Public health economics of chlamydia and other STIs : aspects of risk, prevention and resources

Sammanfattning: The overall aim of this thesis was to increase the knowledge of the public health economic aspects of chlamydia and other STIs, in terms of risk, prevention and resources. In Study I, we examined the association between demographic, socioeconomic and lifestyle factors and the risk of self-reported chlamydial infection among young adults in the Stockholm public health cohort. We found that the risk of self-reported chlamydia infection among young adults in Sweden was associated with lower age, high alcohol consumption, lower educational level and being employed or unemployed, on sick leave or pre-retired compared to being a student. In Study II, we identified potential key factors for successful regional prevention of chlamydia and other STIs by a case study including seven Swedish counties. We found that potential key factors include adequate programme- and county council investments, suitable organizational structure, strong leadership, management of regional networks, research connection, multiple local collaborations, high testing coverage and a strategic risk approach. In Study III, we analyzed the cost-effectiveness of the intervention Chlamydia Monday by estimating costs, savings and health gains generated by the intervention and analyzed whether the cost-effectiveness varied between men and women. We found that this testing intervention of a self-selected sample of individuals was cost-effective for both sexes with a discounted average cost of €8,346 per QALY. Sensitivity analyses showed consistent results for changes in parameters, and all scenarios except exclusion of contact tracing for males, generated a cost per QALY below the established threshold. In Study IV, we estimated the additional resources required to scale up adolescent- friendly health services to universal coverage in 74 low-and middle-income countries. We found that the financial costs for scaling up key adolescent-friendly health services was US$ 15.4 billion through 2015. The cost for STI management was approximately US$ 226.97 million of which approximately 20% constituted management of chlamydia. The estimated required resources illustrate a substantial investment gap in relation to current expenditure. In conclusion, the thesis illustrates a public health economic approach to studying STI- prevention. The findings show that chlamydia in young adults in Stockholm is associated with social and lifestyle factors, that greater consideration should be taken to the structural factors of prevention, that one of the common testing interventions implemented in many parts of Sweden is cost-effective and finally that considerable investment is required to improve quality and expand reproductive health care services to universal coverage for adolescents in the least developed countries in the world.