Direct and Indirect Cost Savings from STI Testing, Treatment, and Counseling among Foster Youth

Abstract

Background

Sexually transmitted infection (STI) prevention programs can decrease the economic burden of STIs. Foster youth have higher rates of STIs compared to their peers; however, information on direct costs and indirect costs averted by STI testing, treatment, and counseling among foster youth is lacking.

Methods

This study utilized data from a comprehensive medical center for foster youth over a three-year study period from July 2017 to June 2020. Direct and indirect costs averted by testing and treatment of chlamydia, gonorrhea, and syphilis, as well as HIV testing and counseling, were calculated based on formulas developed by the Centers for Disease Control and Prevention (CDC) and adjusted for inflation.

Results

Among the 316 youth who received medical services during this time, 206 were sexually active and tested for STIs and/or HIV. Among 121 positive STI tests, 64.5% (n = 78) were positive for chlamydia, 30.6% (n = 37) were positive for gonorrhea, and 5.0% (n = 6) were positive for syphilis. Treatment was provided to all. Overall, $60,049.68 in direct medical costs and $73,956.36 in indirect costs were averted.

Conclusions

Given the rates of STIs among this population as well as the economic benefit of STI treatment, it is imperative to continue to provide intensive and comprehensive, individualized sexual healthcare for foster youth. Traditional care management may miss the opportunity to prevent, identify, and treat STIs that comprehensive wraparound care can achieve. This study suggests that comprehensive wraparound care is a cost-effective way to identify, treat, and prevent STIs among foster youth.

Short Summary

A study of 206 sexually active foster youth in St. Louis, MO calculated $134,006.04 in direct and indirect cost savings from STI testing and treatment at a comprehensive medical clinic.

Sexually transmitted infections (STIs) impact the health and wellbeing of individuals and create a financial burden for both individuals and society at large.¹ Rates of STIs like chlamydia, gonorrhea, and syphilis are increasing.¹ In the United States, almost 27 million new STIs are transmitted each year according to estimates from 2018.² Adolescents and young adults (AYA) aged 15–24 have the highest rates of sexually transmitted infections.^1,3 Given that they account for almost half of new STI infections each year, it is especially important to investigate ways to reduce these costs among the AYA community.¹

Within the AYA population, foster youth are an especially vulnerable population, have higher rates of STIs compared to their peers, and have limited access to sexual health information.⁴ Foster care youth are at 3–14 times higher risk for contracting STIs than their non-foster youth peers.^4,5 One reason for the high rates of STIs is that foster youth are more likely to participate in risky sexual behaviors after experiencing trauma, abuse, neglect, or family disruption.^6,7 Foster youth are also 2–4 times more likely to engage in transactional sex, the trading of sex for money or drugs, which increases risk of STIs compared to the general youth population.⁸ In addition, youth in foster care generally have less access to medically accurate sexual health information to help navigate puberty and sexual health, leading to higher rates of STIs, and unintended pregnancy.^6,9

The economic burden of STIs in the United States is high with the direct medical costs hovering around 16 billion dollars in 2018.^2,10 However, there is no published data on these medical costs for AYA in foster care. The costs of STIs manifest themselves in two ways, as direct and indirect costs. Direct costs encompass the money spent treating the disease and its sequelae, often including the price of testing, treatment, and doctors’ visits, along with the cost of transportation to and from the hospital.^11–13 However, when understanding the costs to society, it is important to look beyond the direct medical costs.

In contrast to direct costs, indirect costs look at the non-health care costs of illness. Indirect costs include areas like lost productivity from workplace absences, work/school absences, and reduced wellbeing, as well as the socioeconomic impacts on family and support networks.¹⁴ These costs are not insignificant. One study found productivity losses of $206 for chlamydia and $246 for gonorrhea, more than the direct cost to treat these illnesses.¹⁵

If the STI is not identified and treated early on, its sequelae can raise both direct and indirect costs. For instance, when an adolescent with a uterus is not treated for gonorrhea or chlamydia in a timely manner, they may develop pelvic inflammatory disease (PID). The disease can cost an average of $3025 per episode, but the cost may go up if the patient needs to spend extended time in the hospital.¹⁶

Prevention and screening may alleviate some of the costs associated with STIs. For chlamydia detection, some of the most cost-effective screening strategies involve testing all youth 15–29 years old.¹⁷ The Centers for Disease Control and Prevention (CDC) recommend all sexually active females be tested for gonorrhea and chlamydia annually. The costs shift from higher costs of PID to a lower cost of screening for and treating chlamydia early, resulting in less money spent on later sequelae such as PID, ectopic pregnancy, and infertility.^18–21 The same is true for gonorrhea. Investing in screening among high-risk populations, like youth in foster care, can result in lower costs spent on treating the illness and its sequelae.^22,23 Similarly, routinely testing for syphilis in high frequency areas, especially among pregnant women, can be a cost-effective measure.²⁴ Along with screening and treatment, investing in prevention efforts can also drive down adverse health outcomes and costs.²³

Given that many of the life experiences of foster youth put them at greater risk for STIs, we hypothesize that investing in screening and prevention may reduce direct and indirect costs associated with STIs. Specific information on costs averted by STI testing, treatment, and counseling among foster youth is lacking. Using formulas created by the CDC,²⁵ this study aims to calculate both direct and indirect costs averted by screening and treating chlamydia, syphilis, and gonorrhea, as well as counseling and screening for HIV among foster youth in a Midwestern metropolitan medical home.

