{"paper_id":"7ae6e91c-896e-4cd4-b69e-1ac535c16ada","body_text":"Cost analysis of genital inflammation screening as a predictor of sexually transmitted infections and bacterial vaginosis in women: evidence from the GIFT study in Madagascar, South Africa, and Zimbabwe | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Cost analysis of genital inflammation screening as a predictor of sexually transmitted infections and bacterial vaginosis in women: evidence from the GIFT study in Madagascar, South Africa, and Zimbabwe Elise Smith, Aina Harimanana, Tinashe Mwaturura, Vaomalala Raharimanga, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8120784/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Sexually transmitted infections (STIs) and bacterial vaginosis (BV) are significant public health issues, particularly in sub-Saharan Africa, and are associated with genital inflammation and increased HIV acquisition risk. A substantial proportion of these infections are asymptomatic, limiting the effectiveness of a syndromic approach. The Genital InFlammation Test (GIFT), a rapid point-of-care (POC) test, was developed to detect increases in inflammatory biomarkers associated with genital inflammation. The first-in-field prototype of the GIFT device was evaluated in a multicenter observational study conducted in South Africa, Zimbabwe, and Madagascar. While previous cost estimates for a hypothetical GIFT prototype exist for South Africa, this study provides an updated, real-world cost analysis of implementing GIFT screening within routine family planning services in South Africa and extends this analysis to Madagascar and Zimbabwe. Methods A provider-perspective, combining a top-down and bottom-up costing approach, was conducted at device evaluation observational study sites in Madagascar, South Africa, and Zimbabwe. Economic costs, including capital and recurrent expenditures, were collected through facility records, interviews, and self-reported provider timesheets to determine the incremental cost of integrating GIFT screening into family planning consultations. Research-related costs were excluded. A probabilistic sensitivity analysis using Monte Carlo simulation was performed to address parameter uncertainty, particularly around GIFT’s estimated market price of US $ 5.00. Results The incremental cost per woman screened with GIFT was estimated to be US $ 6.46 (95% CI: US $ 1.98 – US $ 12.22) in Madagascar, US $ 9.05 (95% CI: US $ 3.78 – US $ 15.83) in South Africa, and US $ 8.28 (95% CI: US $ 3.04 – US $ 16.52) in Zimbabwe. Recurrent costs (personnel, supplies, and overheads) constituted more than 98% of this cost, with the GIFT device being the primary cost driver. Conclusions This analysis suggests that the affordability and potential scale-up of GIFT and other novel POC screening tools will depend heavily on their final market price. The findings provide critical economic evidence to inform the broader adoption of GIFT into routine practice, including cost-effectiveness, affordability, and optimal strategies for its integration into sexual and reproductive healthcare services in low- and middle-income countries. Sexually transmitted infections Bacterial vaginosis Screening Genital inflammation Point-of-care testing Cost analysis Women's health Sub-Saharan Africa Figures Figure 1 Introduction Sexually transmitted infections (STIs) remain a public health concern globally, with the most recent evidence from the World Health Organization (WHO) estimating that approximately one million new infections of the four most prevalent curable STIs, Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Trichomonas vaginalis (TV) and syphilis are acquired worldwide daily ( 1 ) Bacterial vaginosis (BV) is a common vaginal condition, affecting approximately one in four women of reproductive age. It is characterized by disruption of the normal vaginal microbiome, with a reduction in protective lactobacilli and an overgrowth of anaerobic bacteria. This imbalance may cause symptoms such as abnormal discharge and odor in some women, while others remain asymptomatic ( 2 ) A substantial proportion of both STIs and BV present without symptoms, especially in women and girls. When symptoms do occur, they are often non-specific and may not be perceived as abnormal, complicating case detection and clinical management ( 3 ) WHO has set ambitious targets aimed at reducing the global incidence of STIs by 2030, emphasizing the need to scale-up prevention and control measures, particularly in sub-Saharan Africa, which bears the highest burden worldwide( 1 ) Progress towards these goals, however, remains challenging, in part due to limited diagnostic capacity in many low- and middle-income countries (LMICs). In addition, these targets do not encompass BV, despite its substantial global prevalence and comparable adverse effects on reproductive health outcomes to those of STIs ( 2 ). In settings where syndromic management remains the standard of care its limitations are significant: it has low predictive value for discharge-causing STIs such as CT, NG, TV and for BV and it is unable to identify asymptomatic infections.( 3 ) A recent meta-analysis estimated that 61% of CT, 53% of NG and 57% of TV infections in women from LMICs are asymptomatic, with even higher proportions among women in Africa (69%, 67%, and 65%, respectively) ( 4 ). Estimates for asymptomatic BV range from 47% to 50% in LMICs, while studies in high income settings have found it to be above 80% ( 5 – 8 ). Both STIs and BV are known to induce genital inflammation in women, regardless of symptoms ( 9 , 10 ). Genital inflammation, in turn, is strongly associated with increased risk of HIV acquisition and adverse birth outcomes( 11 , 12 ) This is particularly relevant in sub-Saharan Africa, where women are disproportionately affected by curable STIs and a substantial proportion of new HIV infections occur in women( 3 , 13 ) However, progress in developing point-of-care (POC) rapid diagnostics for CT, NG, TV and BV that fulfil WHO’s REASSURED criteria (including being affordable, rapid, equipment-free and deliverable to end-users) has been limited, leaving a critical gap in effective disease management( 14 , 15 ) Affordable diagnostic tools capable of delivering same-day results remain a pressing research and program priority, as they are essential for enabling timely initiation of appropriate treatment and reducing onward transmission( 16 , 17 ) To address this need, Masson and colleagues developed the Genital InFlammation Test (GIFT). GIFT is a rapid POC lateral flow assay detecting inflammatory biomarkers interleukin (IL)-1α, IL-1β, and interferon-γ-induced protein (IP)-10 from vaginal swabs and producing results in 15 minutes ( 13 ). By identifying genital inflammation, GIFT could facilitate the identification of women with asymptomatic STIs and BV and at elevated risk of HIV acquisition to strengthen sexual and reproductive health outcomes in settings where syndromic management is the norm. The GIFT study, a multicenter observational study conducted in South Africa, Zimbabwe, and Madagascar, evaluated the first-in-field prototype of the GIFT device. Its primary objective was to assess the sensitivity and specificity of GIFT for detecting asymptomatic, discharge-causing STIs (CT, NG, TV, Mycoplasma genitalium (MG)) and BV in women aged 18–35 years accessing family planning services, using nucleic acid amplification tests (NAATs) and Nugent scoring as reference standards ( 13 ). A key objective of the larger GIFT study was to assess potential pathways for integration into family planning services, including a cost analysis of implementing GIFT screening in real-world clinical settings. An earlier study estimated the costs of GIFT screening for STIs and BV during family planning consultations in South Africa, based on a hypothetical prototype of the GIFT device that was still under development ( 18 ). Cost estimates were derived from three health facilities in Cape Town, including a government clinic, a non-governmental clinic, and a semi-private clinic. The incremental cost of incorporating GIFT screening for the detection of asymptomatic STIs and BV during family planning consultations was estimated between US $ 3.53 (government clinic) and US $ 5.32 (semi-private clinic) (2016 prices inflated to 2023). This included a device cost of US $ 0.30 based on manufacturer’s price estimates of the GIFT ( 18 ) The primary aim of this study was to provide an updated estimate of the incremental cost of GIFT screening (testing of individuals who do not show symptoms to identify infections early and prevent transmission and complications) for STIs and BV in a real-world implementation setting, including South Africa and extending this analysis to Madagascar and Zimbabwe, based on evidence from the multicenter clinical observational GIFT device accuracy study ( 13 ). Methods Study design A combined top-down and bottom-up costing approach was applied to estimate the incremental cost per woman, and per woman per year, screened for STIs and BV using GIFT as part of routine family planning services in the three study settings. Economic costs, including both capital and recurrent costs, were assessed from the provider perspective. All research-related study costs were excluded so that resource utilization reflects the most likely scenario of routine implementation of GIFT screening in a real-world setting. Study sites The GIFT study was conducted at three sites across the three countries. In Madagascar, the study site was the Centre Hospitalier Universitaire de Gynécologie et d’Obstétrique de Befelatanana, a government university hospital in Antananarivo where family planning services are provided in a dedicated outpatient ward of the hospital. The Desmond Tutu Health Foundation (DTHF) Masiphumelele Youth Centre, a non-profit, donor-funded research center in Cape Town, was South Africa’s study site. DTHF operates an on-site clinic where youth-friendly sexual and reproductive health (SRH) services, including STI management, are provided. Given that DTHF is a donor-funded clinic, to estimate costs that are more representative of a public health setting, cost and service utilization data on family planning services were obtained from the nearby government Masiphumelele clinic, a public health clinic offering integrated family planning and STI services. All data related to the clinical study were obtained from the DTHF clinical study site. In Zimbabwe, the study was conducted at the Spillhaus Family planning Centre, a public clinic in Harare offering integrated SRH services including family planning, STI management, HIV prevention and fertility services. Across all three countries and study sites, syndromic management of STIs and BV remains the standard of care. Data collection Cost and resource utilization data of family planning consultations were obtained from facility management at each of the health facilities using semi-structured interview tools. Time allocation of clinical personnel to family planning services was collected through self-reported timesheets over a two-week period per site. Similarly, information on the time and consumables required to conduct GIFT screening was collected using self-reported timesheets completed by GIFT study nurses at each study site. For the base-case analysis, the GIFT device was assigned a cost of US $ 5.00, reflecting the manufacturer’s current best estimate of a potential market price. Where data were unavailable from the study sites, publicly accessible data sources or comparable data from similar study contexts were utilized (Table 1 ). Data Analysis Data were analyzed using a costing model developed in Microsoft Excel 365. The total cost of family planning and incremental cost of GIFT screening were estimated at the facility level. The incremental cost of GIFT screening was divided by the total number of female patients attending the clinic in the 2023 fiscal year to estimate the incremental cost of GIFT screening per woman. The total cost per woman screened per year was calculated as the product of the incremental cost per woman screened and the number of family planning consultations per woman per year. All costs are presented in 2023 United States Dollars (US $ ). Costs were inflated to 2023 prices using locally published inflation data where required and converted to US $ using the published average annual exchange rate for each country for the period 1 January 2023 to 31 December 2023 (US $ 1 = Malagasy Ariary 4,454.62, US $ 1 = South African Rand 18.46, US $ 1 = Zimbabwean Dollar 3,680.52 ( 19 – 21 ) Measurement, valuation, and allocation of costs Capital cost items included buildings, equipment, furniture, and provider training, while recurrent cost items comprised personnel, supplies, and overheads. Table 1 outlines the approach used to measure, value, and allocate these costs to GIFT screening consultations. Capital cost utilization was measured using facility records and interviews with the GIFT study team, and valued using current replacement costs from facility data, market prices, or published sources. These costs were annualized using standard assumptions on useful life and a 3% discount rate ( 22 ). Recurrent cost utilization was primarily measured through self-reported timesheets and facility records. These costs were valued using government salary scales, market prices, and facility expenditure data. Indirect and shared resources were allocated to the GIFT screening consultation using top-down approaches: Building costs were allocated according to the proportion of space used for family planning consultations, further apportioned to GIFT screening based on the share of direct personnel time devoted to GIFT as a proportion of total family planning consultation time; Equipment, furniture, indirect personnel, and overhead and maintenance costs were allocated in proportion to family planning consultations as a share of total outpatient visits. In Madagascar, hospital-wide shared costs (including overheads and maintenance) were allocated to family planning consultations based on the proportion of these visits relative to the total hospital