therapy (7.5%). Potential cost savings if protocol amendments affecting eligibility had been instituted earlier were estimated at US $127,500., Conclusions: Careful attention to reasons for prescreen failure can inform clinical trial protocol development to address trial design features that may impact successful enrollment. More efficient subject enrollment can result in substantial cost savings.

Background: Gonorrhoea is a common sexually transmitted infection which causes genital pain and discomfort; in women it can also lead to pelvic inflammatory disease and infertility, and in men to epididymo-orchitis. Current treatment is with ceftriaxone, but there is increasing evidence of antimicrobial resistance which is reducing its effectiveness against gonorrhoea. A small, but increasing, number of patients have already been found to have highly resistant strains of gonorrhoea which has been associated with clinical failure. This trial aims to determine whether gentamicin is not clinically worse than ceftriaxone in the treatment of gonorrhoea., Methods/design: This is a blinded, two-arm, multicentre, noninferiority randomised trial. Patients are eligible if they are aged 16-70 years with a diagnosis of genital, pharyngeal and/or rectal gonorrhoea. Exclusion criteria are: known concurrent sexually transmitted infection(s) (excluding chlamydia); bacterial vaginosis and/or Trichomonas vaginalis infection; contraindications or an allergy to gentamicin, ceftriaxone, azithromycin or lidocaine; pregnancy or breastfeeding; complicated gonorrhoeal infection; weight under 40 kg; use of ceftriaxone, gentamicin or azithromycin within the preceding 28 days. Randomisation is to receive a single intramuscular injection of either gentamicin or ceftriaxone, all participants receive 1 g oral azithromycin as standard treatment. The estimated sample size is 720 participants (noninferiority limit 5%). The primary outcome is clearance of Neisseria gonorrhoeae at all infected sites by a negative Nucleic Acid Amplification Test, 2 weeks post treatment. Secondary outcomes include clinical resolution of symptoms, frequency of adverse events, tolerability of therapy, relationship between clinical effectiveness and antibiotic minimum inhibitory concentration for N. gonorrhoeae, and cost-effectiveness., Discussion: The options for future treatment of gonorrhoea are limited. Results from this randomised trial will demonstrate whether gentamicin is not clinically worse than ceftriaxone for the treatment of gonorrhoea. This will inform clinical practice and policy for the treatment of gonorrhoea when current therapy with cephalosporins is no longer effective, or is contraindicated., Trial Registration: International Standard Randomised Controlled Trial Number - ISRCTN51783227 , Registered on 18 September 2014. Current protocol version 2.0 17 June 2015.

Background: In response to the rising threat of resistance to first-line antibiotics for gonorrhea, international guidelines recommend dual antimicrobial therapy. However, some countries continue to recommend monotherapy. We assess the cost-effectiveness of dual therapy with ceftriaxone and azithromycin compared with monotherapy with ceftriaxone, for control of gonorrhea among men who have sex with men in the Netherlands., Methods: We developed a transmission model and calculated the numbers of new gonorrhea infections, consultations at health care specialists, tests, and antibiotic doses. With these numbers, we calculated costs and quality-adjusted life-years (QALY) with each treatment; and the incremental cost-effectiveness ratio (ICER) of dual therapy compared to monotherapy. The impact of gonorrhea on human immunodeficiency virus transmission was not included in the model., Results: In the absence of initial resistance, dual therapy can delay the spread of ceftriaxone resistance by at least 15 years, compared to monotherapy. In the beginning, when there is no resistance, dual therapy results in high additional costs, without any QALY gains. When resistance spreads over time, the additional costs of dual therapy decline, the gained QALYs increase, the ICER drops off and, after 50 years, falls below &OV0556;20,000 per QALY gained. If azithromycin resistance is initially prevalent, resistance to the first-line treatment rises almost equally fast with both treatment strategies and the ICER remains extremely high., Conclusions: Compared with ceftriaxone monotherapy, dual therapy with ceftriaxone and azithromycin can considerably delay the spread of ceftriaxone resistance, but may only be cost-effective in the long run and in the absence of initial resistance.