Materials and Methods

Study Design

This study utilized data from the Creating Options and Choosing Health (COACH) Program in St. Louis, MO. COACH is a unique program designed to ensure that foster youth in St. Louis City and St. Louis County have stable and consistent access to comprehensive health care services. The clinic prioritizes improving sexual health and healthcare for foster youth by reducing barriers to care, including STI testing and treatment as well as HIV testing and education. All youth that report current sexual activity are tested for STIs as needed. These services are provided at no cost to foster youth, and any youth that begins care within the COACH program remains eligible to receive services until the age of 25, regardless of any subsequent changes to their status within child welfare.

This study covered a three-year period from July 2017 to June 2020. Averted direct medical costs and indirect costs, from lost productivity, were calculated based on formulas developed by the CDC.²⁵ The formulas were developed based on published studies and assumptions that included “the sequelae costs averted by treatment of people with STIs,” “the interruption of STI transmission in the population, the reduction in STI-attributable HIV infections (HIV infections that would not have occurred without the facilitative effects of STIs on HIV transmission and acquisition), HIV infections averted by HIV counseling and testing, and the corresponding reductions in lost productivity.”²⁵ (A summary of these STI cost estimates with citations to the original published estimate can be found in Chesson, Collins, and Koski’s article (2008), “Formulas for estimating the costs averted by sexually transmitted infection (STI) prevention programs in the United States.”²⁵) These formulas calculated cost savings from 12 inputs including: number of women treated for chlamydia, gonorrhea, and syphilis (1–3); number of men who have sex with women treated for chlamydia, gonorrhea, and syphilis (4–6); number of men who have sex withfor men treated for chlamydia, gonorrhea, and syphilis (7–9); number of women who received HIV counseling and testing (10); number of men who have sex with women who received HIV counseling and testing (11); and number of men who have sex with men who received HIV counseling and testing (12). The 12 inputs for this study came from data from the COACH program. Categories were tallied based on if individual youth had a positive STI test (chlamydia, gonorrhea, or syphilis) within one calendar year²⁵ and all estimates were adjusted for inflation.

Direct medical cost savings included 4 distinct domains: 1 - sequelae costs averted by the treatment of chlamydia, gonorrhea, and syphilis; 2 - treatment and sequelae costs averted by reducing the transmission of chlamydia, gonorrhea, and syphilis in the population; 3 - HIV costs averted by reducing HIV transmission through the treatment of chlamydia, gonorrhea, and syphilis; and 4 - HIV costs averted by HIV counseling and testing. Indirect cost savings included 3 domains: 1 - indirect costs averted by treating chlamydia, gonorrhea, and syphilis; 2 - indirect HIV costs averted by reducing HIV transmission through treatment of STIs; and 3 - indirect costs averted by reducing HIV transmission through HIV counseling and treatment.

Participants

Data from all 584 COACH clients seen within the three-year time period of the study were examined. Of the 584, only 316 received medical services. Among those, 206 unique youth were sexually active and tested for STIs and/or HIV at one or more time points. Treatment was provided to all who received a positive STI test. All youth who received HIV testing also received counseling and education regarding HIV.

Results

The majority of AYA seen in the COACH clinic were female, Black and heterosexual. Of note, however, greater than 10% of AYA identify as lesbian, gay or bisexual. Consistent with the overall demographic data of the program, more females received STI tests (70.4%, n = 145) compared to males (28.6%, n = 59). The majority of youth tested for STIs were Black or African American (79.6%, n = 164) and heterosexual (65.0%, n = 134). The mean age at which youth were tested was 18.2 years, with ages ranging from 13 to 24 years. Demographic information can be found in Table 1.

Table 1.

Demographic Characteristics of Youth Tested for STIs and/or HIV

	N	%
Sex
Female	145	70.4
Male	59	28.6
Transgender	2	1.0
Race
Black or African American	164	79.6
White	25	12.1
More than one race	10	4.9
Chinese	1	0.5
Other	6	2.9
Sexual Orientation
Straight	134	65.0
Bisexual	17	8.3
Lesbian	3	1.5
Gay	2	1.0
Unsure/Other	4	1.9
Unreported	46	22.3
	Mean	SDa
Age at STI Testing Date (years)	18.2	2.44

^aSD = standard deviation

206 reported current sexual activity and were tested for STIs. 31.9% (n = 66) of sexually active youth had at least one positive STI test. In total, 1,049 tests for gonorrhea, chlamydia, or syphilis were conducted during the three-year period. 11.5% (n = 121) of tests were positive. Specifically, among positive tests, 64.5% (n = 78) were positive for chlamydia, 30.6% (n = 37) were positive for gonorrhea, and 5.0% (n = 6) were positive for syphilis. 83 youth were tested and counseled about HIV.