service volume. To ensure comparability between service types, inpatient days were converted to outpatient-equivalent visits using WHO-CHOICE conversion factors ( 23 ) Direct resources, including GIFT provider training, direct personnel time, and medical and non-medical supplies, were allocated directly to GIFT screening. Table 1 Measurement, valuation, and allocation of costs to GIFT screening Measurement Valuation Allocation to GIFT screening Cost category Method Data source Method Data source Method Allocation factor Capital cost items Buildings Square meters of space used for FP consultations Obtained from facilities Current replacement value (cost per m 2 ) ( 24 )* Top-down FP space as % of total facility space x GIFT screening personnel time as % of total direct personnel time for FP Useful life (20 years) ( 25 ) Discount rate (3%) ( 22 , 26 ) Equipment (medical & non-medical) and furniture Items used for FP departments Obtained from facilities** Current replacement value Health facility; market prices Top-down Total FP consultations as % of total outpatient consultations x GIFT screening as % of total direct personnel time for FP Useful life (15 years for furniture, 5 years for equipment) ( 25 ) Discount rate (3%) ( 22 , 26 ) Provider training Provider time GIFT clinical study team Total annual renumeration Government salary scales Bottom-up Fully allocated to GIFT screening Useful life (5 years) ( 25 ) Discount rate (3%) ( 22 , 26 ) Recurrent cost items Indirect personnel Time spent on FP- related support activities Self-reported timesheets Total annual renumeration Government salary scales Top-down Total FP consultations as % of total outpatient consultations x GIFT screening as % of total direct personnel time for FP Direct personnel Time spent on GIFT screening per study participant ¥ Self-reported timesheets Total annual renumeration Government salary scales Bottom-up Direct; based on reported utilization Medical and non-medical supplies Supplies used for to conduct a GIFT test Self-reported reports Unit prices Health facility; market prices Bottom-up Direct; based on reported utilization Overheads & maintenance Apportioned usage Obtained from facilities** Total annual expenditure Facilities Top-down Total FP consultations as % of total outpatient consultations x GIFT screening as % of total direct personnel time for FP Note: FP = family planning; GIFT = Genital InFlammation Test; *Source for the replacement value of the clinic in South Africa. In the absence of data for Madagascar and Zimbabwe, building costs were estimated by applying the proportion of building costs of total unit costs as in South Africa. ** In the absence of available data from the clinic in South Africa, information was sourced from Kairu et al. (2020) and adjusted to 2023 prices. ¥ Excludes study-related activities such as explaining study procedures, obtaining consent, and collecting additional swabs. Sensitivity analysis Univariate sensitivity analysis was conducted to identify the most influential parameters on the results of the analysis. Model parameters were varied to ± 30% of the base-case scenario. Results from this analysis are presented by means of tornado plots. Uncertainty analysis Given the small sample of this study, significant uncertainty existed around the base-case point estimates and the generalizability thereof to other settings within the same country. Parameter uncertainty was characterized using probabilistic sensitivity analysis (PSA) via Monte Carlo simulation with 1,000 iterations. Gamma or uniform distributions were assigned to cost input parameters, while lognormal or uniform distributions were applied to resource utilization parameters. The limited sample size in this study, both in terms of the number of facilities and the number of personnel from whom time estimates were collected, precluded the statistical calculation of means and 95% confidence intervals (CIs) for cost model parameters based on observed data. Consequently, base-case cost parameters primarily reflect single-point estimates or simple averages derived from the available observations (e.g., time measurements) or data collected from the facilities. Where possible, upper, and lower bounds for model parameters were derived from minimum and maximum values based on observed data; in the absence of empirical bounds, a ± 30% variation around the base-case estimate was assumed to parameterize the PSA model ( 27 ). Results from the PSA are presented as 95% CIs around the base-case point estimates. Results Facility and resource utilization, which informed the allocation of shared resources to family planning and ultimately GIFT screening, is presented in Table 2. The proportion of family planning consultations relative to total outpatient visits varied substantially across sites, accounting for 16% in Madagascar, 12% in South Africa, and 88% in Zimbabwe. Across the three facilities, clinical personnel (nurses) spent 71%, 84% and 78% of their time on activities related to family planning services, respectively. In the base-case analysis, each participant was assumed to attend four family planning consultations per year, reflecting an average utilization pattern of one clinic visit every three months. The average time taken by nurses to perform a GIFT test (including explaining the test to the client, collecting the vaginal swab, mixing with buffer and applying it to the test device and reading and interpreting results) excluding research-specific activities and the 15-minute test incubation period, was 11.67 minutes across the three sites. This is slightly higher than the 10 minutes estimated by Kairu et al. (2022) (18). Due the small number of observations across study sites, the average time across observations from all three study sites was applied to the cost estimates for all sites. Incubation time of the GIFT device was excluded based on the assumption that clinical personnel would be able to carry out other routine family planning consultation tasks while waiting for test results. Incubation time for the GIFT device was excluded from the personnel time cost, based on the assumption that nurses could perform other routine family planning consultation tasks while awaiting test results. Table 3 presents the base-case unit cost estimates and the 95% CIs from the PSA. The incremental cost per woman screened with GIFT was estimated to be US $6.46 (US $1.98 – US $12.22) in Madagascar, US $9.05 (US $3.78 – US $15.83) in South Africa and US $8.28 (US $3.04 – US $16.52) Zimbabwe. Recurrent costs accounted for more than 98% of total unit costs in all three countries, with capital costs comprising the remainder. The GIFT device is the primary driver of the incremental cost of GIFT screening at an estimated unit price of US $5.00 (77% in Madagascar, 55% in South Africa and 60% in Zimbabwe). To reflect current uncertainty, a price range between US $1.00 and US $10.00 was applied for the device (refer to Sensitivity Analysis ). The second biggest cost driver was medical supplies in Madagascar (15%), direct personnel in South Africa (30%), and indirect personnel in Zimbabwe (19%). Differences in cost estimates between the three countries were driven by variations in price levels, particularly those related to human resources, as well as differences in the allocation factors of shared costs to family planning and, ultimately, to GIFT. In Zimbabwe, where 88% of facility costs were allocated to family planning the indirect staff costs attributed to GIFT were substantially higher than in the other countries. In contrast, in South Africa, where human resource costs were higher than in Madagascar and Zimbabwe, direct personnel costs were greater despite the same level of direct resource utilization being assumed for GIFT screening. For comparability, costs are also presented in international dollars in Supplementary Table 1. Table 2: Facility and resource utilization n/a: Not applicable *Minimum and maximum values represent +/-30% of reported parameters. ** Based on the cadence of common contraceptive method, uncertainty ranges present likely minimum and maximum number of consultations per year per type of contraceptive method. α Due the small number of observations across study sites, the average time represents the average observations from across the three study sites. Incubation time of the GIFT device is excluded based on the assumption that clinical personnel would be able to carry out other routine family planning consultation tasks while waiting for test results. ¥ Minimum and maximum values from data collected. Table 3 Unit cost results (2023 US $) Madagascar South Africa Zimbabwe Madagascar South Africa Zimbabwe Incremental cost per woman screened with GIFT, US $ (95% CI) Incremental cost per woman screened with GIFT, per year, US $ (95% CI) Capital costs Buildings 0.07 (0.02–0.29) 0.10 (0.05–0.28) 0.09 (0.03–0.39) 0.29 (0.08–0.90) 0.41 (0.12–1.32) 0.38 (0.10–1.69) Equipment and furniture 0.003 (0.001–0.007) 0.001 (0.0004–0.002) 0.05 (0.02–0.12) 0.01 (0.007–0.02) 0.003 (0.001–0.01) 0.19 (0.12–0.28) Procedure training 0.001 (0.0007–0.002) 0.01 (0.01–0.02) 0.01 (0.004–0.01) 0.004 (0.002–0.01) 0.05 (0.02–0.10) 0.03 (0.01–0.05) Total capital costs 0.08 (0.02–0.29) 0.12 (0.06–0.30) 0.15 (0.06–0.52) 0.31 (0.09–0.93) 0.47 (0.13–1.42) 0.59 (0.23–2.02) Recurrent costs Indirect personnel 0.08 (0.04–0.19) 0.26 (0.14–0.60) 1.57 (0.87–3.80) 0.31 (0.23–0.42) 1.04 (0.34–3.04) 6.24 (4.70–8.66) Direct personnel 0.32 (0.22–0.44) 2.67 (1.87–3.55) 0.49 (0.12–0.68) 1.26 (0.51–2.30) 10.68 (4.45–18.90) 1.94 (0.81–3.65) Medical supplies 0.99 (0.70–1.30) 0.99 (0.71–1.33) 0.99 (0.71–1.29) 3.95 (1.60– 7.10) 3.95 (1.64–7.16) 3.95 (1.68–7.15) GIFT device 5.00 (1.00–10.00) 5.00 (1.00–10.00) 5.00 (1.00–10.00) 20.00 (3.00–54.00) 20.00 (3.00–54.00) 20.00 (2.00–54.00) Overheads and maintenance 0.0005 (0.0002–0.001) 0.02 (0.01–0.04) 0.09 (0.04–0.24) 0.002 (0.001–0.003) 0.07 (0.02–0.22) 0.38 (0.24–0.57) Total recurrent costs 6.38 (1.96–11.92) 8.93 (3.72–15.53) 8.13 (2.98–16.00) 25.52 (5.33–63.82) 35.73 (9.46–83.31) 32.54 (9.44–74.03) Total costs 6.46 (1.98–12.22) 9.05 (3.78–15.83) 8.28 (3.04–16.52) 25.83 (5.42–64.75) 36.20 (9.60–84.73) 33.13 (9.67–74.03) Total cost, excluding GIFT device 1.46 (0.98–2.22) 4.05 (2.78–5.83) 3.28 (2.04–6.52) 5.83 (2.83–10.75) 16.20 (6.60–30.73) 13.13 (6.60–20.03) The incremental cost per woman screened per year, assuming routine screening at each of four family planning visits, was estimated to be US $25.83 (US $5.42 – US $64.75) in Madagascar, US $36.20 (US $9.60 – US $84.73) in South Africa and US $33.13 (US $9.67 – US $74.03) in Zimbabwe. Sensitivity analysis Figure 1 shows the results from the univariate sensitivity analysis where model parameters were varied with ± 30%. Across the three countries, a change in the GIFT device price resulted in the greatest change in unit cost, with a ± 30% change resulting in a ± 23%, ± 17% and ± 16% change in the incremental cost per woman screened in Madagascar, South Africa and Zimbabwe, respectively. The second most influential parameter was the time required to administer the GIFT device in Madagascar and South Africa, and the number of family planning consultants per woman, per year in Zimbabwe. The inverse relationship between the number of family planning consultations per woman per year and the cost of GIFT screening suggests that economies of scale could be realized by distributing fixed costs across a larger number of services, albeit relatively modest. Discussion This study provides a multi-country cost analysis of implementing GIFT, a rapid POC test for genital inflammation, or other similar tests, as a screening tool within routine family planning services in Madagascar, South Africa, and Zimbabwe. The use of empirical data from three distinct LMICs settings enhances the relevance of the findings for similar contexts. The incorporation of PSA allows for the quantification of uncertainty around point estimates, reflecting the inherent variability in cost parameters, especially given the small sample size of health facilities. The PSA results indicate a wide range of unit costs, largely attributable to the limited number of facilities sampled and uncertainty regarding the future market price of the GIFT device. As the device cost is the main driver of total implementation costs in our analysis, the overall affordability and scalability of GIFT screening will depend largely on its eventual market price; a critical consideration for implementation in LMIC settings. In the base case analysis, the device price was assumed to be US $ 5.00. However, the final market price will ultimately depend on the device’s components and where they are manufactured. Excluding the cost of the device, estimated screening costs varied from US $ 1.46 (US $ 0.98 – US $ 2.22) in Madagascar, US $ 4.05 (US $ 2.78 – US $ 5.83) in South Africa, and US $ 3.28 (US $ 2.04 – US $ 6.52) in Zimbabwe. The estimates for South Africa are slightly higher than the inflation-adjusted results reported by Kairu et al. (2022) for a government clinic (US $ 3.23, excluding device price), although they fall within the uncertainty range of the present analysis ( 18 ). The observed differences are primarily attributable to variations in human resource utilization. Overall cost estimates, including the device, were higher in our analysis largely because of the increased device price assumed, based on more recent manufacturer estimates. The findings have implications for policy and future research as a unit price of US $ 5.00 for the GIFT device, and overall implementation cost of US $ 6.46 in Madagascar, US $ 9.05 in South Africa and US $ 8.28 in Zimbabwe, may present an affordability challenge. Evidence on the costs of STI screening using POC tests in LMICs, including in Sub-Saharan Africa, remains limited and largely focused on HIV and syphilis. This is likely due to the lack of affordable and effective POC diagnostic tests for other STIs, including CT, TV and NG, and prevailing guidance to use syndromic management in these settings. To our knowledge, no published data currently exist on the cost of CT, NG, or TV screening using rapid POC tests in Africa