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 analytical 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 erythromycin. Compared with syndromic management, testing all attendees on their first visit with a 75% sensitive POC test increased the number of cases cured from 1500 to 3500 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 healthcare budgets.

Trichomoniasis and bacterial vaginosis in pregnancy: inadequately managed with the syndromic approach.

OBJECTIVE: To measure the prevalence of Trichomonas vaginalis (TV) infection and bacterial vaginosis (BV) among pregnant women in Botswana, and to evaluate the syndromic approach and alternative management strategies for these conditions in pregnancy. METHODS: In a cross-sectional study, 703 antenatal care attendees were interviewed and examined, and specimens were collected to identify TV, BV, Candida species, Chlamydia trachomatis and Neisseria gonorrhoeae. Information on reproductive tract infections earlier in pregnancy was obtained from a structured interview and the antenatal record. FINDINGS: TV was found in 19% and BV in 38% of the attendees. Three-fourths of women with TV or BV were asymptomatic. Syndromic management according to the vaginal discharge algorithm would lead to substantial under-diagnosis and over-treatment of TV and BV. Signs of vaginal discharge were more predictive of the presence of these conditions than were symptoms. Among the 546 attendees on a repeat antenatal visit, 142 (26%) had been diagnosed with vaginal discharge earlier in their pregnancy--14 of them twice. In 143 cases, an attendee was diagnosed with vaginal discharge in the second or third trimester; however, metronidazole had been prescribed only 17 times (12%). CONCLUSION: Diagnosis and treatment of TV and BV among pregnant women in sub-Saharan Africa presents major challenges. Half the pregnant women in this study were diagnosed with TV or BV, but these conditions were not detected and treated during antenatal care with syndromic management. Also, health workers did not adhere to treatment guidelines. These results indicate that management guidelines for TV and BV in antenatal care should be revised.