Introduction: After the release of CDC's revised gonorrhea treatment guidelines in April 2007, a study reported the declining use of fluoroquinolones to treat gonorrhea among health departments participating in the Sexually Transmitted Disease Surveillance Network. In this study, we examine the proportion of fluoroquinolone claims among gonorrhea-associated prescription drug claims from a large insurance database from 2000 through 2010., Methods: We extracted drug claims associated with gonorrhea diagnosis claims from the MarketScan database for 2000-2010 and calculated the proportion of the drug claims for fluoroquinolones on a monthly basis. We then used an interrupted time series analysis to investigate trend characteristics of fluoroquinolone claims before and after the gonorrhea treatment guidelines were revised in April 2007., Results: Although there was a monthly decline in the proportion of fluoroquinolone claims before April 2007 (-0.11 percentage points, p<0.01), results indicate a sevenfold (-0.78 percentage points, p<0.01) increase in the rate of decline after the revised guidelines were released in April 2007. We did not find any sudden drop (immediate or delayed) in the proportion of fluoroquinolones after April 2007, implying a gradual permanent decline over the analytic period., Conclusions: Our results are consistent with the findings of the previous study and indicate a gradual and permanent decline (over the analytic period) in the proportion of fluoroquinolone claims among gonorrhea-associated prescription drug claims. However, because this is a convenience sample of claims data, these findings cannot be generalized to the entire privately insured population in the U.S., (Published by Elsevier Inc.)

Description: Update of previous U.S. Preventive Services Task Force (USPSTF) recommendations on screening for chlamydia (2007) and gonorrhea (2005)., Methods: The USPSTF reviewed the evidence on screening for chlamydial and gonococcal infections in asymptomatic patients from studies published since its last reviews. The USPSTF also considered evidence from its previous recommendations and reviews., Population: This recommendation applies to all sexually active adolescents and adults, including pregnant women., Recommendations: The USPSTF recommends screening for chlamydia in sexually active females aged 24 years or younger and in older women who are at increased risk for infection. (B recommendation) The USPSTF recommends screening for gonorrhea in sexually active females aged 24 years or younger and in older women who are at increased risk for infection. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men. (I statement).