or other LMICs. For context, a systematic review estimated the mean cost of facility-based HIV testing using rapid POC tests in Sub-Saharan Africa at US $ 19.63 per person tested (including post-test counselling), although self-testing approaches have achieved lower costs (US $ 12.75 per person tested) ( 28 ). Facility-based antenatal syphilis screening using rapid POC tests has been estimated at approximately US $ 1.00–4.00 per woman screened, with staff time and supplies, including the device itself, typically costing less than US $ 1.00, constituting the main cost drivers. When considering scale-up, screening or testing volumes are an important consideration, as higher volumes allow for economies of scale by spreading fixed costs such as training, start-up activities, facility operations, program supervision, and quality assurance, over a larger number of tests ( 29 – 38 ). Overall, these findings suggest that GIFT screening compares favorably with facility-based HIV testing and self-testing, though generally higher than antenatal syphilis screening. If device costs can be reduced and economies of scale achieved through scaled-up implementation, GIFT screening could represent an economically viable and feasible STI screening strategy in LMICs, with the potential to improve early detection and sexual and reproductive health outcomes. However, these cost considerations, must be interpreted alongside evidence of the device’s effectiveness and subsequent impact on health outcomes. Limitations This study has several limitations. First, data were collected from a single facility per country, which may not be representative of all public health facilities, limiting generalizability. Second, time allocation data relied on self-reported timesheets, which are subject to recall or reporting bias. Third, the US $ 5.00 cost of the GIFT device is a manufacturer’s estimate, and the final market price could differ, substantially impacting overall and relative costs. Fourth, where facility-specific data were unavailable, costs were imputed using published sources or proportional estimates from other sites, such as building costs in Madagascar and Zimbabwe, which may not fully reflect local conditions. Finally, this analysis did not include the costs of confirmatory testing for STIs and BV, which would form a key component of the management of STIs and BV following positive GIFT test results. Conclusion This cost analysis demonstrates that incorporating GIFT screening into routine family planning services costs between US $ 6.46 and US $ 9.05 per test across settings in Madagascar, South Africa, and Zimbabwe. The cost of the device itself is the predominant cost driver, underscoring that the affordability of this novel POC technology will be central to its potential for widespread adoption. These findings provide essential evidence for the broader economic evaluation of implementing GIFT as a screening tool for STIs and BV in LMICs. While this study provides a quantitative assessment of the economic costs associated with GIFT implementation, a comprehensive policy and research perspective requires integrating these cost data with evidence on clinical effectiveness from the ongoing GIFT study. Emerging results on cost-effectiveness, affordability, and acceptability will be essential to guide the design of implementation strategies, such as optimizing screening frequency or targeting high-risk sub-populations, to maximize health benefits within existing resource constraints. Abbreviations AGYW – Adolescent Girls and Young Women BV – Bacterial Vaginosis CI – Confidence Interval CT – Chlamydia trachomatis DTHF – Desmond Tutu Health Foundation FP – Family Planning GIFT – Genital InFlammation Test HIV – Human Immunodeficiency Virus IL-1α / IL-1β – Interleukin-1 alpha / Interleukin-1 beta IP-10 – Interferon gamma-induced protein 10 LMICs – Low- and Middle-Income Countries MG – Mycoplasma genitalium MGA – Malagasy Ariary (currency) NAATs – Nucleic Acid Amplification Tests NG – Neisseria gonorrhoeae POC – Point-of-Care PSA – Probabilistic Sensitivity Analysis SRH – Sexual and Reproductive Health STI– Sexually Transmitted Infection TV – Trichomonas vaginalis US$ – United States Dollar WHO – World Health Organization Declarations Ethics approval and consent to participate Ethical approval for this study was granted by the following research ethics committees: Human Research Ethics Committee, University of Cape Town (UCT) (Ref: 366/2022 and 173/2023), Observation/Intervention Research Ethics Committee, London School of Hygiene & Tropical Medicine (Ref: 28046), Ministère de la Santé Publique (Ref: 64-MSANP/SG/AMM/CNPN/CERMB), Research Council of Zimbabwe (Ref: 04768), City Health, City of Cape Town (Ref: 9870). The study was conducted in compliance with the Declaration of Helsinki (2013). Informed consent for the costing study was waived as the research involved the analysis of fully de-identified data with minimal risk to participants. Consent for publication Not applicable Availability of data and materials Research generated in this study is available upon reasonable request from the corresponding author. Competing Interests Jo-Ann Passmore and Lindi Masson are co-inventors on a patent related to the combination of three inflammatory biomarkers (IL-1α, IL-1β, and IP-10) used in the GIFT diagnostic assay for genital inflammation (South African Patent No. 2016/03606 and European Patent No. 14809984.9). Both inventors declare that while this intellectual property is related to the biomarker combination evaluated in the current study, neither they nor their institutions currently receive personal financial benefits from the patent. Funding This research was funded under the European and Developing Countries Clinical Trials Partnership (EDCTP) (grant number RIA2020I-3297). Authors' contributions E. Smith (ESm) drafted the main manuscript and, together with E. Sinanovic (ESi), led the conceptualisation and design of the study. AH, TM, VR, TMG, and KG supported and facilitated data collection. ESm conducted the data analysis. ESi, EHE, KG, LM, and JAP contributed to the interpretation of the findings. All authors reviewed and approved the final manuscript. Acknowledgements Not applicable References World Health Organization. Global progress report on HIV, viral hepatitis and sexually transmitted infections, 2021: accountability for the global health sector strategies 2016–2021: actions for impact [Internet]. 2021 [cited 2025 Aug 31]. Available from: https://iris.who.int/handle/10665/341412 World Health Organization. Recommendations for the treatment of Trichomonas vaginalis, Mycoplasma genitalium, Candida albicans, bacterial vaginosis and human papillomavirus (anogenital warts). Geneva; 2024. Michalow J, Hall L, Rowley J, Anderson RL, Hayre Q, Chico RM, et al. Prevalence of chlamydia, gonorrhoea, and trichomoniasis among male and female general populations in sub-Saharan Africa from 2000 to 2024: a systematic review and meta-regression analysis. EClinicalMedicine. 2025 May 1;83. Fortas C, Delarocque-Astagneau E, Randremanana RV, Crucitti T, Huynh BT. Asymptomatic infections with Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis among women in low- and middle-income countries: A systematic review and meta-analysis. PLOS Global Public Health. 2024 May 1;4(5). Joyisa N, Moodley D, Nkosi T, Talakgale R, Sebitloane M, Naidoo M, et al. Asymptomatic Bacterial Vaginosis in Pregnancy and Missed Opportunities for Treatment: A Cross-Sectional Observational Study. Infect Dis Obstet Gynecol. 2019; Rajalakshmi R, Kalaivani S. Prevalence of asymptomatic infections in sexually transmitted diseases attendees diagnosed with bacterial vaginosis, vaginal candidiasis, and trichomoniasis. Indian J Sex Transm Dis. 2016 Jul 1;37(2):139–42. Sherrard J, Wilson J, Donders G, Mendling W, Jensen JS. 2018 European (IUSTI/WHO) International Union against sexually transmitted infections (IUSTI) World Health Organisation (WHO) guideline on the management of vaginal discharge. Int J STD AIDS. 2018 Nov 1;29(13):1258–72. Koumans EH, Sternberg M, Bruce C, McQuillan G, Kendrick J, Sutton M, et al. The prevalence of bacterial vaginosis in the United States, 2001-2004; associations with symptoms, sexual behaviors, and reproductive health. Sex Transm Dis. 2007 Nov;34(11):864–9. Mlisana K, Naicker N, Werner L, Roberts L, Loggerenberg F Van, Baxter C, et al. Symptomatic Vaginal Discharge Is a Poor Predictor of Sexually Transmitted Infections and Genital Tract In fl ammation in High-Risk Women in South Africa. Journal of Infectious Diseases [Internet]. 2012;206(1):6–14. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3490689/ Gosmann C, Anahtar MN, Handley SA, Farcasanu M, Abu-Ali G, Bowman BA, et al. Lactobacillus-Deficient Cervicovaginal Bacterial Communities Are Associated with Increased HIV Acquisition in Young South African Women. Immunity. 2017 Jan 17;46(1):29–37. Masson L, Passmore JAS, Liebenberg LJ, Werner L, Baxter C, Arnold KB, et al. Genital Inflammation and the Risk of HIV Acquisition in Women. Clinical Infectious Diseases. 2015;61(2):260–9. Ng PY, Ireland DJ, Keelan JA. Drugs to block cytokine signaling for the prevention and treatment of inflammation induced preterm birth. Front Immunol. 2015;6(MAR). Ramboarina S, Crucitti T, Gill K, Bekker LG, Harding-Esch EM, van de Wijgert JHHM, et al. Novel point-of-care cytokine biomarker lateral flow test for the screening for sexually transmitted infections and bacterial vaginosis: study protocol of a multicentre multidisciplinary prospective observational clinical study to evaluate the performance and feasibility of the Genital InFlammation Test (GIFT). BMJ Open. 2024 May 1;14(5). Land KJ, Boeras DI, Chen XS, Ramsay AR, Peeling RW. REASSURED diagnostics to inform disease control strategies, strengthen health systems and improve patient outcomes. Vol. 4, Nature Microbiology. Nature Publishing Group; 2019. p. 46–54. Unemo M, Cole M, Lewis D, Ndowa F, Van Der Pol B, Wi T. Laboratory and point-of-care diagnostic testing for sexually transmitted infections, including HIV [Internet]. Geneva: World Health Organization; 2023. Available from: https://www.who.int/publications/book-orders. Verwijs MC, Agaba SK, Sumanyi JC, Umulisa MM, Mwambarangwe L, Musengamana V, et al. Targeted point-of-care testing compared with syndromic management of urogenital infections in women (WISH): a cross-sectional screening and diagnostic accuracy study. Lancet Infect Dis [Internet]. 2019;19(6):658–69. Available from: http://dx.doi.org/10.1016/S1473-3099(18)30724-2 Garrett N, Mtshali A, Osman F, Masson L, Mckinnon LR, Singh R, et al. Impact of point-of-care testing and treatment of sexually transmitted infections and bacterial vaginosis on genital tract inflammatory cytokines in a cohort of young South African women. Sex Transm Infect. 2021 Dec 1;97(8):555–65. Kairu A, Masson L, Passmore JAS, Cunnama L, Sinanovic E. Rapid Point-of-Care Testing for Genital Tract Inflammatory Cytokine Biomarkers to Diagnose Asymptomatic Sexually Transmitted Infections and Bacterial Vaginosis in Women: Cost Estimation and Budget Impact Analysis. Sex Transm Dis. 2022;49(3):237–43. XE. USD to MGA currency chart [Internet]. [cited 2024 Jun 7]. Available from: https://www.xe.com/currencycharts/?from=USD&to=MGA South African Reserve Bank. Selected Historical Rates. In Key statistics. [Internet]. 2024 [cited 2024 Jun 7]. Available from: https://www.resbank.co.za/en/home/what-we-do/statistics/key-statistics/selected-historical-rates Reserve Bank of Zimbabwe. Quarterly economic review: December 2023 (Q4 2023). Harare, Zimbabwe; 2023. Vassall A, Sweeney S, Kahn JG, Gomez GB, Bollinger L, Marseille E, et al. Reference Case for Estimating the Costs of Global Health Services and Interventions [Internet]. 2017. Available from: https://ghcosting.org/pages/standards/reference_case World Health Organization. WHO-CHOICE estimates of cost for inpatient and outpatient health service delivery. 2021. IUSS Cost Committee. Clinic, CDC and CHC Maintenance OoM Estimator [Internet]. 2021 [cited 2024 Mar 10]. Available from: https://www.ukesa.info/library/view/estimators-for-infrastructure-cost-of-health-facilities2 Drummond MF, Sculpher MJ, Claxton K, Stoddart GL, Torrance GW. Methods for the economic evaluation of health care programmes. Oxford University Press; 2015. Walker D, Kumaranayake L. Introduction: costs over time How to do (or not to do). .. Allowing for differential timing in cost analyses: discounting and annualization. 2002. Briggs AH, Weinstein MC, Fenwick EAL, Karnon J, Sculpher MJ, Paltiel AD. Model parameter estimation and uncertainty: A report of the ISPOR-SMDM modeling good research practices task force-6. Value in Health. 2012 Sep;15(6):835–42. Ahmed N, Ong JJ, McGee K, d’Elbée M, Johnson C, Cambiano V, et al. Costs of HIV testing services in sub-Saharan Africa: a systematic literature review. Vol. 22, BMC Infectious Diseases. BioMed Central Ltd; 2022. Romoren M, Sundby J, Velauthapillai M, Rahman M, Klouman E, Hjortdahl P. Chlamydia and gonorrhoea in pregnant Batswana women: Time to discard the syndromic approach? BMC Infect Dis. 2007 Apr 16;7. Blandford JM, Gift TL, Vasaikar S, Mwesigwa-Kayongo D, Dlali P, Bronzan RN. Cost-effectiveness of on-site antenatal screening to prevent congenital syphilis in rural Eastern Cape Province, Republic of South Africa. Sex Transm Dis. 2007 Jul;34(7 SUPPL.). Levin CE, Steele M, Atherly D, García SG, Tinajeros F, Revollo R, et al. Analysis of the operational costs of using rapid syphilis tests for the detection of maternal syphilis in Bolivia and Mozambique. Sex Transm Dis. 2007;34(7 SUPPL.). Shelley KD, Ansbro ÉM, Ncube AT, Sweeney S, Fleischer C, Mumba GT, et al. Scaling down to scale up: A health economic analysis of integrating point-of-care syphilis testing into antenatal care in Zambia during pilot and national rollout implementation. PLoS One. 2015 May 13;10(5). Rydzak CE, Goldie SJ. Cost-effectiveness of rapid point-of-care prenatal syphilis screening in sub-Saharan Africa. Sex Transm Dis. 2008 Sep;35(9):775–84. Larson BA, Lembela-Bwalya D, Bonawitz R, Hammond EE, Thea DM, HerlihyJulie H. Finding a Needle in the Haystack: The costs and cost-effectiveness of syphilis diagnosis and treatment during pregnancy to prevent congenital syphilis in Kalomo District of Zambia. PLoS One. 2014 Dec 5;9(12). Sweeney S, Mosha JF, Terris-Prestholt F, Sollis KA, Kelly H, Changalucha J, et al. The costs of accessible quality assured syphilis diagnostics: Informing quality systems for rapid syphilis tests in a Tanzanian setting. Health Policy Plan. 2014;29(5):633–41. Vickerman P, Peeling RW, Terris-Prestholt F, Changalucha J, Mabey D, Watson-Jones D, et al. Modelling the cost-effectiveness of introducing rapid syphilis tests into an antenatal syphilis screening programme in Mwanza, Tanzania. Sex Transm Infect. 