Cost-Effectiveness of Testing and Screening Strategies for Trichomoniasis among Asymptomatic and Symptomatic Women in U.S. Outpatient Clinical Settings

Abstract Background T. vaginalis, the most common non-viral sexually transmitted infection among women, is associated with multiple adverse health outcomes. Screening asymptomatic women is not recommended except among HIV-infected women. We aimed to evaluate the cost-effectiveness of T. vaginalis testing and screening strategies among asymptomatic and symptomatic women, respectively, in U.S. primary care settings. Methods We developed a decision tree model to evaluate 11 testing/screening strategies (using combinations of wet mount microscopy, rapid antigen testing, and T. vaginalis nucleic acid amplification testing [NAAT]) for a hypothetical cohort of 8,000 women aged 15-59 years presenting to U.S. primary care clinics in 2023. We estimated the risk, societal economic burden, and quality-adjusted life year (QALY) losses for trichomonas sequelae—preterm birth, low birthweight, premature rupture of membranes, HIV infection, and cervical cancer—over the cohort’s lifetime. Results Adding T. vaginalis NAAT to wet mount for symptomatic women provided 0.3 additional QALYs at an incremental cost of $24,785 (ICER: $83,097/QALY). Adding NAAT to rapid antigen testing for symptomatic women yielded 0.1 additional QALYs at an incremental cost of $35,628 (ICER: $324,617/QALY). Screening asymptomatic women with NAAT cost $403,541/QALY. Conclusions Incorporating NAAT into current testing practices for symptomatic women improved health outcomes but increased costs. At a willingness-to-pay threshold of $100,000/QALY, adding NAAT to wet mount for symptomatic women was cost-effective whereas adding NAAT to rapid antigen testing was not. Universal NAAT screening among asymptomatic women was also not cost-effective, suggesting that broader screening strategies may require substantially higher willingness-to-pay thresholds to be economically justified.