Objectives: To compare point-of-care (POC) systems in two different periods: (1) before 2010 when all high-risk patients were offered POC management for urogenital gonorrhoea by Gram stain examination; and (2) after 2010 when only those with symptoms were offered Gram stain examination., Methods: Retrospective comparison of a Gram stain POC system to all high-risk patients (2008-2009) with only those with urogenital symptoms (2010-2011) on diagnostic accuracy, loss to follow-up, presumptively and correctly treated infections and diagnostic costs. Culture was the reference diagnostic method., Results: In men the sensitivity of the Gram stain was 95.9% (95% CI 93.1% to 97.8%) in 2008-2009 and 95.4% (95% CI 93.7% to 96.8%) in 2010-2011, and in women the sensitivity was 32.0% (95% CI 19.5% to 46.7%) and 23.1% (95% CI 16.1% to 31.3%), respectively. In both periods the overall specificity was high (99.9% (95% CI 99.8% to 100%) and 99.8% (95% CI 99.7% to 99.9%), respectively). The positive predictive value (PPV) and negative predictive value (NPV) before and after 2010 were also high: PPV 97.0% (95% CI 94.5% to 98.5%) and 97.7% (95% CI 96.3% to 98.6%), respectively; NPV 99.6% (95% CI 99.4% to 99.7%) and 98.8% (95% CI 98.5% to 99.0%), respectively. There were no differences between the two time periods in loss to follow-up (7.1% vs 7.0%). Offering Gram stains only to symptomatic high-risk patients as opposed to all high-risk patients saved €2.34 per correctly managed consultation (a reduction of 7.7%)., Conclusions: The sensitivity of the Gram stain is high in men but low in women. When offered only to high-risk patients with urogenital symptoms, the cost per correctly managed consultation is reduced by 7.7% without a significant difference in accuracy and loss to follow-up., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objectives: We aimed to explore patient pathways using a chlamydia/gonorrhoea point-of-care (POC) nucleic acid amplification test (NAAT), and estimate and compare the costs of the proposed POC pathways with the current pathways using standard laboratory-based NAAT testing., Design/participants: Workshops were conducted with healthcare professionals at four sexual health clinics representing diverse models of care in the UK. They mapped out current pathways that used chlamydia/gonorrhoea tests, and constructed new pathways using a POC NAAT. Healthcare professionals' time was assessed in each pathway., Outcome Measure: The proposed POC pathways were then priced using a model built in Microsoft Excel, and compared to previously published costs for pathways using standard NAAT-based testing in an off-site laboratory., Results: Pathways using a POC NAAT for asymptomatic and symptomatic patients and chlamydia/gonorrhoea-only tests were shorter and less expensive than most of the current pathways. Notably, we estimate that POC testing as part of a sexual health screen for symptomatic patients, or as stand-alone chlamydia/gonorrhoea testing, could reduce costs per patient by as much as £16 or £6, respectively. In both cases, healthcare professionals' time would be reduced by approximately 10 min per patient., Conclusions: POC testing for chlamydia/gonorrhoea in a clinical setting may reduce costs and clinician time, and may lead to more appropriate and quicker care for patients. Further study is warranted on how to best implement POC testing in clinics, and on the broader clinical and cost implications of this technology., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Introduction: Limited data exist on insured patients who receive care at publically funded sexually transmitted disease (STD) clinics, despite having access to a primary care provider. In this analysis, we compare patients with and without health insurance who sought services at City Clinic, the San Francisco municipal STD clinic., Methods: We analyzed San Francisco City Clinic patients between August 1, 2011, and December 31, 2012. Insurance was self-reported and included both private and public insurance. Variables from the clinic electronic medical record were examined and included basic demographic and risk behavior questions, as well as positivity among patients tested for chlamydial and gonoccocal infection. We compared the characteristics of insured and uninsured patients using χ test., Results: There were 13,104 patients in this analysis, of whom 4981 (38%) were categorized as insured and 8123 (62%) as uninsured. Overall, insured patients were older, more likely to be male, more likely to be white, and less likely to be Hispanic compared with uninsured patients (all P < 0.05). In addition, insured patients were more likely to be among men who have sex with men and among HIV-infected individuals compared with uninsured patients (all P < 0.0001). Insured patients were less likely to have a diagnosis of chlamydia at any site or a diagnosis of rectal gonorrhea., Conclusions: In our municipal STD clinic, more than one-third of patients report currently having insurance, yet still choose to seek care at the STD clinic. The different characteristics between insured and uninsured patients may reflect reasons other than affordability; therefore, STD clinics remain an important source of care for at-risk populations. These data suggest that the expansion of access to insurance may not result in a reduced need for categorical STD services. Maintaining access to high-quality sexual health services should remain a priority in the era of expanded health care access.

Objectives: To estimate the costs and benefits of clinical pathways incorporating a point of care (POC) nucleic acid amplification test (NAAT) for chlamydia and gonorrhoea in genitourinary medicine (GUM) clinics compared with standard off-site laboratory testing., Method: We simulated 1.2 million GUM clinic attendees in England. A simulation in Microsoft Excel was developed to compare existing standard pathways of management for chlamydia and gonorrhoea with a POC NAAT. We conducted scenario analyses to evaluate the robustness of the model findings. The primary outcome was the incremental cost-effectiveness ratio. Secondary outcomes included the number of inappropriate treatments, complications and transmissions averted., Results: The baseline cost of using the point of POC NAAT was £103.9 million compared with £115.6 million for standard care. The POC NAAT was also associated with a small increase of 46 quality adjusted life years, making the new test both more effective and cheaper. Over 95 000 inappropriate treatments might be avoided by using a POC NAAT. Patients receive diagnosis and treatment on the same day as testing, which may also prevent 189 cases of pelvic inflammatory disease and 17 561 onward transmissions annually., Discussion: Replacing standard laboratory tests for chlamydia and gonorrhoea with a POC test could be cost saving and patients would benefit from more accurate diagnosis and less unnecessary treatment. Overtreatment currently accounts for about a tenth of the reported treatments for chlamydia and gonorrhoea and POC NAATs would effectively eliminate the need for presumptive treatment.