2006 Dec;82(SUPPL. 5). Bristow CC, Larson E, Anderson LJ, Klausner JD. Cost-effectiveness of HIV and syphilis antenatal screening: A modelling study. Sex Transm Infect. 2016 Aug 1;92(5):340–6. Terris-Prestholt F, Vickerman P, Torres-Rueda S, Santesso N, Sweeney S, Mallma P, et al. The cost-effectiveness of 10 antenatal syphilis screening and treatment approaches in Peru, Tanzania, and Zambia. International Journal of Gynecology and Obstetrics. 2015 Jun 1;130(S1):S73–80. Additional Declarations Competing interest reported. Jo-Ann Passmore and Lindi Masson are co-inventors on a patent related to the combination of three inflammatory biomarkers (IL-1α, IL-1β, and IP-10) used in the GIFT diagnostic assay for genital inflammation (South African Patent No. 2016/03606 and European Patent No. 14809984.9). Both inventors declare that while this intellectual property is related to the biomarker combination evaluated in the current study, neither they nor their institutions currently receive personal financial benefits from the patent. Supplementary Files GIFTcostanalysisSupplementarymaterials.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 23 Dec, 2025 Reviews received at journal 21 Dec, 2025 Reviews received at journal 15 Dec, 2025 Reviewers agreed at journal 12 Dec, 2025 Reviews received at journal 09 Dec, 2025 Reviewers agreed at journal 01 Dec, 2025 Reviewers agreed at journal 25 Nov, 2025 Reviewers invited by journal 24 Nov, 2025 Editor assigned by journal 20 Nov, 2025 Submission checks completed at journal 19 Nov, 2025 First submitted to journal 19 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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09:58:17\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":42772,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eUnivariate sensitivity analysis results\\u003c/p\\u003e\\n\\u003cp\\u003eNote: FP = family planning GIFT = Genital InFlammation Test; Across countries, the GIFT device price had the greatest impact on unit cost; a ±30% change led to ±23%, ±17%, and ±16% changes in incremental cost per woman screened in Madagascar, South Africa, and Zimbabwe, respectively. The next most influential parameters were administration time (Madagascar, South Africa) and the number of FP visits per woman per year (Zimbabwe).\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8120784/v1/53b10af1f80a21b682a9c55c.png\"},{\"id\":97144820,\"identity\":\"ab68c17b-13e5-4230-b170-988a46b1aa57\",\"added_by\":\"auto\",\"created_at\":\"2025-12-01 10:12:11\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1502181,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8120784/v1/a8fd81de-5bb1-47ec-b6f6-ff03854785e3.pdf\"},{\"id\":96995592,\"identity\":\"58039d7b-c060-4043-8f8c-9e0ef127dbdd\",\"added_by\":\"auto\",\"created_at\":\"2025-11-28 12:09:50\",\"extension\":\"docx\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":31973,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"GIFTcostanalysisSupplementarymaterials.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8120784/v1/df3e094608e8cfc03669331c.docx\"}],\"financialInterests\":\"Competing interest reported. Jo-Ann Passmore and Lindi Masson are co-inventors on a patent related to the combination of three inflammatory biomarkers (IL-1α, IL-1β, and IP-10) used in the GIFT diagnostic assay for genital inflammation (South African Patent No. 2016/03606 and European Patent No. 14809984.9). Both inventors declare that while this intellectual property is related to the biomarker combination evaluated in the current study, neither they nor their institutions currently receive personal financial benefits from the patent.\",\"formattedTitle\":\"Cost analysis of genital inflammation screening as a predictor of sexually transmitted infections and bacterial vaginosis in women: evidence from the GIFT study in Madagascar, South Africa, and Zimbabwe\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eSexually transmitted infections (STIs) remain a public health concern globally, with the most recent evidence from the World Health Organization (WHO) estimating that approximately one million new infections of the four most prevalent curable STIs, \\u003cem\\u003eChlamydia trachomatis\\u003c/em\\u003e (CT), \\u003cem\\u003eNeisseria gonorrhoeae\\u003c/em\\u003e (NG), \\u003cem\\u003eTrichomonas vaginalis\\u003c/em\\u003e (TV) and syphilis are acquired worldwide daily (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e) Bacterial vaginosis (BV) is a common vaginal condition, affecting approximately one in four women of reproductive age. It is characterized by disruption of the normal vaginal microbiome, with a reduction in protective lactobacilli and an overgrowth of anaerobic bacteria. This imbalance may cause symptoms such as abnormal discharge and odor in some women, while others remain asymptomatic (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e) A substantial proportion of both STIs and BV present without symptoms, especially in women and girls. When symptoms do occur, they are often non-specific and may not be perceived as abnormal, complicating case detection and clinical management (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e)\\u003c/p\\u003e\\u003cp\\u003eWHO has set ambitious targets aimed at reducing the global incidence of STIs by 2030, emphasizing the need to scale-up prevention and control measures, particularly in sub-Saharan Africa, which bears the highest burden worldwide(\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e) Progress towards these goals, however, remains challenging, in part due to limited diagnostic capacity in many low- and middle-income countries (LMICs). In addition, these targets do not encompass BV, despite its substantial global prevalence and comparable adverse effects on reproductive health outcomes to those of STIs (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e). In settings where syndromic management remains the standard of care its limitations are significant: it has low predictive value for discharge-causing STIs such as CT, NG, TV and for BV and it is unable to identify asymptomatic infections.(\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e) A recent meta-analysis estimated that 61% of CT, 53% of NG and 57% of TV infections in women from LMICs are asymptomatic, with even higher proportions among women in Africa (69%, 67%, and 65%, respectively) (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e). Estimates for asymptomatic BV range from 47% to 50% in LMICs, while studies in high income settings have found it to be above 80% (\\u003cspan additionalcitationids=\\\"CR6 CR7\\\" citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eBoth STIs and BV are known to induce genital inflammation in women, regardless of symptoms (\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e). Genital inflammation, in turn, is strongly associated with increased risk of HIV acquisition and adverse birth outcomes(\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e) This is particularly relevant in sub-Saharan Africa, where women are disproportionately affected by curable STIs and a substantial proportion of new HIV infections occur in women(\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e) However, progress in developing point-of-care (POC) rapid diagnostics for CT, NG, TV and BV that fulfil WHO\\u0026rsquo;s REASSURED criteria (including being affordable, rapid, equipment-free and deliverable to end-users) has been limited, leaving a critical gap in effective disease management(\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e) Affordable diagnostic tools capable of delivering same-day results remain a pressing research and program priority, as they are essential for enabling timely initiation of appropriate treatment and reducing onward transmission(\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e) To address this need, Masson and colleagues developed the Genital InFlammation Test (GIFT). GIFT is a rapid POC lateral flow assay detecting inflammatory biomarkers interleukin (IL)-1α, IL-1β, and interferon-γ-induced protein (IP)-10 from vaginal swabs and producing results in 15 minutes (\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e). By identifying genital inflammation, GIFT could facilitate the identification of women with asymptomatic STIs and BV and at elevated risk of HIV acquisition to strengthen sexual and reproductive health outcomes in settings where syndromic management is the norm.\\u003c/p\\u003e\\u003cp\\u003eThe GIFT study, a multicenter observational study conducted in South Africa, Zimbabwe, and Madagascar, evaluated the first-in-field prototype of the GIFT device. Its primary objective was to assess the sensitivity and specificity of GIFT for detecting asymptomatic, discharge-causing STIs (CT, NG, TV, \\u003cem\\u003eMycoplasma genitalium\\u003c/em\\u003e (MG)) and BV in women aged 18\\u0026ndash;35 years accessing family planning services, using nucleic acid amplification tests (NAATs) and Nugent scoring as reference standards (\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eA key objective of the larger GIFT study was to assess potential pathways for integration into family planning services, including a cost analysis of implementing GIFT screening in real-world clinical settings. An earlier study estimated the costs of GIFT screening for STIs and BV during family planning consultations in South Africa, based on a hypothetical prototype of the GIFT device that was still under development (\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e). Cost estimates were derived from three health facilities in Cape Town, including a government clinic, a non-governmental clinic, and a semi-private clinic. The incremental cost of incorporating GIFT screening for the detection of asymptomatic STIs and BV during family planning consultations was estimated between US \\u003cspan\\u003e$\\u003c/span\\u003e3.53 (government clinic) and US \\u003cspan\\u003e$\\u003c/span\\u003e5.32 (semi-private clinic) (2016 prices inflated to 2023). This included a device cost of US \\u003cspan\\u003e$\\u003c/span\\u003e0.30 based on manufacturer\\u0026rsquo;s price estimates of the GIFT (\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e)\\u003c/p\\u003e\\u003cp\\u003eThe primary aim of this study was to provide an updated estimate of the incremental cost of GIFT screening (testing of individuals who do not show symptoms to identify infections early and prevent transmission and complications) for STIs and BV in a real-world implementation setting, including South Africa and extending this analysis to Madagascar and Zimbabwe, based on evidence from the multicenter clinical observational GIFT device accuracy study (\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e).\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eStudy design\\u003c/h2\\u003e\\u003cp\\u003eA combined top-down and bottom-up costing approach was applied to estimate the incremental cost per woman, and per woman per year, screened for STIs and BV using GIFT as part of routine family planning services in the three study settings. Economic costs, including both capital and recurrent costs, were assessed from the provider perspective. All research-related study costs were excluded so that resource utilization reflects the most likely scenario of routine implementation of GIFT screening in a real-world setting.\\u003c/p\\u003e\\u003c/div\\u003e\\n\\u003ch3\\u003eStudy sites\\u003c/h3\\u003e\\n\\u003cp\\u003eThe GIFT study was conducted at three sites across the three countries. In Madagascar, the study site was the Centre Hospitalier Universitaire de Gyn\\u0026eacute;cologie et d\\u0026rsquo;Obst\\u0026eacute;trique de Befelatanana, a government university hospital in Antananarivo where family planning services are provided in a dedicated outpatient ward of the hospital. The Desmond Tutu Health Foundation (DTHF) Masiphumelele Youth Centre, a non-profit, donor-funded research center in Cape Town, was South Africa\\u0026rsquo;s study site. DTHF operates an on-site clinic where youth-friendly sexual and reproductive health (SRH) services, including STI management, are provided. Given that DTHF is a donor-funded clinic, to estimate costs that are more representative of a public health setting, cost and service utilization data on family planning services were obtained from the nearby government Masiphumelele clinic, a public health clinic offering integrated family planning and STI services. All data related to the clinical study were obtained from the DTHF clinical study site. In Zimbabwe, the study was conducted at the Spillhaus Family planning Centre, a public clinic in Harare offering integrated SRH services including family planning, STI management, HIV prevention and fertility services. Across all three countries and study sites, syndromic management of STIs and BV remains the standard of care.\\u003c/p\\u003e\\n\\u003ch3\\u003eData collection\\u003c/h3\\u003e\\n\\u003cp\\u003eCost and resource utilization data of family planning consultations were obtained from facility management at each of the health facilities using semi-structured interview tools. Time allocation of clinical personnel to family planning services was collected through self-reported timesheets over a two-week period per site. Similarly, information on the time and consumables required to conduct GIFT screening was collected using self-reported timesheets completed by GIFT study nurses at each study site. For the base-case analysis, the GIFT device was assigned a cost of US \\u003cspan\\u003e$\\u003c/span\\u003e5.00, reflecting the manufacturer\\u0026rsquo;s current best estimate of a potential market price.