Overall, $60,049.68 in direct medical costs and $73,956.36 in indirect costs were averted by treatment of positive STI tests and HIV testing and counseling. See Table 2 for breakdown. Direct medical costs included the average cost per case of pelvic inflammatory disease (for females), epididymitis (for males), chlamydia, gonorrhea, syphilis, HIV, and average sequelae costs per case of syphilis.²⁵ Indirect costs referred to lost productivity and were computed based on the average cost per case of HIV, untreated case of chlamydia, untreated case of gonorrhea, untreated case of syphilis, case of chlamydia, case of gonorrhea, and case of syphilis. ²⁵ Assumptions for cost estimates as well as original sources can be found in the article from 2008 by Chesson, Collins, and Koski.²⁵

Table 2.

Direct and Indirect Medical Costs Averted by STI Prevention Program among Foster Youth^a

Direct Medical Costs Avertedb
Sequelae costs averted by treatment of people with chlamydia, gonorrhea, and syphilis
Chlamydia	$19,788.77
Gonorrhea	$4,874.64
Syphilis	$5,029.44
Total	$29,692.85
Treatment and sequelae costs averted by reducing transmission of chlamydia, gonorrhea, and syphilis in the population
Chlamydia	$9,241.88
Gonorrhea	$4,877.03
Syphilis	$2,514.72
Total	$16,633.63
HIV costs averted by reducing HIV transmission through treatment of chlamydia, gonorrhea, and syphilis
Chlamydia	$4,429.10
Gonorrhea	$1,189.76
Syphilis	$4,554.16
Total	$10,173.02
HIV costs averted by HIV counseling and testing
Total	$3,550.18
Indirect Medical Costs Avertedb
Indirect STI costs averted
Chlamydia	$10,876.41
Gonorrhea	$4,101.13
Syphilis	$1,477.17
Total	$16,454.71
Indirect HIV costs averted by reducing HIV transmission through treatment of STIs
Chlamydia	$18,558.38
Gonorrhea	$4,985.20
Syphilis	$19,082.42
Total	$42,626.00
Indirect HIV costs averted by reducing HIV transmission through HIV counseling and testing
Total	$14,875.65
Overall Total	$134,006.04

^aAverted costs calculated based on formulas published in:

Chesson HW, Collins D, Koski K. Formulas for estimating the costs averted by sexually transmitted infection (STI) prevention programs in the United States. Cost Eff Resour Alloc. 2008;6(1):10.

^bBased on the number of unique positive cases of chlamydia, gonorrhea, and syphilis per calendar year and 83 youth tested and counseled for HIV

Discussion

Over the study’s three years, using the CDC’s cumulative direct and indirect costs of STIs, significant cost savings accumulated.²⁵ To date this study is the first of its kind showing STI cost savings among a population of youth in foster care. The testing, done in the context of a medical home dedicated to serving AYA in foster care with services that include sexual health, is one indicator of possible health cost savings.

We found high rates of positive STI tests among AYA in foster care. Given the rates of STIs among this population of AYA as well as the health and economic benefit of STI care, the data supports comprehensive sexual healthcare for foster youth. Comprehensive care includes one-on-one clinical encounters with STI testing, treatment, and prevention counseling. Traditional care management may miss the opportunity to prevent, identify, and treat STIs that comprehensive wraparound care, like that provided by the COACH Program, may achieve. This study suggests that not only is sexual health care necessary and ethically desirable, but it is also a cost-effective way to identify, treat, and reduce the harm of STIs among foster youth.

There are several limitations to this study. This work represents data from one Midwestern program in a metropolitan area. As such it may not be generalizable to other areas. Also, this study only represents the AYA in foster care who came to the program, not the entire population of AYA in foster care in the area. It is possible that we underestimated STI cost savings as many of the youth had immediate STI testing on entry to care or care at other sites and thus did not receive further testing with us. The tests outside our site were not included in our cost savings model. We were unable to compare the COACH model cost savings with usual care received by youth in foster care. In this study we only explore the cost savings for those in this model of care. Lastly, there are a few problems inherent with cost estimates. Although these cost estimates were the best available at the time, they are only estimates and any individual case of an STI may result in higher or lower costs. Indirect costs are particularly hard to quantify and encapsulate.

Regular and consistent access to STI counseling, care, and treatment for AYA in foster care is not only important for health and wellbeing but also is a potential cost savings strategy. This cost savings could possibly be reinvested in other care and services these youth need including other health care services, contraception, and behavioral health care. Future efforts could explore cost savings comparing different models of care for AYA in foster care as well as estimating cost savings in other locations.