Background: The demand for low-cost sexually transmitted disease (STD) services in Maricopa County (Phoenix area) is high. Improved methods for STD/HIV testing are needed to increase the number of patients receiving testing., Objectives: The present study sought to evaluate an STD/HIV express testing (ET) option for patients identified as being at lower risk for infection., Methods: Clients reporting current STD symptoms, contact to an infected partner, or health department referral were identified via questionnaire and routed to a traditional provider visit (PV); those not reporting these situations were routed to ET (laboratory-only). Demographics, treatment completion, and treatment intervals were compared among patients diagnosed as having chlamydia and gonorrhea through ET and PV encounters in September 2008 to July 2011. Personnel costs were compared for each of the 2 visit types. The number of clinic turn-aways for the 2-month time interval before the start of the program was compared with the 2-month interval at the end of the evaluation., Results: Of the 36,946 clients seen at Maricopa County Department of Public Health, 7466 (20.2%) were patients seen through express visits. Overall chlamydia and gonorrhea positivity was lower among ET patients (527/7466; 7.1%) as compared with those tested through PVs (6323/29,480; 21.4%). Treatment completion rates were comparable but were higher among patients seen through PVs (99%) as compared with ET (94%). A savings of $2936 per 1000 patients seen was achieved when 20% of clients were routed through ET. Clinic turn-aways decreased significantly, from 159 clients during the 2 months before implementation of ET to 6 patients during the last 2 months of evaluation (96% reduction)., Conclusions: This ET system included an effective patient routing process that provided an efficient way to increase access to STD testing among persons at lower risk, at a reduced cost per patient, while maintaining high treatment coverage.

The fitness cost of antibiotic resistance in the absence of treatment raises the possibility that prudent use of drugs may slow or reverse the rise of resistance. Unfortunately, compensatory mutations that lower this cost may lead to entrenched resistance. Here, we develop a mathematical model of resistance evolution and compensatory mutation to determine whether reversion to sensitivity can occur, and how disease control might be facilitated by a second-line therapy. When only a single antibiotic is available, sensitive bacteria reach fixation only under treatment rates so low that hardly any cases are treated. We model a scenario in which drug sensitivity can be accurately tested so that a second-line therapy is administered to resistant cases. Before the rise of resistance to the second drug, disease eradication is possible if resistance testing and second-line treatment are conducted at a high enough rate. However, if double drug resistance arises, the possibility of disease eradication is greatly reduced and compensated resistance prevails in most of the parameter space. The boundary separating eradication from fixation of compensated resistance is strongly influenced by the underlying basic reproductive number of the pathogen and drug efficacy in sensitive cases, but depends less on the resistance cost and compensation. When double resistance is possible, the boundary is affected by the relative strengths of resistance against the two drugs in the double-resistant-compensated strain., (Copyright © 2013 Elsevier B.V. All rights reserved.)

Background: Productivity losses can arise when employees miss work to seek care for sexually transmissible infections (STIs). We estimated the average productivity loss per acute case of four nonviral STIs: chlamydia, gonorrhoea, syphilis and trichomoniasis., Methods: We extracted outpatient claims from 2001-2005 MarketScan databases using International Classification Disease ver. 9 (ICD-9) codes. We linked claims with their absence records in the Health and Productivity Management database by matching enrolee identifiers and the service dates from the claims such that our final data included only those who were absent because they were sick and were diagnosed with an STI on the day of their visit. To ensure that the visit was for the STIs being examined, we restricted the criteria to records with the specified ICD-9 codes only, excluding claims with other codes. We estimated the average number of hours absent and multiplied it by the mean hourly wage rate including benefits ($29.72 in 2011 United States dollars) to estimate the average productivity loss per case., Results: The average productivity losses per case were: $262 for chlamydia, $197 for gonorrhoea, $419 for syphilis and $289 for trichomoniasis. There were no significant differences between males and females., Conclusions: Among those who take sick leave to seek care, productivity losses associated with treating nonviral STIs may be higher than their estimated direct medical costs. These productivity cost estimates can help to quantify the overall STI burden, and inform cost-effectiveness analyses of prevention and control efforts.

