A cost effectiveness analysis of repeat screening for syphilis in pregnancy as an alternative screening strategy in the UK

Syphilis is a treatable sexually transmitted infection (STI) which can be passed from mother to foetus during pregnancy resulting in congenital syphilis. Syphilis infection also increases the risk of adverse pregnancy outcomes such as stillbirth and pre-term delivery. Most cases of congenital syphilis and adverse pregnancy outcomes can be avoided if the infection is diagnosed and correctly treated during pregnancy.

In the UK, pregnant women are offered screening for syphilis, HIV and hepatitis at their first antenatal appointment, typically at or before 12 weeks gestation. Despite the very high coverage of these routine screens plus repeat screening in some higher risk women, a handful of congenital syphilis cases still occur each year, either in women who miss screening or in women who become infected with syphilis after their antenatal screen. For this reason, the UK National Screening Committee (UK NSC) commissioned Aquarius to assess the cost effectiveness of offering a repeat screen to all pregnant women later in pregnancy.

We worked closely with a small group of experts to compare the current strategy – screening in the first trimester only – with an alternative strategy – screening in the first trimester and a repeat screen later in pregnancy.  We developed a decision tree and model inputs which accounted for the sensitivity and specificity of the syphilis assay, the small number of women who do not attend antenatal care until their third trimester (thereby missing the opportunity for repeat screening) and the costs associated with screening, delivery and antenatal care for all women delivering in the UK in one year.

The model revealed that repeat screening would prevent 5.5 cases of congenital syphilis each year but at cost of £1.8 million per case avoided. When a lifetime horizon was considered, the incremental cost-effectiveness ratio (ICER) for the repeat screening strategy was £120,494 per QALY gained – well above the £20k-30k cost per QALY threshold that NICE uses to assess interventions.

The paper concludes that in the UK setting, where prevalence of syphilis is very low, repeat screening for syphilis in pregnancy would not be a cost-effective strategy and alternative strategies should be sought to prevent congenital syphilis.

This is the first published study from outside the US to compare these two screening strategies. The results will be used to inform national screening policy and are relevant countries with similar syphilis prevalence and healthcare costs. 

Huntington S, Weston G, Seedat F, et al Repeat screening for syphilis in pregnancy as an alternative screening strategy in the UK: a cost-effectiveness analysis BMJ Open 2020;10:e038505. doi: 10.1136/bmjopen-2020-038505

Examining the acceptability of offering STI screening in higher educational settings

Uptake of screening for STIs, such as chlamydia and gonorrhoea, is often inadequate in young people despite provision of open-access sexual health services. Offering STI tests outside medical settings is currently being explored as a way to increase uptake in this group.

In 2017, St George’s University of London ran the ‘Test n Treat’ feasibility trial where free, confidential on-site testing for chlamydia and gonorrhoea was offered to students at six higher-education colleges in South London. We have previously reported on the main results of the trial and the cost estimates of providing such a service .

As part of the trial, the research team wanted to understand the acceptability of this type of service among students as well as the barriers and facilitators to its use. They interviewed a small sample of students, some of whom used the service and some of whom did not, as well teachers and the research team. The results of this qualitative study, which Aquarius Population Health gave advisory support to, were published in August 2020.

The paper reports that students who used the service had a very positive opinion of it. There were a number of barriers to using the service identified, including embarrassment about STI testing and the perceived view that individuals would be viewed negatively by their peers if they had an STI test. On the flip side, peers also acted as facilitators to uptake, for example, if a group of friends encouraged each other to get tested. A lack of understanding of STIs was another major barrier, with many students lacking understanding about the long-term consequences of STIs or having the misconception that only people with symptoms should get tested.  Where a £5 honorarium was given to students using the service, this acted as a legitimate incentive for testing, mitigating the (perceived) social stigma of testing.

The paper concludes that if a similar service were provided in future, uptake could be improved if education about sexual health was offered alongside testing, if small cash incentives were given and if peer influencers were engaged to promote the service.

