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  • RST was introduced in two low prevalence (≤1%) settings in Peru: (1) a tertiary-level referral maternity hospital with the largest number of deliveries in the country, the Instituto Nacional Materno Perinatal (INMP); and (2) the Ventanilla Network, consisting of 16 health facilities (which include 15 health centers and one small hospital), where RST was implemented together with rapid HIV testing: “two tests one stick, or two for one”[18]. The Peruvian National Guidelines recommended syphilis screening with RPR for all pregnant women at the first ANC visit and also for pregnant women seen at miscarriage services and delivery/emergency services, mainly to detect congenital syphilis cases and treat them appropriately (with Benzathine penicillin 1.2 million units IM every week for three weeks) and to prevent future new cases of congenital syphilis. For the cost-effectiveness analysis we included INMP and five of the health facilities of the Ventanilla Network. We classified all the health facilities within the Ventanilla Network into four types: (1) type I, small hospital with laboratory; (2) type II, health center with laboratory; (3) type III, health center without a laboratory (blood is drawn at the facility, sent daily to type II facilities where samples are processed and returned to type III facility), and (4) type IV, health center without a laboratory (patients are referred to type II facility to have blood drawn, they have to return to the type II facility at a later date to pick up results, and then go back to the type IV facility to see their provider). For the study we randomly chose one facility each from type I (the only one of this type), type III, and type IV, and two facilities from type II. All the costing data were obtained in early 2010. Patient flows for RST and RPR were mapped. Cost data were collected for both RPR and RST based on the Guidelines for Cost Effectiveness Analysis of Syphilis Screening Strategies [19]. Costs considered for RPR included: laboratory supplies, space rental, allocated staff salaries and treatment costs. These costs were associated with blood sampling, processing of the blood sample and reading of the RPR, and with treatment of a positive index case and of one partner. Costs considered for RST included: expenses for the implementation activities (advocacy meetings with authorities, training, supervision, and monitoring) and the cost of implementing the QA system. Costs of supplies, such as lancets, alcohol swabs, kits (cassette and buffer), gloves, biosecurity devices, supplies for treatment of the positive index case and partner (assuming all partners receive treatment), among others, as well as allocated staff salaries, were also included. For the Ventanilla Network facilities, costs of personnel time and building space were allocated equally between HIV and syphilis screening, as RST was rolled out alongside rapid HIV testing. The information on unit price of materials and supplies, and costs associated with personnel, laboratory equipment, electricity and water consumption of the respective health facilities, were provided by offices of the Callao Regional Health Directorate for the Ventanilla Network. For INMP, data were obtained through the logistics office of the hospital. Each of the offices was visited, staff responsible for purchasing supplies were interviewed and information from invoices and reports was collected. Data on training costs associated with RST were collected through bills, invoices of supplies and reagents purchased by the CISNE Project provided by the project manager. Data on associated costs of training were obtained by allocating salaries of project staff involved in the activities. Project Outputs and Unit Costs: Project outputs included: number of pregnant women tested in each of the facilities, number of women with reactive tests for syphilis and number of women treated. The data for RST was obtained from records of the CISNE Project implementation, which took place from January to November 2010 (data was projected for the whole year). Data for RPR were obtained from 2009 statistical reports from each health facility. The economic unit cost per woman tested and the cost per woman treated were both calculated for each service within each facility. Based on the model presented by Terris-Prestholt et al [20] true cases treated were estimated. This model used quality assurance data from Ventanilla to assess the performance of the RPR and RST tests in this setting. Based on this model, the percentage of true cases treated among women who were tested and treated is 90.7% with RST and 33% with RPR. These figures were obtained by comparing field performances against laboratory-based RPR and Treponema Pallidum Hemagglutination Assay tests (TPHA). Disability-adjusted life years (DALY) averted were only calculated for adverse outcomes in infants, and estimated by the number of women seen in ANC, prevalences, diagnostic performance and treatment rates. Using standard DALY inputs (3% discount rate and stillbirth considered a full life lost), each true case treated is assumed to avert 5.73 DALYs in Peru. The estimation of DALYs for this study followed the methods presented by Terris-Prestholt et al [20]. A univariate sensitivity analysis was performed to determine the impact of uncertainty of costs and output. Factors included were: discount rate (variation from 3% to 9%); working hours of the health workers (variation from 6 to 8 hours per day); screening rates for syphilis (variation from 57% to 100%); exchange rate (US dollars (USD) to Peruvian new soles (PNS) with a variation of 2.638 to 2.910 PNS:USD); syphilis prevalence (variation from 0.6% to 2.2%); building costs (increments of 22.1%); and health personnel salaries (both for screening and for treatment, variation between 0% to 50%). The Ethics Committee at Universidad Peruana Cayetano Heredia reviewed and approved the main study (Approval number 55202). The current study did not involve participation of human beings. We have verified and confirmed that we have no identifying information for patients.
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