Background: Chlamydia and gonorrhea infections can lead to serious and costly sequelae in women, but sequelae in men are rare. In accordance with the Centers for Disease Control and Prevention guidelines, female jail inmates in Maricopa County (Phoenix area), Arizona, are screened for these infections. Owing to lack of evidence of screening benefits in men, male inmates are tested and treated based on symptoms only., Methods: We developed a probabilistic simulation model to simulate chlamydia and gonorrhea infections in Maricopa County jail male inmates and transmissions to female partners per year. We estimated the cost-effectiveness of screening as the cost per infection averted. Costs were estimated from the perspective of the Maricopa County Department of Public Health and the Correctional Health Services., Results: Compared with symptom-based testing and treating strategy, screening male arrestees of all ages and only those 35 years or younger yielded the following results: averted approximately 556 and 491 cases of infection in women at a cost of approximately US $1240 and $860 per case averted, respectively, if screened during physical examination (between days 8 and 14 from entry to jail), and averted approximately 1100 and 995 cases of infections averted at a cost of US $1030 and $710 per infection averted, respectively, if screened early, within 2 to 3 days from entry to jail., Conclusions: Screening of male inmates incurs a modest cost per infection averted in women compared with symptom-based testing. Screening in correctional settings can be used by public health programs to reduce disease burden, sequelae, and associated costs.

In November 2011, the National Institutes of Health convened a workshop of basic researchers, epidemiologists, and clinical experts in pelvic inflammatory disease to identify research gaps hindering advances in diagnosis, treatment, and prevention. This article summarizes the presentations, discussions, and conclusions of this group and highlights significant controversies that reveal aspects of pelvic inflammatory disease research that would most greatly benefit from the application of newer molecular, immunologic, and radiologic techniques. Multiple limitations to performing new clinical trials exist; however, emerging data from ongoing clinical trials will add to the current body of knowledge regarding prevention and treatment strategies. In addition, use of established health care databases could serve as a valuable tool for performance of unbiased epidemiologic outcome studies.

Objectives: We examined the association between racial disparity in income and reported race-specific county-level bacterial sexually transmitted infections (STIs) in the United States focusing on disparities between Blacks and Whites., Methods: Data are from the US 2000 decennial census. We defined 2 race-income county groups (high and low race-income disparity) on the basis of the difference between Black and White median household incomes. We used 2 approaches to examine disparities in STI rates across the groups. In the first approach, we computed and compared race-specific STI rates for the groups. In the second approach, we used spatial regression analyses to control for potential confounders., Results: Consistent with the STI literature, chlamydia, gonorrhea, and syphilis rates for Blacks were substantially higher than were those for Whites. We also found that racial disparities in income were associated with racial disparities in chlamydia and gonorrhea rates and, to a lesser degree, syphilis rates., Conclusions: Racial disparities in household income may be a more important determinant of racial disparities in reported STI morbidity than are absolute levels of household income.

Background: Men who have sex with men (MSM) who have a current or recent history of rectal Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) infection are at greater risk for HIV than MSM with no history of rectal infection. Screening and treating MSM for rectal CT/GC infection may help reduce any increased biological susceptibility to HIV infection., Methods: We used 2 versions of a Markov state-transition model to examine the impact and cost-effectiveness of screening MSM for rectal CT/GC infection in San Francisco: a static version that included only the benefits to those screened and a dynamic version that accounted for population-level impacts of screening. HIV prevention through reduced susceptibility to HIV was the only potential benefit of rectal CT/GC screening that we included in our analysis. Parameter values were based on San Francisco program data and the literature., Results: In the base case, the cost per quality-adjusted life year gained through screening MSM for rectal CT/GC infection was $16,300 in the static version of the model. In the dynamic model, the cost per quality-adjusted life year gained was less than $0, meaning that rectal screening was cost-saving. The impact of rectal CT/GC infection on the risk of HIV acquisition was the most influential model parameter., Conclusions: Although more information is needed regarding the impact of rectal CT/GC screening on HIV incidence, rectal CT/GC screening of MSM can potentially be a cost-effective, scalable intervention targeted to at-risk MSM in certain urban settings such as San Francisco.