\\u003c/p\\u003e\\u003cp\\u003eWhere data were unavailable from the study sites, publicly accessible data sources or comparable data from similar study contexts were utilized (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cdiv id=\\\"Sec6\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eData Analysis\\u003c/h2\\u003e\\u003cp\\u003eData were analyzed using a costing model developed in Microsoft Excel 365. The total cost of family planning and incremental cost of GIFT screening were estimated at the facility level. The incremental cost of GIFT screening was divided by the total number of female patients attending the clinic in the 2023 fiscal year to estimate the incremental cost of GIFT screening per woman. The total cost per woman screened per year was calculated as the product of the incremental cost per woman screened and the number of family planning consultations per woman per year.\\u003c/p\\u003e\\u003cp\\u003eAll costs are presented in 2023 United States Dollars (US \\u003cspan\\u003e$\\u003c/span\\u003e). Costs were inflated to 2023 prices using locally published inflation data where required and converted to US \\u003cspan\\u003e$\\u003c/span\\u003e using the published average annual exchange rate for each country for the period 1 January 2023 to 31 December 2023 (US \\u003cspan\\u003e$\\u003c/span\\u003e1\\u0026thinsp;=\\u0026thinsp;Malagasy Ariary 4,454.62, US \\u003cspan\\u003e$\\u003c/span\\u003e1\\u0026thinsp;=\\u0026thinsp;South African Rand 18.46, US \\u003cspan\\u003e$\\u003c/span\\u003e1\\u0026thinsp;=\\u0026thinsp;Zimbabwean Dollar 3,680.52 (\\u003cspan additionalcitationids=\\\"CR20\\\" citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e)\\u003c/p\\u003e\\u003c/div\\u003e\\n\\u003ch3\\u003eMeasurement, valuation, and allocation of costs\\u003c/h3\\u003e\\n\\u003cp\\u003eCapital cost items included buildings, equipment, furniture, and provider training, while recurrent cost items comprised personnel, supplies, and overheads. Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e outlines the approach used to measure, value, and allocate these costs to GIFT screening consultations.\\u003c/p\\u003e\\u003cp\\u003eCapital cost utilization was measured using facility records and interviews with the GIFT study team, and valued using current replacement costs from facility data, market prices, or published sources. These costs were annualized using standard assumptions on useful life and a 3% discount rate (\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e). Recurrent cost utilization was primarily measured through self-reported timesheets and facility records. These costs were valued using government salary scales, market prices, and facility expenditure data.\\u003c/p\\u003e\\u003cp\\u003eIndirect and shared resources were allocated to the GIFT screening consultation using top-down approaches: Building costs were allocated according to the proportion of space used for family planning consultations, further apportioned to GIFT screening based on the share of direct personnel time devoted to GIFT as a proportion of total family planning consultation time; Equipment, furniture, indirect personnel, and overhead and maintenance costs were allocated in proportion to family planning consultations as a share of total outpatient visits. In Madagascar, hospital-wide shared costs (including overheads and maintenance) were allocated to family planning consultations based on the proportion of these visits relative to the total hospital service volume. To ensure comparability between service types, inpatient days were converted to outpatient-equivalent visits using WHO-CHOICE conversion factors (\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e) Direct resources, including GIFT provider training, direct personnel time, and medical and non-medical supplies, were allocated directly to GIFT screening.\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eMeasurement, valuation, and allocation of costs to GIFT screening\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"7\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c3\\\" namest=\\\"c2\\\"\\u003e\\u003cp\\u003eMeasurement\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c5\\\" namest=\\\"c4\\\"\\u003e\\u003cp\\u003eValuation\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c7\\\" namest=\\\"c6\\\"\\u003e\\u003cp\\u003eAllocation to GIFT screening\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eCost category\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eMethod\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eData source\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eMethod\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eData source\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eMethod\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eAllocation factor\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colspan=\\\"7\\\" nameend=\\\"c7\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eCapital cost items\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eBuildings\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e\\u003cp\\u003eSquare meters of space used for FP consultations\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e\\u003cp\\u003eObtained from facilities\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eCurrent replacement value (cost per m\\u003csup\\u003e2\\u003c/sup\\u003e)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e(\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e)*\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e\\u003cp\\u003eTop-down\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e\\u003cp\\u003eFP space as % of total facility space x \\u003cem\\u003eGIFT screening personnel time as % of total direct personnel time for FP\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eUseful life (20 years)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e(\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eDiscount rate (3%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e(\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eEquipment (medical \\u0026amp; non-medical) and furniture\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e\\u003cp\\u003eItems used for FP departments\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e\\u003cp\\u003eObtained from facilities**\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eCurrent replacement value\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003eHealth facility; market prices\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e\\u003cp\\u003eTop-down\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e\\u003cp\\u003eTotal FP consultations as % of total outpatient consultations x \\u003cem\\u003eGIFT screening as % of total direct personnel time for FP\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eUseful life (15 years for furniture, 5 years for equipment)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e(\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eDiscount rate (3%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e(\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eProvider training\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e\\u003cp\\u003eProvider time\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e\\u003cp\\u003eGIFT clinical study team\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eTotal annual renumeration\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003eGovernment salary scales\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e\\u003cp\\u003eBottom-up\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e\\u003cp\\u003eFully allocated to GIFT screening\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eUseful life (5 years)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e(\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eDiscount rate (3%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e(\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"7\\\" nameend=\\\"c7\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eRecurrent cost items\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eIndirect personnel\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eTime spent on FP- related support activities\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eSelf-reported timesheets\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eTotal annual renumeration\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003eGovernment salary scales\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003eTop-down\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003eTotal FP consultations as % of total outpatient consultations x \\u003cem\\u003eGIFT screening as % of total direct personnel time for FP\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eDirect personnel\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eTime spent on GIFT screening per study participant\\u003csup\\u003e\\u0026yen;\\u003c/sup\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eSelf-reported timesheets\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eTotal annual renumeration\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003eGovernment salary scales\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003eBottom-up\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003eDirect; based on reported utilization\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eMedical and non-medical supplies\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eSupplies used for to conduct a GIFT test\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eSelf-reported reports\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eUnit prices\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003eHealth facility; market prices\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003eBottom-up\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003eDirect; based on reported utilization\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eOverheads \\u0026amp; maintenance\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eApportioned usage\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eObtained from facilities**\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eTotal annual expenditure\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003eFacilities\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003eTop-down\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003eTotal FP consultations as % of total outpatient consultations x \\u003cem\\u003eGIFT screening as % of total direct personnel time for FP\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003ctfoot\\u003e\\u003ctr\\u003e\\u003ctd colspan=\\\"7\\\"\\u003eNote: FP\\u0026thinsp;=\\u0026thinsp;family planning; GIFT\\u0026thinsp;=\\u0026thinsp;Genital InFlammation Test;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tfoot\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003e*Source for the replacement value of the clinic in South Africa. In the absence of data for Madagascar and Zimbabwe, building costs were estimated by applying the proportion of building costs of total unit costs as in South Africa.\\u003c/p\\u003e\\u003cp\\u003e** In the absence of available data from the clinic in South Africa, information was sourced from Kairu et al. (2020) and adjusted to 2023 prices.\\u003c/p\\u003e\\u003cp\\u003e\\u003csup\\u003e\\u0026yen;\\u003c/sup\\u003eExcludes study-related activities such as explaining study procedures, obtaining consent, and collecting additional swabs.\\u003c/p\\u003e\\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eSensitivity analysis\\u003c/h2\\u003e\\u003cp\\u003eUnivariate sensitivity analysis was conducted to identify the most influential parameters on the results of the analysis. Model parameters were varied to \\u0026plusmn;\\u0026thinsp;30% of the base-case scenario. Results from this analysis are presented by means of tornado plots.\\u003c/p\\u003e\\u003c/div\\u003e\\n\\u003ch3\\u003eUncertainty analysis\\u003c/h3\\u003e\\n\\u003cp\\u003eGiven the small sample of this study, significant uncertainty existed around the base-case point estimates and the generalizability thereof to other settings within the same country. Parameter uncertainty was characterized using probabilistic sensitivity analysis (PSA) via Monte Carlo simulation with 1,000 iterations. Gamma or uniform distributions were assigned to cost input parameters, while lognormal or uniform distributions were applied to resource utilization parameters. The limited sample size in this study, both in terms of the number of facilities and the number of personnel from whom time estimates were collected, precluded the statistical calculation of means and 95% confidence intervals (CIs) for cost model parameters based on observed data. Consequently, base-case cost parameters primarily reflect single-point estimates or simple averages derived from the available observations (e.g., time measurements) or data collected from the facilities. Where possible, upper, and lower bounds for model parameters were derived from minimum and maximum values based on observed data; in the absence of empirical bounds, a\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;30% variation around the base-case estimate was assumed to parameterize the PSA model (\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e). Results from the PSA are presented as 95% CIs around the base-case point estimates.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eFacility and resource utilization, which informed the allocation of shared resources to family planning and ultimately GIFT screening, is presented in Table\\u0026nbsp;2. The proportion of family planning consultations relative to total outpatient visits varied substantially across sites, accounting for 16% in Madagascar, 12% in South Africa, and 88% in Zimbabwe. Across the three facilities, clinical personnel (nurses) spent 71%, 84% and 78% of their time on activities related to family planning services, respectively.