The results of this study indicate that there may be substantial benefits in changing current diagnostic and treatment strategies for chlamydia in antenatal care in sub‐Saharan Africa. The prevailing syndromic management of all attendees appears to be the least effective; it incurs high costs per case cured and entails considerable overtreatment.
The study is limited by uncertainties in several of the model parameters. There is a paucity of high‐quality studies providing data relevant for sub‐Saharan Africa, and many probabilities are based partly on expert advice. For the POC‐test strategy, the level of correct prescription, patient compliance and partner notification have a high degree of uncertainty, and were provided with broad uncertainty ranges. The sensitivity analyses show that partner notification with POC tests is important for the effectiveness of the strategy, also indicating the potential impact of strategies to improve partner notification. The cost of the POC test, which was the largest source of variation in the results, will be known by authorities who consider implementating a POC‐test strategy.
Large evidence gaps and conflicting evidence exist regarding chlamydia‐related complications and their economic consequences.19,20
Because of this lack of knowledge, especially for developing countries, cured infections was used as the effect measure; thus important health benefits of case detection and treatment are not captured in this analysis. Short‐term outcomes are not ideal for making policy recommendations, but as the existing management requires substantial resources, information about possibilities for more advantageous resource allocation should be highly relevant to health policy makers. If successful chlamydia treatment reduces complications such as neonatal infections and postpartum infections, or reduces HIV transmission,4,5
it would strengthen the conclusions of this study.21
To our knowledge, no studies in resource‐poor settings have explored the costs and health consequences of chlamydia management strategies in pregnancy. One study has estimated the incremental cost‐effectiveness of using POC tests for chlamydia and gonorrhoea among sex workers in Benin. Compared with syndromic management, such tests were cost‐effective, averting HIV infections and decreasing inappropriate treatment.18
Reviews of economic evaluations, mainly from developed countries, indicate that chlamydia screening is cost‐effective, depending on prevalence; azithromycin is cost‐effective; and partner notification is essential.21,22
The studies showed considerable variability with regard to probabilities used, complications and costing considered, and were hampered by methodological problems. The reviews point out the need for more data, particularly on the risk of complications.
We used a static model to evaluate the chlamydia management of antenatal care attendees, a relatively small, non‐core group within the total population. Static models assume constant infection prevalence, even when strategies result in fewer or more infections being cured. In contrast, dynamic models incorporate the impact of changes in strategy on infection prevalence. In recent years, the use of dynamic models has been advocated.22,23
However, chlamydia programmes targeting pregnant women are less likely to lower prevalence, and have been specifically mentioned as an example in which static models may be the preferred option.23
Botswana was used as the case for this analysis, but the model should be applicable to other sub‐Saharan countries. In the majority of countries in the region, 70% or more of pregnant women attend antenatal care at least once,24
providing a convenient framework for diagnosis, treatment and follow‐up. Botswana is classified as “upper‐middle income”, but the cost estimates will nevertheless be applicable to less wealthy settings with lower labour costs. The cost drivers in the model are POC tests and drugs purchased in international markets, and these prices will be relatively similar across countries. The sensitivity analysis indicates how higher or lower parameter values would change the results. To the extent that model data differ from those of other countries, the analysis can be revised on the basis of local data.
Improving maternal and perinatal conditions and combatting HIV/AIDS received substantial attention in the Millennium Declaration.25
It has been said that if countries are to have any chance of achieving their development goals, they need to re‐evaluate existing strategies and replace less effective strategies with more effective ones.26
Treatment of STIs is a strategy area that has already been prioritised in sub‐Saharan Africa.27
Chlamydia management in pregnancy is well within the scope of the development goals, and this study points to changes in diagnosis and treatment which may contribute to achieving these goals.
First, single‐dose treatment with azithromycin should be preferred, providing lower costs and higher efficacy than does the week‐long erythromycin regimen. Azithromycin is safe in pregnancy, with fewer side effects and less interaction with other drugs.28
Second, POC tests are necessary to improve effectiveness and reduce excessive overtreatment with the current management. In Botswana, the direct cost of introducing POC tests in antenatal care would increase the total health expenditure by 0.006%, an investment which may be more than offset by the reduced cost of the medical consequences of infection. Third, targeted partner notification is a good argument for introducing specific POC tests. Managing sexual partners of STI patients is essential to prevent reinfection, cure partners, break the chain of transmission and prevent complications;8
in studies from Africa, partner notification has been associated with potential harm, including domestic violence, and using an unspecific syndrome diagnosis as a basis for notifying partners is questionable.8,29
If POC tests are introduced, however, patient‐delivered medication or information for partners should be considered.30
Finally, the use of POC tests entails lowest incremental cost per case cured in populations with high prevalence. Adoption of age‐restricted chlamydia treatment will entail lower programme costs and be more cost‐effective than would the management of all pregnant women. Testing pregnant teenagers may be a feasible and reasonable way of introducing POC tests for chlamydia to antenatal care programmes in sub‐Saharan Africa.