Background: Private sector utilization and cost information on testing for sexually transmitted infections (STIs) in the United States is limited., Methods: We used current procedural terminology codes for tests for HIV, human papillomavirus (HPV), genital herpes simplex virus type 2, hepatitis B virus, chlamydia, gonorrhea, trichomoniasis, and syphilis. We extracted outpatient claims for persons aged 15 to 24 years in 2008 from the MarketScan database. Utilization was measured as the number of claims per 100,000 enrollees for tests specific to a given infection. We estimated claims rates and average costs by sex, compared these with Centers for Medicare and Medicaid Services (CMS) fees, and estimated the overall total cost of STI testing., Results: The claims rate for HPV was higher than for any other STI (P < 0.001) at 18,085/100,000, whereas that for trichomoniasis was lower than all other STIs (P < 0.001) at 517/100,000. Claims rates for females were higher than for males (P < 0.001) for all STIs. Average costs were as follows: $24 (HIV), $34 (HPV), $29 (hepatitis B virus), $25 (herpes simplex virus type 2), $43 (chlamydia), $42 (gonorrhea), $28 (trichomoniasis), and $24 (syphilis). Costs exceeded CMS fees for 67 of 78 current procedural terminologies by an average of 40%. The estimated total cost for all STIs was $403.1 million for the privately insured population aged 15 to 24 years., Conclusions: We found that the utilization rates and many test costs varied by sex. Private insurers typically paid more than the CMS fee schedule for testing.

We aimed to examine whether out-of-pocket (OOP) costs associated with chlamydia (CT) and gonorrhoea (GC) screening tests is a barrier to receiving CT/GC re-screening and follow-up annual screening. A major health insurance claims database 2006-2010 was used for analysis. The date of first CT/GC diagnosis was used as the index date, and OOP costs at index date for screening tests were retrieved. A re-screening test and an annual screening were defined as tests that occurred within 90-180 days and 181-395 days of the index date, respectively. Re-screening rates were 11.7% and 10.9% and annual screening rates were 24.7% and 23.7% for CT and GC cases, respectively. Compared with the CT patients without OOP expenses, those with OOP expenses of $30 or higher had significantly reduced likelihood of receiving re-screening and annual screening. Similar results were found for GC patients. We concluded that OOP costs serve as a significant barrier to re-screening and annual screening.

Background: Millions of cases of sexually transmitted infections (STIs) occur in the United States each year, resulting in substantial medical costs to the nation. Previous estimates of the total direct cost of STIs are quite dated. We present updated direct medical cost estimates of STIs in the United States., Methods: We assembled recent (i.e., 2002-2011) cost estimates to determine the lifetime cost per case of 8 major STIs (chlamydia, gonorrhea, hepatitis B virus, human immunodeficiency virus (HIV), human papillomavirus, genital herpes simplex virus type 2, trichomoniasis and syphilis). The total direct cost for each STI was computed as the product of the number of new or newly diagnosed cases in 2008 and the estimated discounted lifetime cost per case. All costs were adjusted to 2010 US dollars., Results: Results indicated that the total lifetime direct medical cost of the 19.7 million cases of STIs that occurred among persons of all ages in 2008 in the United States was $15.6 (range, $11.0-$20.6) billion. Total costs were as follows: chlamydia ($516.7 [$258.3-$775.0] million), gonorrhea ($162.1 [$81.1-$243.2] million), hepatitis B virus ($50.7 [$41.3-$55.6] million), HIV ($12.6 [$9.5-$15.7] billion), human papillomavirus ($1.7 [$0.8-$2.9] billion), herpes simplex virus type 2 ($540.7 [$270.3-$811.0] million), syphilis ($39.3 [$19.6-$58.9] million), and trichomoniasis ($24.0 [$12.0-$36.0] million). Costs associated with HIV infection accounted for more than 81% of the total cost. Among the nonviral STIs, chlamydia was the most costly infection., Conclusions: Sexually transmitted infections continue to impose a substantial cost burden on the payers of medical care in the United States. The burden of STIs would be even greater in the absence of STI prevention and control efforts.