\\u003c/p\\u003e\\n\\u003cp\\u003eIn the base-case analysis, each participant was assumed to attend four family planning consultations per year, reflecting an average utilization pattern of one clinic visit every three months.\\u003c/p\\u003e\\n\\u003cp\\u003eThe average time taken by nurses to perform a GIFT test (including explaining the test to the client, collecting the vaginal swab, mixing with buffer and applying it to the test device and reading and interpreting results) excluding research-specific activities and the 15-minute test incubation period, was 11.67 minutes across the three sites. This is slightly higher than the 10 minutes estimated by Kairu et al. (2022) (18). Due the small number of observations across study sites, the average time across observations from all three study sites was applied to the cost estimates for all sites. Incubation time of the GIFT device was excluded based on the assumption that clinical personnel would be able to carry out other routine family planning consultation tasks while waiting for test results. Incubation time for the GIFT device was excluded from the personnel time cost, based on the assumption that nurses could perform other routine family planning consultation tasks while awaiting test results.\\u003c/p\\u003e\\n\\u003cp\\u003eTable 3 presents the base-case unit cost estimates and the 95% CIs from the PSA. The incremental cost per woman screened with GIFT was estimated to be US $6.46 (US $1.98 \\u0026ndash; US $12.22) in Madagascar, US $9.05 (US $3.78 \\u0026ndash; US $15.83) in South Africa and US $8.28 (US $3.04 \\u0026ndash; US $16.52) Zimbabwe. Recurrent costs accounted for more than 98% of total unit costs in all three countries, with capital costs comprising the remainder. The GIFT device is the primary driver of the incremental cost of GIFT screening at an estimated unit price of US $5.00 (77% in Madagascar, 55% in South Africa and 60% in Zimbabwe). To reflect current uncertainty, a price range between US $1.00 and US $10.00 was applied for the device (refer to \\u003cem\\u003eSensitivity Analysis\\u003c/em\\u003e). The second biggest cost driver was medical supplies in Madagascar (15%), direct personnel in South Africa (30%), and indirect personnel in Zimbabwe (19%).\\u003c/p\\u003e\\n\\u003cp\\u003eDifferences in cost estimates between the three countries were driven by variations in price levels, particularly those related to human resources, as well as differences in the allocation factors of shared costs to family planning and, ultimately, to GIFT. In Zimbabwe, where 88% of facility costs were allocated to family planning the indirect staff costs attributed to GIFT were substantially higher than in the other countries. In contrast, in South Africa, where human resource costs were higher than in Madagascar and Zimbabwe, direct personnel costs were greater despite the same level of direct resource utilization being assumed for GIFT screening. For comparability, costs are also presented in international dollars in Supplementary Table 1.\\u003c/p\\u003e\\n\\u003cp\\u003eTable 2: Facility and resource utilization\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cimg 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\\\"\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003en/a: Not applicable\\u003c/p\\u003e\\n\\u003cp\\u003e*Minimum and maximum values represent +/-30% of reported parameters.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003csup\\u003e**\\u003c/sup\\u003eBased on the cadence of common contraceptive method, uncertainty ranges present likely minimum and maximum number of consultations per year per type of contraceptive method.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003csup\\u003e\\u0026alpha;\\u003c/sup\\u003eDue the small number of observations across study sites, the average time represents the average observations from across the three study sites. Incubation time of the GIFT device is excluded based on the assumption that clinical personnel would be able to carry out other routine family planning consultation tasks while waiting for test results.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003csup\\u003e\\u0026yen;\\u003c/sup\\u003e Minimum and maximum values from data collected.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ctable id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e\\n \\u003ccaption language=\\\"En\\\"\\u003e\\n \\u003cdiv\\u003eTable 3\\u003c/div\\u003e\\n \\u003cdiv\\u003e\\n \\u003cp\\u003eUnit cost results (2023 US $)\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\" rowspan=\\\"2\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMadagascar\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eSouth Africa\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eZimbabwe\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMadagascar\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eSouth Africa\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eZimbabwe\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\" colspan=\\\"3\\\"\\u003e\\n \\u003cp\\u003eIncremental cost per woman screened with GIFT, US $ (95% CI)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" colspan=\\\"3\\\"\\u003e\\n \\u003cp\\u003eIncremental cost per woman screened with GIFT, per year, US $ (95% CI)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\" colspan=\\\"7\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eCapital costs\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eBuildings\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.07\\u003c/p\\u003e\\n \\u003cp\\u003e(0.02\\u0026ndash;0.29)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.10\\u003c/p\\u003e\\n \\u003cp\\u003e(0.05\\u0026ndash;0.28)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.09\\u003c/p\\u003e\\n \\u003cp\\u003e(0.03\\u0026ndash;0.39)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.29\\u003c/p\\u003e\\n \\u003cp\\u003e(0.08\\u0026ndash;0.90)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.41\\u003c/p\\u003e\\n \\u003cp\\u003e(0.12\\u0026ndash;1.32)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.38\\u003c/p\\u003e\\n \\u003cp\\u003e(0.10\\u0026ndash;1.69)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eEquipment and furniture\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.003\\u003c/p\\u003e\\n \\u003cp\\u003e(0.001\\u0026ndash;0.007)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.001\\u003c/p\\u003e\\n \\u003cp\\u003e(0.0004\\u0026ndash;0.002)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.05\\u003c/p\\u003e\\n \\u003cp\\u003e(0.02\\u0026ndash;0.12)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.01\\u003c/p\\u003e\\n \\u003cp\\u003e(0.007\\u0026ndash;0.02)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.003\\u003c/p\\u003e\\n \\u003cp\\u003e(0.001\\u0026ndash;0.01)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.19\\u003c/p\\u003e\\n \\u003cp\\u003e(0.12\\u0026ndash;0.28)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eProcedure training\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.001\\u003c/p\\u003e\\n \\u003cp\\u003e(0.0007\\u0026ndash;0.002)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.01\\u003c/p\\u003e\\n \\u003cp\\u003e(0.01\\u0026ndash;0.02)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.01\\u003c/p\\u003e\\n \\u003cp\\u003e(0.004\\u0026ndash;0.01)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.004\\u003c/p\\u003e\\n \\u003cp\\u003e(0.002\\u0026ndash;0.01)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.05\\u003c/p\\u003e\\n \\u003cp\\u003e(0.02\\u0026ndash;0.10)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.03\\u003c/p\\u003e\\n \\u003cp\\u003e(0.01\\u0026ndash;0.05)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eTotal capital costs\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.08\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(0.02\\u0026ndash;0.29)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.12\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(0.06\\u0026ndash;0.30)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.15\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(0.06\\u0026ndash;0.52)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.31\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(0.09\\u0026ndash;0.93)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.47\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(0.13\\u0026ndash;1.42)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.59\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(0.23\\u0026ndash;2.02)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"7\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRecurrent costs\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eIndirect personnel\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.08\\u003c/p\\u003e\\n \\u003cp\\u003e(0.04\\u0026ndash;0.19)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.26\\u003c/p\\u003e\\n \\u003cp\\u003e(0.14\\u0026ndash;0.60)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.57\\u003c/p\\u003e\\n \\u003cp\\u003e(0.87\\u0026ndash;3.80)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.31\\u003c/p\\u003e\\n \\u003cp\\u003e(0.23\\u0026ndash;0.42)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.04\\u003c/p\\u003e\\n \\u003cp\\u003e(0.34\\u0026ndash;3.04)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e6.24\\u003c/p\\u003e\\n \\u003cp\\u003e(4.70\\u0026ndash;8.66)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eDirect personnel\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.32\\u003c/p\\u003e\\n \\u003cp\\u003e(0.22\\u0026ndash;0.44)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e2.67\\u003c/p\\u003e\\n \\u003cp\\u003e(1.87\\u0026ndash;3.55)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.49\\u003c/p\\u003e\\n \\u003cp\\u003e(0.12\\u0026ndash;0.68)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.26\\u003c/p\\u003e\\n \\u003cp\\u003e(0.51\\u0026ndash;2.30)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e10.68\\u003c/p\\u003e\\n \\u003cp\\u003e(4.45\\u0026ndash;18.90)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.94\\u003c/p\\u003e\\n \\u003cp\\u003e(0.81\\u0026ndash;3.65)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMedical supplies\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.99\\u003c/p\\u003e\\n \\u003cp\\u003e(0.70\\u0026ndash;1.30)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.99\\u003c/p\\u003e\\n \\u003cp\\u003e(0.71\\u0026ndash;1.33)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.99\\u003c/p\\u003e\\n \\u003cp\\u003e(0.71\\u0026ndash;1.29)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e3.95\\u003c/p\\u003e\\n \\u003cp\\u003e(1.60\\u0026ndash; 7.10)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e3.95\\u003c/p\\u003e\\n \\u003cp\\u003e(1.64\\u0026ndash;7.16)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e3.95\\u003c/p\\u003e\\n \\u003cp\\u003e(1.68\\u0026ndash;7.15)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eGIFT device\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e5.00\\u003c/p\\u003e\\n \\u003cp\\u003e(1.00\\u0026ndash;10.00)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e5.00\\u003c/p\\u003e\\n \\u003cp\\u003e(1.00\\u0026ndash;10.00)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e5.00\\u003c/p\\u003e\\n \\u003cp\\u003e(1.00\\u0026ndash;10.00)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e20.00\\u003c/p\\u003e\\n \\u003cp\\u003e(3.00\\u0026ndash;54.00)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e20.00\\u003c/p\\u003e\\n \\u003cp\\u003e(3.00\\u0026ndash;54.00)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e20.00\\u003c/p\\u003e\\n \\u003cp\\u003e(2.00\\u0026ndash;54.00)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eOverheads and maintenance\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.0005\\u003c/p\\u003e\\n \\u003cp\\u003e(0.0002\\u0026ndash;0.001)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.02\\u003c/p\\u003e\\n \\u003cp\\u003e(0.01\\u0026ndash;0.04)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.09\\u003c/p\\u003e\\n \\u003cp\\u003e(0.04\\u0026ndash;0.24)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.002\\u003c/p\\u003e\\n \\u003cp\\u003e(0.001\\u0026ndash;0.003)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.07\\u003c/p\\u003e\\n \\u003cp\\u003e(0.02\\u0026ndash;0.22)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.38\\u003c/p\\u003e\\n \\u003cp\\u003e(0.24\\u0026ndash;0.57)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eTotal recurrent costs\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e6.38\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(1.96\\u0026ndash;11.92)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e8.93\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(3.72\\u0026ndash;15.53)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e8.13\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(2.98\\u0026ndash;16.00)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e25.52\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(5.33\\u0026ndash;63.82)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e35.73\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(9.46\\u0026ndash;83.31)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e32.54\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(9.44\\u0026ndash;74.03)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eTotal costs\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e6.46\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(1.98\\u0026ndash;12.22)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e9.05\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(3.78\\u0026ndash;15.83)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e8.28\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(3.04\\u0026ndash;16.52)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e25.83\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(5.42\\u0026ndash;64.75)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e36.20\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(9.60\\u0026ndash;84.73)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e33.13\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(9.67\\u0026ndash;74.03)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eTotal cost, excluding GIFT device\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e1.46\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(0.98\\u0026ndash;2.22)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e4.05\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(2.78\\u0026ndash;5.83)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e3.28\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(2.04\\u0026ndash;6.52)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e5.83\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(2.83\\u0026ndash;10.75)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e16.20\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(6.60\\u0026ndash;30.73)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e13.13\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(6.60\\u0026ndash;20.03)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003eThe incremental cost per woman screened per year, assuming routine screening at each of four family planning visits, was estimated to be US $25.83 (US $5.42 \\u0026ndash; US $64.75) in Madagascar, US $36.20 (US $9.60 \\u0026ndash; US $84.73) in South Africa and US $33.13 (US $9.67 \\u0026ndash; US $74.03) in Zimbabwe.