Fleming, C., Drennan, V.M., Kerry-Barnard, S. et al. Understanding the acceptability, barriers and facilitators for chlamydia and gonorrhoea screening in technical colleges: qualitative process evaluation of the “Test n Treat” trial. BMC Public Health 20, 1212 (2020). https://doi.org/10.1186/s12889-020-09285-1

Cost analysis of near patient chlamydia and gonorrhoea screening and treatment in further education/technical colleges

Aquarius collaborated with St George’s University of London on an NIHR-funded study, ‘Test n Treat’ (TnT). In this cluster randomised feasibility trial, rapid chlamydia (CT) and gonorrhoea (NG) testing and same day on-site chlamydia treatment in six technical colleges in South London was delivered. 

Using process data from the trial (the main results of which were published last year) and NHS cost data, the overall cost of providing the TnT service was calculated, as well as the cost per CT/NG screen and the cost per CT/NG infection diagnosed. These took into account the fixed daily costs, such as staff time and equipment use, and the per screen costs, i.e. the consumables used to collect and test samples, and were dependent on uptake of screening. Since the average cost per screen was higher if uptake was low as per what was observed in the trial, and lower if uptake was high, costs for a range of update scenarios were assessed. If daily capacity for screening was achieved (calculated as 49 screens/day), the cost per screen was £47 (including the £10 incentive given to students to encourage participation). This increased to £91, if uptake was equivalent to the average uptake observed on the trial (19 screens/day). The paper concluded that delivering this type of service is more expensive per person than CT and NG screening in sexual health clinics but could be more comparable in areas of high CT/NG prevalence.

Publication

Kerry-Barnard S, Huntington, S, Fleming C, et al. Near patient chlamydia and gonorrhoea screening and treatment in further education/technical colleges: a cost analysis of the ‘Test n Treat’ feasibility trial. BMC Health Services Research. https://doi.org/10.1186/s12913-020-5062-5

Cluster-randomised feasibility trial of a chlamydia test and treat (TnT) service in further education colleges

Aquarius were involved in a recent cluster-randomised feasibility trial looking at whether provision of a same day test and treatment (TnT) service for chlamydia in further education colleges could be used to improve uptake of chlamydia testing in sexually active 16-24 year olds. The trial found that despite a high prevalence of chlamydia among sexually active students at the colleges, uptake of the free confidential TnT service was low. At the three colleges, 13% of students were tested when the service was first offered and 10% when it was offered again three months later. Interviews with students revealed that low uptake was associated with not feeling at risk of a sexually transmitted infection, perceptions of stigma, and lack of knowledge about sexually transmitted infections, while all students interviewed were positive about the TnT service itself.

PublicationOakeshott P, Kerry-Barnard S, Fleming C, et al. “Test n Treat” (TnT): a cluster randomised feasibility trial of on-site rapid Chlamydia trachomatis tests and treatment in ethnically diverse, sexually active teenagers attending technical colleges. Clinical Microbiology and Infection. https://doi.org/10.1016/j.cmi.2018.10.019.

Three simple tests could save the NHS nearly £6.9 billion

This year marks the 70th birthday of the NHS – a time to celebrate its achievements and the dedicated staff who keep its wheels turning. Yet, there is increasing concern about the future of the NHS, and particularly its funding. In this article, jointly commissioned by the British In Vitro Diagnostics Association (BIVDA) and Innovate UK, we showcase three tried and tested in vitro diagnostics, which, if more widely adopted, could save the NHS an estimated £6.9 billion over the next five years.

 

Read Article

 

Test n Treat – rapid STI testing and treatment in colleges: study protocol

Sexually active young people attending London further education (FE) colleges have high rates of chlamydia, but screening rates are low. We describe the study protocol for “Test and Treat” (TnT), an NIHR-funded research study. This is a cluster randomised feasibility trial of frequent, rapid, on-site chlamydia testing using the Cepheid GeneXpert system and same-day treatment in six FE colleges. As part of the study we also conducted qualitative and economic assessments to assess the feasibility of conducting a future large-scale trial to investigate if TnT reduces chlamydia rates. The methods for recruitment, participant data collection, sample collection and testing are described, for baseline and follow-up in the control and intervention groups. The statistical analysis plan for TnT has been published separately.