Objectives: To undertake a cost-consequence analysis to assess two new models of partner notification (PN), known as Accelerated Partner Therapy (APT Hotline and APT Pharmacy), as compared with routine patient referral PN, for sex partners of people with chlamydia, gonorrhoea and non-gonococcal urethritis., Methods: Comparison of costs and outcomes alongside an exploratory trial involving two genitourinary medicine clinics and six community pharmacies. Index patients selected the PN method (APT Hotline, APT Pharmacy or routine PN) for their partners. Clinics and pharmacies recorded cost and resource use data including duration of consultation and uptake of treatment pack. Cost data were collected prospectively for two out of three interventions, and data were synthesised and compared in terms of effectiveness and costs., Results: Routine PN had the lowest average cost per partner treated (approximately £46) compared with either APT Hotline (approximately £54) or APT Pharmacy (approximately £53) strategies. The cost-consequence analysis revealed that APT strategies were more costly but also more effective at treating partners compared to routine PN., Conclusion: The hotline strategy costs more than both the alternative PN strategies. If we accept that strategies which identify and treat partners the fastest are likely to be the most effective in reducing reinfection and onward transmission, then APT Hotline appears an effective PN strategy by treating the highest number of partners in the shortest duration. Whether the additional benefit is worth the additional cost cannot be determined in this preliminary analysis. These data will be useful for informing development of future randomised controlled trials of APT.

Objective: To determine the utility and cost of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) screening in infertile males., Design: Cohort study., Setting: Canadian tertiary-level male infertility clinic and university-affiliated laboratories., Patient(s): 5,588 male infertility patients., Intervention(s): CT and NG testing on 8,972 urine and semen samples., Main Outcome Measure(s): Prevalence of CT and NG infection in infertile males versus general male population in Canada over 8 years (2003-2010) and the reagent cost to detect one case of CT or NG., Result(s): In infertile males, the prevalence rate for CT and NG was 0.304% and 0.0537%, which was statistically significantly lower (3.4- and 8.1-fold lower, respectively) than the age-adjusted general population prevalence. With the reagents costing $86.20 per patient tested, the reagent cost alone to diagnose one case of CT or NG was $38,669., Conclusion(s): The prevalence of CT and NG in this study are among the lowest reported in the male infertility literature. These findings question the utility of CT/NG screening in this low-risk population and emphasize that decisions about the utility of screening must be based on the prevalence rates of the disease in the studied population., (Copyright © 2012 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Idaho Chlamydia trachomatis-Neisseria gonorrhoeae specimens from July 2009 were pooled by stratified specimen pooling, an approach that removes high-risk specimens from the pooling population and pools low-risk specimens to maximize pooling efficiency. This approach reduced pool positivity rates by 8%, repeated tests by 9%, and saved 47.4% in direct costs.

Background: Partner treatment is an important component of sexually transmitted disease control. Several randomized controlled trials have compared expedited partner treatment (EPT) to unassisted standard partner referral (SR). All of these trials found that EPT significantly increased partner treatment over SR, whereas some found that EPT significantly lowered reinfection rates in index patients., Methods: We collected cost data to assess the payer-specific, health care system, and societal-level cost of EPT and SR. We used data on partner treatment and index patient reinfection rates from 2 randomized controlled trials examining EPT and SR for patients diagnosed with chlamydia or gonorrhea. Additional elements were estimated or drawn from the literature. We used a Monte Carlo simulation to assess the impact on cost and effectiveness of varying several variables simultaneously, and calculated threshold values for selected variables at which EPT and SR costs per patient were equal., Results: From a health care system or societal perspective, EPT was less costly and it treated more partners than SR. From the perspective of an individual payer, EPT was less costly than SR if ≥32% to 37% of male index patients' female partners or ≥29% of female index patients' male partners received care from the same payer., Conclusions: EPT has a lower cost from a societal or health care system perspective than SR and treats more partners. Individual payers may find EPT to be more costly than SR, depending on how many of their patients' partners receive care from the same payer.

We used 2003-2007 claims data to estimate the direct cost of medical care per case of acute gonorrhea infection. The estimated average total cost per episode for those who were treated was $210 (male, $227; female, $205). This estimate does not include intangible (e.g., pain) and indirect costs (e.g., lost productivity).