\\u003c/p\\u003e\\n\\u003cdiv id=\\\"Sec11\\\"\\u003e\\n \\u003ch2\\u003eSensitivity analysis\\u003c/h2\\u003e\\n \\u003cp\\u003eFigure 1 shows the results from the univariate sensitivity analysis where model parameters were varied with \\u0026plusmn;\\u0026thinsp;30%. Across the three countries, a change in the GIFT device price resulted in the greatest change in unit cost, with a\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;30% change resulting in a\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;23%, \\u0026plusmn;\\u0026thinsp;17% and \\u0026plusmn;\\u0026thinsp;16% change in the incremental cost per woman screened in Madagascar, South Africa and Zimbabwe, respectively. The second most influential parameter was the time required to administer the GIFT device in Madagascar and South Africa, and the number of family planning consultants per woman, per year in Zimbabwe. The inverse relationship between the number of family planning consultations per woman per year and the cost of GIFT screening suggests that economies of scale could be realized by distributing fixed costs across a larger number of services, albeit relatively modest.\\u003c/p\\u003e\\n\\u003c/div\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis study provides a multi-country cost analysis of implementing GIFT, a rapid POC test for genital inflammation, or other similar tests, as a screening tool within routine family planning services in Madagascar, South Africa, and Zimbabwe. The use of empirical data from three distinct LMICs settings enhances the relevance of the findings for similar contexts. The incorporation of PSA allows for the quantification of uncertainty around point estimates, reflecting the inherent variability in cost parameters, especially given the small sample size of health facilities.\\u003c/p\\u003e\\u003cp\\u003eThe PSA results indicate a wide range of unit costs, largely attributable to the limited number of facilities sampled and uncertainty regarding the future market price of the GIFT device. As the device cost is the main driver of total implementation costs in our analysis, the overall affordability and scalability of GIFT screening will depend largely on its eventual market price; a critical consideration for implementation in LMIC settings. In the base case analysis, the device price was assumed to be US \\u003cspan\\u003e$\\u003c/span\\u003e5.00. However, the final market price will ultimately depend on the device\\u0026rsquo;s components and where they are manufactured.\\u003c/p\\u003e\\u003cp\\u003eExcluding the cost of the device, estimated screening costs varied from US \\u003cspan\\u003e$\\u003c/span\\u003e1.46 (US \\u003cspan\\u003e$\\u003c/span\\u003e0.98 \\u0026ndash; US \\u003cspan\\u003e$\\u003c/span\\u003e2.22) in Madagascar, US \\u003cspan\\u003e$\\u003c/span\\u003e4.05 (US \\u003cspan\\u003e$\\u003c/span\\u003e2.78 \\u0026ndash; US \\u003cspan\\u003e$\\u003c/span\\u003e5.83) in South Africa, and US \\u003cspan\\u003e$\\u003c/span\\u003e3.28 (US \\u003cspan\\u003e$\\u003c/span\\u003e2.04 \\u0026ndash; US \\u003cspan\\u003e$\\u003c/span\\u003e6.52) in Zimbabwe. The estimates for South Africa are slightly higher than the inflation-adjusted results reported by Kairu et al. (2022) for a government clinic (US \\u003cspan\\u003e$\\u003c/span\\u003e3.23, excluding device price), although they fall within the uncertainty range of the present analysis (\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e). The observed differences are primarily attributable to variations in human resource utilization. Overall cost estimates, including the device, were higher in our analysis largely because of the increased device price assumed, based on more recent manufacturer estimates.\\u003c/p\\u003e\\u003cp\\u003eThe findings have implications for policy and future research as a unit price of US \\u003cspan\\u003e$\\u003c/span\\u003e5.00 for the GIFT device, and overall implementation cost of US \\u003cspan\\u003e$\\u003c/span\\u003e6.46 in Madagascar, US \\u003cspan\\u003e$\\u003c/span\\u003e9.05 in South Africa and US \\u003cspan\\u003e$\\u003c/span\\u003e8.28 in Zimbabwe, may present an affordability challenge.\\u003c/p\\u003e\\u003cp\\u003eEvidence on the costs of STI screening using POC tests in LMICs, including in Sub-Saharan Africa, remains limited and largely focused on HIV and syphilis. This is likely due to the lack of affordable and effective POC diagnostic tests for other STIs, including CT, TV and NG, and prevailing guidance to use syndromic management in these settings. To our knowledge, no published data currently exist on the cost of CT, NG, or TV screening using rapid POC tests in Africa or other LMICs. For context, a systematic review estimated the mean cost of facility-based HIV testing using rapid POC tests in Sub-Saharan Africa at US\\u003cspan\\u003e$\\u003c/span\\u003e19.63 per person tested (including post-test counselling), although self-testing approaches have achieved lower costs (US\\u003cspan\\u003e$\\u003c/span\\u003e12.75 per person tested) (\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e). Facility-based antenatal syphilis screening using rapid POC tests has been estimated at approximately US\\u003cspan\\u003e$\\u003c/span\\u003e1.00\\u0026ndash;4.00 per woman screened, with staff time and supplies, including the device itself, typically costing less than US\\u003cspan\\u003e$\\u003c/span\\u003e1.00, constituting the main cost drivers. When considering scale-up, screening or testing volumes are an important consideration, as higher volumes allow for economies of scale by spreading fixed costs such as training, start-up activities, facility operations, program supervision, and quality assurance, over a larger number of tests (\\u003cspan additionalcitationids=\\\"CR30 CR31 CR32 CR33 CR34 CR35 CR36 CR37\\\" citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eOverall, these findings suggest that GIFT screening compares favorably with facility-based HIV testing and self-testing, though generally higher than antenatal syphilis screening. If device costs can be reduced and economies of scale achieved through scaled-up implementation, GIFT screening could represent an economically viable and feasible STI screening strategy in LMICs, with the potential to improve early detection and sexual and reproductive health outcomes. However, these cost considerations, must be interpreted alongside evidence of the device\\u0026rsquo;s effectiveness and subsequent impact on health outcomes.\\u003c/p\\u003e\\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eLimitations\\u003c/h2\\u003e\\u003cp\\u003eThis study has several limitations. First, data were collected from a single facility per country, which may not be representative of all public health facilities, limiting generalizability. Second, time allocation data relied on self-reported timesheets, which are subject to recall or reporting bias. Third, the US \\u003cspan\\u003e$\\u003c/span\\u003e5.00 cost of the GIFT device is a manufacturer\\u0026rsquo;s estimate, and the final market price could differ, substantially impacting overall and relative costs. Fourth, where facility-specific data were unavailable, costs were imputed using published sources or proportional estimates from other sites, such as building costs in Madagascar and Zimbabwe, which may not fully reflect local conditions. Finally, this analysis did not include the costs of confirmatory testing for STIs and BV, which would form a key component of the management of STIs and BV following positive GIFT test results.\\u003c/p\\u003e\\u003c/div\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eThis cost analysis demonstrates that incorporating GIFT screening into routine family planning services costs between US \\u003cspan\\u003e$\\u003c/span\\u003e6.46 and US \\u003cspan\\u003e$\\u003c/span\\u003e9.05 per test across settings in Madagascar, South Africa, and Zimbabwe. The cost of the device itself is the predominant cost driver, underscoring that the affordability of this novel POC technology will be central to its potential for widespread adoption. These findings provide essential evidence for the broader economic evaluation of implementing GIFT as a screening tool for STIs and BV in LMICs.\\u003c/p\\u003e\\u003cp\\u003eWhile this study provides a quantitative assessment of the economic costs associated with GIFT implementation, a comprehensive policy and research perspective requires integrating these cost data with evidence on clinical effectiveness from the ongoing GIFT study. Emerging results on cost-effectiveness, affordability, and acceptability will be essential to guide the design of implementation strategies, such as optimizing screening frequency or targeting high-risk sub-populations, to maximize health benefits within existing resource constraints.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cp\\u003eAGYW \\u0026ndash; Adolescent Girls and Young Women\\u003c/p\\u003e\\n\\u003cp\\u003eBV \\u0026ndash; Bacterial Vaginosis\\u003c/p\\u003e\\n\\u003cp\\u003eCI \\u0026ndash; Confidence Interval\\u003c/p\\u003e\\n\\u003cp\\u003eCT \\u0026ndash; \\u003cem\\u003eChlamydia trachomatis\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eDTHF \\u0026ndash; Desmond Tutu Health Foundation\\u003c/p\\u003e\\n\\u003cp\\u003eFP \\u0026ndash; Family Planning\\u003c/p\\u003e\\n\\u003cp\\u003eGIFT \\u0026ndash; Genital InFlammation Test\\u003c/p\\u003e\\n\\u003cp\\u003eHIV \\u0026ndash; Human Immunodeficiency Virus\\u003c/p\\u003e\\n\\u003cp\\u003eIL-1\\u0026alpha; / IL-1\\u0026beta; \\u0026ndash; Interleukin-1 alpha / Interleukin-1 beta\\u003c/p\\u003e\\n\\u003cp\\u003eIP-10 \\u0026ndash; Interferon gamma-induced protein 10\\u003c/p\\u003e\\n\\u003cp\\u003eLMICs \\u0026ndash; Low- and Middle-Income Countries\\u003c/p\\u003e\\n\\u003cp\\u003eMG \\u0026ndash; \\u003cem\\u003eMycoplasma genitalium\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eMGA \\u0026ndash; Malagasy Ariary (currency)\\u003c/p\\u003e\\n\\u003cp\\u003eNAATs \\u0026ndash; Nucleic Acid Amplification Tests\\u003c/p\\u003e\\n\\u003cp\\u003eNG \\u0026ndash; \\u003cem\\u003eNeisseria gonorrhoeae\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003ePOC \\u0026ndash; Point-of-Care\\u003c/p\\u003e\\n\\u003cp\\u003ePSA \\u0026ndash; Probabilistic Sensitivity Analysis\\u003c/p\\u003e\\n\\u003cp\\u003eSRH \\u0026ndash; Sexual and Reproductive Health\\u003c/p\\u003e\\n\\u003cp\\u003eSTI\\u0026ndash; Sexually Transmitted Infection\\u003c/p\\u003e\\n\\u003cp\\u003eTV \\u0026ndash; \\u003cem\\u003eTrichomonas vaginalis\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eUS$ \\u0026ndash; United States Dollar\\u003c/p\\u003e\\n\\u003cp\\u003eWHO \\u0026ndash; World Health Organization\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eEthical approval for this study was granted by the following research ethics committees: Human Research Ethics Committee, University of Cape Town (UCT) (Ref: 366/2022 and 173/2023), Observation/Intervention Research Ethics Committee, London School of Hygiene \\u0026amp; Tropical Medicine (Ref: 28046), Minist\\u0026egrave;re de la Sant\\u0026eacute; Publique (Ref: 64-MSANP/SG/AMM/CNPN/CERMB), Research Council of Zimbabwe (Ref: 04768), City Health, City of Cape Town (Ref: 9870). The study was conducted in compliance with the Declaration of Helsinki (2013). Informed consent for the costing study was waived as the research involved the analysis of fully de-identified data with minimal risk to participants.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of data and materials\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eResearch generated in this study is available upon reasonable request from the corresponding author.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting Interests\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eJo-Ann Passmore and Lindi Masson are co-inventors on a patent related to the combination of three inflammatory biomarkers (IL-1\\u0026alpha;, IL-1\\u0026beta;, and IP-10) used in the GIFT diagnostic assay for genital inflammation (South African Patent No. 2016/03606 and European Patent No. 14809984.9). Both inventors declare that while this intellectual property is related to the biomarker combination evaluated in the current study, neither they nor their institutions currently receive personal financial benefits from the patent.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp;\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis research was funded under the European and Developing Countries Clinical Trials Partnership (EDCTP) (grant number RIA2020I-3297).