 

PublicationKerry-Barnard S, Fleming C, Reid F, et al. ‘Test n Treat (TnT)’- Rapid testing and same-day, on-site treatment to reduce rates of chlamydia in sexually active further education college students: study protocol for a cluster randomised feasibility trial. Trials. 2018 Jun 5;19(1):311. doi: 10.1186/s13063-018-2674-8.

To request a copy of the published article, please email caroline.dombrowski@aquariusph.com.

Assessing the impact of point-of-care testing for influenza and respiratory syncytial virus in children admitted to hospital

We assessed the impact and economic benefits of using a point-of-care (POC) assay instead of standard laboratory testing to detect influenza and respiratory syncytial virus (RSV) in children and infants admitted to hospital . This real-world evaluation was conducted in two subsequent ‘flu seasons at the Evelina Children’s Hospital in London. Results showed that following the introduction of the POC testing, children with influenza were more likely to receive oseltamivir treatment, the antiviral recommended for influenza. Although there was no statistically significant reduction in the average length of hospital admission or in the number of antibiotics prescribed, there was a reduction in laboratory costs and in reimbursement charges for hospital admissions suggesting that use of the POC assay resulted in fewer procedures and interventions performed during admissions.

Publication Vecino-Ortiz AI, Goldenberg SD, Douthwaite ST, et alImpact of a multiplex PCR point-of-care test for influenza A/B and respiratory syncytial virus on an acute pediatric hospital ward. Diagnostic Microbiology and Infectious Disease,  Volume 91, Issue 4, August 2018, Pages 331-335. 

 

To request a copy of the published article, please email caroline.dombrowski@aquariusph.com.

 

Read Abstract

 

Exploring HCV eradication through diagnosis and treatment strategies

The World Health Organization aims to eradicate hepatitis C virus (HCV) by 2030. To achieve this, improved HCV diagnosis and treatment coverage are required. We explored the relationship between diagnosis and treatment in the next 5 years in Italy, France, and the UK to understand how to achieve the most benefit.

presentation_icon
Harvey MJ, Cheng C-Y, Leone E, et al. Exploring HCV eradication through diagnosis and treatment strategies. EASL Monothematic Conference, Striving Towards the Elimination of HCV Infection. 2-3 February 2018, Berlin, Germany.

 

Read Publication

Evaluating the costs, benefits and cost-effectiveness of multi-pathogen point-of-care tests for sexually transmitted infections

We estimated costs, benefits and cost-effectiveness of three accurate 30-minute NAAT POCT strategies that detect different STI combinations, compared with standard care  (laboratory-based NAAT for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG)).  We found the CT-NG-MG-TV POCT strategy was the cheapest using tariff costing. It offered the most benefits, which in turn may have wider public health impacts through rapid and accurate STI diagnosis and management. Different testing strategies may be more cost-effective in different SHCs and patient groups. Further evidence is needed to capture the diversity of STI prevalence and management of patients across clinical services to better inform economic analyses.

presentation_icon
Harding-Esch EM, Huntington SE, Burns RM, et al. Evaluating the costs, benefits and cost-effectiveness of multi-pathogen point-of-care tests for sexually transmitted infections STI & HIV World Congress. 9-12 July 2017. Rio de Janiero, Brazil.

 

Read Publication

 

Modelling how point-of-care tests can enable personalised treatment for resistant gonorrhoea infections

We created a mathematical model to investigate the treatment impact and economic implications of introducing an antimicrobial resistance point-of-care test (AMR POCT) for gonorrhoea as a way of extending the life of current last-line treatments. The introduction of AMR POCT could allow clinicians to discern between the majority of gonorrhoea-positive patients with strains that could be treated with older, previously abandoned first-line treatments, and those requiring our current last-line dual therapy. Such tests could extend the useful life of dual ceftriaxone and azithromycin therapy, thus pushing back the time when gonorrhoea may become untreatable.

Publication

Turner KM, Christensen H, Adams EJ, et al Analysis of the potential for point-of-care test to enable individualised treatment of infections caused by antimicrobial-resistant and susceptible strains of Neisseria gonorrhoeae: a modelling study

Read Publication