GHENT UNIVERSITY Karoline FONCK - International Centre for ...
GHENT UNIVERSITY Karoline FONCK - International Centre for ... GHENT UNIVERSITY Karoline FONCK - International Centre for ...
program has prevented the harmful effects of syphilis on the unborn child in 388 women, given that treatment is 100% effective. This would result in a cost of US$ 56 per averted case. The real effectiveness can be estimated at 50% to 70% because of late treatment or reinfection. Hence, the cost per case averted will vary between US$ 95 and US$ 112. Discussion Syphilis seroprevalence among pregnant women in Nairobi has decreased significantly in recent years. The RPR seroprevalence was 7.2% in 1993, 4.5% in 1996, and 3.4% in 1998 (Temmerman 1999). This decline might be the result of different intervention programs and improved health care services, including the syphilis control program, which may have had an independent effect. Hence, the program may also have had an indirect influence on the spread of HIV in this population. Overall, the clinics performed well in screening and treating RPR-seropositive women and their partners. The partner notification rate of 53% reported here is twice as high as for nonpregnant patients with an STD other than HIV who attended the same Clinic (Gichangi 2000). Concern about the unborn baby seems to motivate future fathers to get treatment (Pido 1993, Njeru 1995) and may help women to inform their partners despite the threat of possible physical abuse (Temmerman 1995). The effectiveness of the treatment may be limited because women in Kenya tend to come late for prenatal care (Temmerman 1993, Pido 1993). It is also hampered by weak screening performance in field conditions. In 1993, only 17% of RPR-positive results and 1.2% of RPRnegative results were found to be false, but monitoring and external supervision were very intensive in the early years (Jenniskens 1995). The observed reduction in the quality of the test over a 6-year period raises questions about the viability of the programs. In addition, false-positive reactions might be higher in the presence of HIV (Nandwani 1995, Joyanes 1998, Fonck 2000). Cost-effectiveness estimates of syphilis screening during pregnancy vary widely, depending on the underlying assumptions (Hira 1991, Stray-Pedersen 1980, Abyad 1995, McDermott 1993, Schmid 1996). According to a World Bank study, the prevention of congenital syphilis by routine screening and treatment is one of the most cost-effective interventions for improving child health (World Bank 1993). Our findings underscore this statement, but they also stress technical, logistic, and financial drawbacks that have been pointed out by others (Temmerman 1993, Jenniskens 1995, Rutgers 1993). PREVENTION OF SEXUALLY TRANSMITTED INFECTIONS INCLUDING HIV 71
One should keep these problems in mind when planning HIV mother-to-child transmission programs, an area where testing and antiretroviral treatment have many more implications than with syphilis testing. The question remains whether case detection and treatment is the best option. An alternative strategy could be mass treatment with penicillin in pregnancy. With a cost of US$ 1.50 per dose and an estimated acceptability of 75%, the total cost for such a program would be US$ 30,799, similar to the cost of US$ 30,966 for the current program in Nairobi. With this strategy, 1075 true-positive cases (75%) would be treated compared with 583 now. If the treatment is effective in 50% of the cases, the cost per averted case of congenital syphilis would be US$ 86, a reduction of 23%. The systematic administration of antibiotics during pregnancy may also have a positive impact on pregnancy outcome (Temmerman 1995, Gichangi 1997). Similarly, routine treatment would reduce the negative aspects of contact tracing. Concerns of mass treatment, however, are the potentially increased resistance patterns and the massive use of needles and syringes. Syphilis control during pregnancy is an effective intervention, especially in high-prevalence areas, but it requires careful monitoring, quality control, and close supervision. PREVENTION OF SEXUALLY TRANSMITTED INFECTIONS INCLUDING HIV 72
- Page 21 and 22: 2.2.3. Laboratory procedures The mi
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- Page 55 and 56: Men reported more extramarital affa
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- Page 59 and 60: discharge and abdominal pain-two co
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- Page 65 and 66: Evaluation of Algorithms The result
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- Page 111 and 112: to protect themselves and be empowe
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- Page 115 and 116: Fleming D and Wasserheit J. From ep
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program has prevented the harmful effects of syphilis on the unborn child in 388 women,<br />
given that treatment is 100% effective. This would result in a cost of US$ 56 per averted<br />
case. The real effectiveness can be estimated at 50% to 70% because of late treatment or<br />
reinfection. Hence, the cost per case averted will vary between US$ 95 and US$ 112.<br />
Discussion<br />
Syphilis seroprevalence among pregnant women in Nairobi has decreased significantly in<br />
recent years. The RPR seroprevalence was 7.2% in 1993, 4.5% in 1996, and 3.4% in 1998<br />
(Temmerman 1999). This decline might be the result of different intervention programs and<br />
improved health care services, including the syphilis control program, which may have had<br />
an independent effect. Hence, the program may also have had an indirect influence on the<br />
spread of HIV in this population.<br />
Overall, the clinics per<strong>for</strong>med well in screening and treating RPR-seropositive women and<br />
their partners. The partner notification rate of 53% reported here is twice as high as <strong>for</strong> nonpregnant<br />
patients with an STD other than HIV who attended the same Clinic (Gichangi<br />
2000). Concern about the unborn baby seems to motivate future fathers to get treatment<br />
(Pido 1993, Njeru 1995) and may help women to in<strong>for</strong>m their partners despite the threat of<br />
possible physical abuse (Temmerman 1995).<br />
The effectiveness of the treatment may be limited because women in Kenya tend to come<br />
late <strong>for</strong> prenatal care (Temmerman 1993, Pido 1993). It is also hampered by weak screening<br />
per<strong>for</strong>mance in field conditions. In 1993, only 17% of RPR-positive results and 1.2% of RPRnegative<br />
results were found to be false, but monitoring and external supervision were very<br />
intensive in the early years (Jenniskens 1995). The observed reduction in the quality of the<br />
test over a 6-year period raises questions about the viability of the programs. In addition,<br />
false-positive reactions might be higher in the presence of HIV (Nandwani 1995, Joyanes<br />
1998, Fonck 2000).<br />
Cost-effectiveness estimates of syphilis screening during pregnancy vary widely, depending<br />
on the underlying assumptions (Hira 1991, Stray-Pedersen 1980, Abyad 1995, McDermott<br />
1993, Schmid 1996). According to a World Bank study, the prevention of congenital syphilis<br />
by routine screening and treatment is one of the most cost-effective interventions <strong>for</strong><br />
improving child health (World Bank 1993). Our findings underscore this statement, but they<br />
also stress technical, logistic, and financial drawbacks that have been pointed out by others<br />
(Temmerman 1993, Jenniskens 1995, Rutgers 1993).<br />
PREVENTION OF SEXUALLY TRANSMITTED INFECTIONS INCLUDING HIV 71
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