Background: Local assessment of sexually transmitted infections (STI) magnitude and economic burden can aid in targeting resources and prevention programs., Methods: Reported cases of Chlamydia, gonorrhea, and primary and secondary syphilis (obtained from the Illinois Department of Public Health) were used to estimate the number of incident cases among persons aged 15 to 24 years, accounting for the proportion of undiagnosed and unreported cases, and sexually active population. STI costs were obtained from the published literature, and multiplied by the estimated incident cases of STIs in 2005 and 2006 to determine direct medical costs of incident infections. Incident rates per 100,000 population and costs in 2007 US dollars are estimated by age, gender, race, and county., Results: Chlamydia incidence and cost were estimated at 5030 infections per 100,000 population and $27,576,686 in 2005, and 5259 infections per 100,000 population and $28,779,734 in 2006. Gonorrhea incidence and cost were estimated at 1740 infections per 100,000 population and $7,698,135 in 2005, and 1704 infections per 100,000 population and $7,546,500 in 2006. Syphilis incidence and cost were estimated at 9.4 per 100,000 and $59,940 in 2005, and 10.4 per 100,000 population and $66,333 in 2006. Incidence and costs of all STIs were highest among women and blacks. Ten counties accounted for >80% of the estimated statewide morbidity and costs., Conclusions: Estimates of STI incidence and costs are conservative, yet represent a significant economic burden in Illinois. Focusing prevention efforts on locales with the highest STI rates may maximize effectiveness in terms of disease prevention and cost reduction.

To assess the feasibility of testing indoor commercial sex workers (CSW) for Chlamydia trachomatis and Neisseria gonorrhoeae in an outreach setting. All CSW seen on outreach over a 6-week period were offered self-taken vulval swabs for chlamydia and gonorrhoea testing. Feasibility was assessed by all the outreach workers on a standardised proforma. Of the 93 women offered the service, 40 accepted, of whom five (12%) had not previously accessed sexual health services. The majority of women declining the service had recently attended a sexual health clinic. Three cases of chlamydia and one of gonorrhoea were diagnosed. The cost per sexually transmitted infection (STI) was pound 392.50. Most of this group of women were knowledgeable about sexual health and were already having regular check-ups, but a significant minority did not know how to access STI care. Offering STI testing on outreach was feasible and cost effective.

Objective: Decision analytic techniques use formal specifications of utility for the four fundamental decision events: true positives, false positives, true negatives, and false negatives. An optimal policy is the one with the lowest expected net cost. In this paper, decision analytic techniques for treatment selection based on patient characteristics are applied to a resource-poor setting., Study Design and Setting: A cohort of 986 female sex workers in Antananarivo and Tamatave, Madagascar were tested for cervical infection at baseline and again 2 months later after presumptive treatment for gonorrhea and chlamydia., Results: Three equivalent approaches to identify the optimal policy based on patient characteristic subgroups are demonstrated. Two of them require exhaustive searches of all possible alternatives. The third identifies the optimal policy as an analytic expression that compares a decision function with a threshold and leads to a closed-form solution. With this approach, the optimal policy can be expressed in four equivalent forms using basic epidemiological measures: likelihood ratio, predicted probability of disease, logistic regression parameters, and total risk score., Conclusion: These methods illustrate the application of a decision analysis to clinical epidemiology. Management of cervical infection for sex workers in Madagascar occurs under severe resource constraints, and therefore requires an algorithm for identifying optimal treatment regimens.

Objectives: To consider whether a local-enhanced service in sexual health in City and Hackney, London, added to the services already provided within the borough and to compare the cost to the Primary Care Trust of diagnosing sexually transmitted infections (STI) in general practice and in the genitourinary medicine clinic., Method: An observational study describing the local-enhanced service in primary care, including a quantitative analysis of swabs taken for chlamydial and gonorrhoeal infections at different venues before and after the introduction of the local-enhanced service., Results: 32 out of 51 general practices (63%) within City and Hackney joined the local-enhanced service. An upward trend in the proportion of chlamydial infection swabs taken in general practice compared with other venues predated the introduction of the local-enhanced service. Practices participating in the local-enhanced service accounted for over 99% of the STI diagnosed in primary care and for 8% of the cases of chlamydial infection diagnosed in the borough. The cost per STI diagnosed within the local-enhanced service was pound930., Conclusion: The local-enhanced service provided a supportive and incentivised framework for STI testing within primary care. An inequity in service provision within general practice predating the local-enhanced service continued at the same level after the introduction of the local-enhanced service.