BRIDGING THE GAP BETWEEN PILOT AND SCALE-UP: A MODEL OF ANTENATAL TESTING FOR CURABLE SEXUALLY TRANSMITTED INFECTIONS FROM BOTSWANA.

Introduction Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are common sexually transmitted infections (STIs) associated with adverse outcomes - yet most countries do not test and conduct syndromic management, which lacks sensitivity and specificity. Innovations allow for expanded STI testing; however, cost is a barrier. Methods Using inputs from a pilot program in Botswana, we developed a model among a hypothetical population of 50,000 pregnant women to compare one-year costs and outcomes associated with three antenatal STI testing strategies: 1) point-of-care, 2) centralized laboratory hubs, and 3) a mixed approach (point-of-care at high-volume sites, and hubs elsewhere); and syndromic management. Results Syndromic management had the lowest delivery cost, but was associated with the most infections at delivery, uninfected women treated, CT/NG-related low birth weight (LBW) infants, disability adjusted life years (DALYs), and LBW hospitalization costs. Point-of-care CT/NG testing would treat and cure the most infections, but had the highest delivery cost. Among the testing scenarios, the mixed scenario had the most favorable cost per woman treated and cured ($534/cure). Compared to syndromic management, the mixed approach resulted in a mean incremental cost-effectiveness ratio of $953 per DALY averted, which is cost-effective under WHO's one-time per-capita GDP willingness-to-pay threshold. Conclusion As countries consider new technologies to strengthen health services, there is an opportunity to determine how to best deploy resources. Compared to point-of-care, centralized lab, and syndromic management, the mixed approach offered the lowest cost per infection averted and is cost-effective if policy-makers' willingness to pay is informed by the WHO's Gross Domestic Product / capita threshold.