T Gift 1 , EF Dunne 1 , J Chapin 1 , C Kent 2 , C Gaydos 3 , JM Marrazzo 4 ,

1. The Cost-Effectiveness of Screening Asymptomatic Men for Chlamydia to Prevent Pelvic Inflammatory Disease (PID) in Women T Gift1, EF Dunne1, J Chapin1, C Kent2, C Gaydos3, JM Marrazzo4, J Ellen3,C Rietmeijer5, J Schillinger1, LE Markowitz1 1Centers for Disease Control and Prevention, Atlanta, GA 2San Francisco Department of Public Health, San Francisco, CA 3Johns Hopkins University School of Medicine, Baltimore, MD 4University of Washington School of Medicine, Seattle, WA 5Denver Public Health, Denver, CO

2. Background • Data from demo project and longitudinal study: • prevalence and re-infection • partners (pre-screening and follow-up) • symptoms • cost of screening activities, by venue • Data from literature: • sequelae and sequelae costs • STD visit costs • Data used in female screening comparison model • Schillinger, et al. Sex Transm Dis 30:49-56, 2003, and others

3. Model Construction & Assumptions Index male is screened and tests positive for CT

4. Model, Continued Male has recent partner(s), who may be infected

5. Model, Continued • Average number of recent partners: 1.67 • 48% of infected males’ partners infected • 16% of infected partners seek treatment if not notified by DIS

6. Model, Continued Male may have partners during the follow-up period (4 months)

7. Model, Continued • Average number of partners during follow-up: 1.2 • Male may infect them if: • he is re-infected (12%) • his original infection is not treated (15%) • If women infected, they are assumed to seek treatment on their own at the same rate as past partners (16%)

8. Model, Continued • We assumed male is screened opportunistically (cheaply) • Cost per index male for testing: $14.37 • Cost of treatment: $22.50 • Prevalence of CT among men screened = 6.0% • based on 6.6% positivity

9. Model, Continued-Screening Women • For comparison purposes • convenience-based screening • same re-infection rate as with men (12%) • patient referral for partners (no DIS field work) • 25% of asymptomatic partners seek care if referred

10. Results for Men* *At baseline prevalence of 6.0% †Costs in 2001 US dollars ‡Cases of PID in men’s female partners

11. Results for Men* *At baseline prevalence of 6.0% †Costs in 2001 US dollars ‡Compared to no screening; PID cost per case = $1303 Two costs used for PID: low = $1303, high = $3071

12. Results for Men* *At baseline prevalence of 6.0% †Costs in 2001 US dollars ‡Compared to no screening; PID cost per case = $1303 §Net cost of program = program cost – sequelae cost averted

13. Results for Women* *At baseline prevalence of 2.0% †Costs in 2001 US dollars ‡ PID cost per case = $1303

14. $14.99 0.8 cases of PID averted 3.8 cases of PID averted Screening women at a prevalence of 1% costs the same (in terms of net program costs) as screening men at a prevalence of 6%, but averts fewer cases of PID *Cost per case of PID = $1303

15. $14.99 $12.84 Screening women at a prevalence of 4.6% is as effective (in terms of cases of PID prevented) as screening men at a prevalence of 6% *Cost per case of PID = $1303

16. $8.39 3.8 cases of PID averted  3.6% $6.34 2.9 cases of PID averted *Cost per case of PID = $3071

17. Limitations • Results would differ with different partnership structures • value of treating men declines as partner numbers decline • Partner management options for men’s partners limited to PN vs. no PN • other options (partner-delivered therapy) may yield different results • Results would differ with more-costly non-opportunistic screening

18. Conclusions • Screening men can benefit women by: • reducing the number of infectious men • leading to the treatment of asymptomatic women through PN • Screening men can be cost-effective: • if the prevalence among unscreened women who can potentially be screened is lower than the prevalence among men who can be screened, all else equal • e.g., men in detention settings vs. women > 25 or > 30 in family planning settings