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors\\u0026apos; contributions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eE. Smith (ESm) drafted the main manuscript and, together with E. Sinanovic (ESi), led the conceptualisation and design of the study. AH, TM, VR, TMG, and KG supported and facilitated data collection. ESm conducted the data analysis. ESi, EHE, KG, LM, and JAP contributed to the interpretation of the findings. All authors reviewed and approved the final manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgements\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable\\u003c/p\\u003e\\n\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eWorld Health Organization. Global progress report on HIV, viral hepatitis and sexually transmitted infections, 2021: accountability for the global health sector strategies 2016\\u0026ndash;2021: actions for impact [Internet]. 2021 [cited 2025 Aug 31]. Available from: https://iris.who.int/handle/10665/341412\\u003c/li\\u003e\\n\\u003cli\\u003eWorld Health Organization. Recommendations for the treatment of Trichomonas vaginalis, Mycoplasma genitalium, Candida albicans, bacterial vaginosis and human papillomavirus (anogenital warts). Geneva; 2024. \\u003c/li\\u003e\\n\\u003cli\\u003eMichalow J, Hall L, Rowley J, Anderson RL, Hayre Q, Chico RM, et al. Prevalence of chlamydia, gonorrhoea, and trichomoniasis among male and female general populations in sub-Saharan Africa from 2000 to 2024: a systematic review and meta-regression analysis. EClinicalMedicine. 2025 May 1;83. \\u003c/li\\u003e\\n\\u003cli\\u003eFortas C, Delarocque-Astagneau E, Randremanana RV, Crucitti T, Huynh BT. Asymptomatic infections with Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis among women in low- and middle-income countries: A systematic review and meta-analysis. PLOS Global Public Health. 2024 May 1;4(5). \\u003c/li\\u003e\\n\\u003cli\\u003eJoyisa N, Moodley D, Nkosi T, Talakgale R, Sebitloane M, Naidoo M, et al. Asymptomatic Bacterial Vaginosis in Pregnancy and Missed Opportunities for Treatment: A Cross-Sectional Observational Study. Infect Dis Obstet Gynecol. 2019; \\u003c/li\\u003e\\n\\u003cli\\u003eRajalakshmi R, Kalaivani S. Prevalence of asymptomatic infections in sexually transmitted diseases attendees diagnosed with bacterial vaginosis, vaginal candidiasis, and trichomoniasis. Indian J Sex Transm Dis. 2016 Jul 1;37(2):139\\u0026ndash;42. \\u003c/li\\u003e\\n\\u003cli\\u003eSherrard J, Wilson J, Donders G, Mendling W, Jensen JS. 2018 European (IUSTI/WHO) International Union against sexually transmitted infections (IUSTI) World Health Organisation (WHO) guideline on the management of vaginal discharge. Int J STD AIDS. 2018 Nov 1;29(13):1258\\u0026ndash;72. \\u003c/li\\u003e\\n\\u003cli\\u003eKoumans EH, Sternberg M, Bruce C, McQuillan G, Kendrick J, Sutton M, et al. 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Immunity. 2017 Jan 17;46(1):29\\u0026ndash;37. \\u003c/li\\u003e\\n\\u003cli\\u003eMasson L, Passmore JAS, Liebenberg LJ, Werner L, Baxter C, Arnold KB, et al. Genital Inflammation and the Risk of HIV Acquisition in Women. Clinical Infectious Diseases. 2015;61(2):260\\u0026ndash;9. \\u003c/li\\u003e\\n\\u003cli\\u003eNg PY, Ireland DJ, Keelan JA. Drugs to block cytokine signaling for the prevention and treatment of inflammation induced preterm birth. Front Immunol. 2015;6(MAR). \\u003c/li\\u003e\\n\\u003cli\\u003eRamboarina S, Crucitti T, Gill K, Bekker LG, Harding-Esch EM, van de Wijgert JHHM, et al. Novel point-of-care cytokine biomarker lateral flow test for the screening for sexually transmitted infections and bacterial vaginosis: study protocol of a multicentre multidisciplinary prospective observational clinical study to evaluate the performance and feasibility of the Genital InFlammation Test (GIFT). BMJ Open. 2024 May 1;14(5). \\u003c/li\\u003e\\n\\u003cli\\u003eLand KJ, Boeras DI, Chen XS, Ramsay AR, Peeling RW. REASSURED diagnostics to inform disease control strategies, strengthen health systems and improve patient outcomes. Vol. 4, Nature Microbiology. Nature Publishing Group; 2019. p. 46\\u0026ndash;54. \\u003c/li\\u003e\\n\\u003cli\\u003eUnemo M, Cole M, Lewis D, Ndowa F, Van Der Pol B, Wi T. Laboratory and point-of-care diagnostic testing for sexually transmitted infections, including HIV [Internet]. Geneva: World Health Organization; 2023. Available from: https://www.who.int/publications/book-orders.\\u003c/li\\u003e\\n\\u003cli\\u003eVerwijs MC, Agaba SK, Sumanyi JC, Umulisa MM, Mwambarangwe L, Musengamana V, et al. Targeted point-of-care testing compared with syndromic management of urogenital infections in women (WISH): a cross-sectional screening and diagnostic accuracy study. Lancet Infect Dis [Internet]. 2019;19(6):658\\u0026ndash;69. Available from: http://dx.doi.org/10.1016/S1473-3099(18)30724-2\\u003c/li\\u003e\\n\\u003cli\\u003eGarrett N, Mtshali A, Osman F, Masson L, Mckinnon LR, Singh R, et al. Impact of point-of-care testing and treatment of sexually transmitted infections and bacterial vaginosis on genital tract inflammatory cytokines in a cohort of young South African women. Sex Transm Infect. 2021 Dec 1;97(8):555\\u0026ndash;65. \\u003c/li\\u003e\\n\\u003cli\\u003eKairu A, Masson L, Passmore JAS, Cunnama L, Sinanovic E. Rapid Point-of-Care Testing for Genital Tract Inflammatory Cytokine Biomarkers to Diagnose Asymptomatic Sexually Transmitted Infections and Bacterial Vaginosis in Women: Cost Estimation and Budget Impact Analysis. Sex Transm Dis. 2022;49(3):237\\u0026ndash;43. \\u003c/li\\u003e\\n\\u003cli\\u003eXE. USD to MGA currency chart [Internet]. [cited 2024 Jun 7]. Available from: https://www.xe.com/currencycharts/?from=USD\\u0026amp;to=MGA\\u003c/li\\u003e\\n\\u003cli\\u003eSouth African Reserve Bank. Selected Historical Rates. In Key statistics. [Internet]. 2024 [cited 2024 Jun 7]. Available from: https://www.resbank.co.za/en/home/what-we-do/statistics/key-statistics/selected-historical-rates\\u003c/li\\u003e\\n\\u003cli\\u003eReserve Bank of Zimbabwe. Quarterly economic review: December 2023 (Q4 2023). Harare, Zimbabwe; 2023. \\u003c/li\\u003e\\n\\u003cli\\u003eVassall A, Sweeney S, Kahn JG, Gomez GB, Bollinger L, Marseille E, et al. Reference Case for Estimating the Costs of Global Health Services and Interventions [Internet]. 2017. Available from: https://ghcosting.org/pages/standards/reference_case\\u003c/li\\u003e\\n\\u003cli\\u003eWorld Health Organization. WHO-CHOICE estimates of cost for inpatient and outpatient health service delivery. 2021. \\u003c/li\\u003e\\n\\u003cli\\u003eIUSS Cost Committee. Clinic, CDC and CHC Maintenance OoM Estimator [Internet]. 2021 [cited 2024 Mar 10]. Available from: https://www.ukesa.info/library/view/estimators-for-infrastructure-cost-of-health-facilities2\\u003c/li\\u003e\\n\\u003cli\\u003eDrummond MF, Sculpher MJ, Claxton K, Stoddart GL, Torrance GW. Methods for the economic evaluation of health care programmes. Oxford University Press; 2015. \\u003c/li\\u003e\\n\\u003cli\\u003eWalker D, Kumaranayake L. Introduction: costs over time How to do (or not to do). .. Allowing for differential timing in cost analyses: discounting and annualization. 2002. \\u003c/li\\u003e\\n\\u003cli\\u003eBriggs AH, Weinstein MC, Fenwick EAL, Karnon J, Sculpher MJ, Paltiel AD. Model parameter estimation and uncertainty: A report of the ISPOR-SMDM modeling good research practices task force-6. Value in Health. 2012 Sep;15(6):835\\u0026ndash;42. \\u003c/li\\u003e\\n\\u003cli\\u003eAhmed N, Ong JJ, McGee K, d\\u0026rsquo;Elb\\u0026eacute;e M, Johnson C, Cambiano V, et al. Costs of HIV testing services in sub-Saharan Africa: a systematic literature review. Vol. 22, BMC Infectious Diseases. BioMed Central Ltd; 2022. \\u003c/li\\u003e\\n\\u003cli\\u003eRomoren M, Sundby J, Velauthapillai M, Rahman M, Klouman E, Hjortdahl P. Chlamydia and gonorrhoea in pregnant Batswana women: Time to discard the syndromic approach? BMC Infect Dis. 2007 Apr 16;7. \\u003c/li\\u003e\\n\\u003cli\\u003eBlandford JM, Gift TL, Vasaikar S, Mwesigwa-Kayongo D, Dlali P, Bronzan RN. Cost-effectiveness of on-site antenatal screening to prevent congenital syphilis in rural Eastern Cape Province, Republic of South Africa. Sex Transm Dis. 2007 Jul;34(7 SUPPL.). \\u003c/li\\u003e\\n\\u003cli\\u003eLevin CE, Steele M, Atherly D, Garc\\u0026iacute;a SG, Tinajeros F, Revollo R, et al. Analysis of the operational costs of using rapid syphilis tests for the detection of maternal syphilis in Bolivia and Mozambique. Sex Transm Dis. 2007;34(7 SUPPL.). \\u003c/li\\u003e\\n\\u003cli\\u003eShelley KD, Ansbro \\u0026Eacute;M, Ncube AT, Sweeney S, Fleischer C, Mumba GT, et al. Scaling down to scale up: A health economic analysis of integrating point-of-care syphilis testing into antenatal care in Zambia during pilot and national rollout implementation. PLoS One. 2015 May 13;10(5). \\u003c/li\\u003e\\n\\u003cli\\u003eRydzak CE, Goldie SJ. Cost-effectiveness of rapid point-of-care prenatal syphilis screening in sub-Saharan Africa. Sex Transm Dis. 2008 Sep;35(9):775\\u0026ndash;84. \\u003c/li\\u003e\\n\\u003cli\\u003eLarson BA, Lembela-Bwalya D, Bonawitz R, Hammond EE, Thea DM, HerlihyJulie H. Finding a Needle in the Haystack: The costs and cost-effectiveness of syphilis diagnosis and treatment during pregnancy to prevent congenital syphilis in Kalomo District of Zambia. PLoS One. 2014 Dec 5;9(12). \\u003c/li\\u003e\\n\\u003cli\\u003eSweeney S, Mosha JF, Terris-Prestholt F, Sollis KA, Kelly H, Changalucha J, et al. The costs of accessible quality assured syphilis diagnostics: Informing quality systems for rapid syphilis tests in a Tanzanian setting. Health Policy Plan. 2014;29(5):633\\u0026ndash;41. \\u003c/li\\u003e\\n\\u003cli\\u003eVickerman P, Peeling RW, Terris-Prestholt F, Changalucha J, Mabey D, Watson-Jones D, et al. Modelling the cost-effectiveness of introducing rapid syphilis tests into an antenatal syphilis screening programme in Mwanza, Tanzania. Sex Transm Infect. 2006 Dec;82(SUPPL. 5). \\u003c/li\\u003e\\n\\u003cli\\u003eBristow CC, Larson E, Anderson LJ, Klausner JD. Cost-effectiveness of HIV and syphilis antenatal screening: A modelling study. Sex Transm Infect. 2016 Aug 1;92(5):340\\u0026ndash;6. \\u003c/li\\u003e\\n\\u003cli\\u003eTerris-Prestholt F, Vickerman P, Torres-Rueda S, Santesso N, Sweeney S, Mallma P, et al. The cost-effectiveness of 10 antenatal syphilis screening and treatment approaches in Peru, Tanzania, and Zambia. International Journal of Gynecology and Obstetrics. 2015 Jun 1;130(S1):S73\\u0026ndash;80. \\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-womens-health\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bmwh\",\"sideBox\":\"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/bmwh/default.aspx\",\"title\":\"BMC Women's Health\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Sexually transmitted infections, Bacterial vaginosis, Screening, Genital inflammation, Point-of-care testing, Cost analysis, Women's health, Sub-Saharan Africa\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8120784/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8120784/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cb\\u003eBackground\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eSexually transmitted infections (STIs) and bacterial vaginosis (BV) are significant public health issues, particularly in sub-Saharan Africa, and are associated with genital inflammation and increased HIV acquisition risk. A substantial proportion of these infections are asymptomatic, limiting the effectiveness of a syndromic approach. The Genital InFlammation Test (GIFT), a rapid point-of-care (POC) test, was developed to detect increases in inflammatory biomarkers associated with genital inflammation. The first-in-field prototype of the GIFT device was evaluated in a multicenter observational study conducted in South Africa, Zimbabwe, and Madagascar. While previous cost estimates for a hypothetical GIFT prototype exist for South Africa, this study provides an updated, real-world cost analysis of implementing GIFT screening within routine family planning services in South Africa and extends this analysis to Madagascar and Zimbabwe.\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eMethods\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eA provider-perspective, combining a top-down and bottom-up costing approach, was conducted at device evaluation observational study sites in Madagascar, South Africa, and Zimbabwe. Economic costs, including capital and recurrent expenditures, were collected through facility records, interviews, and self-reported provider timesheets to determine the incremental cost of integrating GIFT screening into family planning consultations. Research-related costs were excluded. A probabilistic sensitivity analysis using Monte Carlo simulation was performed to address parameter uncertainty, particularly around GIFT\\u0026rsquo;s estimated market price of US\\u003cspan\\u003e$\\u003c/span\\u003e5.00.\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eResults\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eThe incremental cost per woman screened with GIFT was estimated to be US \\u003cspan\\u003e$\\u003c/span\\u003e6.46 (95% CI: US \\u003cspan\\u003e$\\u003c/span\\u003e1.98 \\u0026ndash; US \\u003cspan\\u003e$\\u003c/span\\u003e12.22) in Madagascar, US \\u003cspan\\u003e$\\u003c/span\\u003e9.05 (95% CI: US \\u003cspan\\u003e$\\u003c/span\\u003e3.78 \\u0026ndash; US \\u003cspan\\u003e$\\u003c/span\\u003e15.83) in South Africa, and US \\u003cspan\\u003e$\\u003c/span\\u003e8.28 (95% CI: US \\u003cspan\\u003e$\\u003c/span\\u003e3.04 \\u0026ndash; US \\u003cspan\\u003e$\\u003c/span\\u003e16.52) in Zimbabwe. Recurrent costs (personnel, supplies, and overheads) constituted more than 98% of this cost, with the GIFT device being the primary cost driver.\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eConclusions\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eThis analysis suggests that the affordability and potential scale-up of GIFT and other novel POC screening tools will depend heavily on their final market price. The findings provide critical economic evidence to inform the broader adoption of GIFT into routine practice, including cost-effectiveness, affordability, and optimal strategies for its integration into sexual and reproductive healthcare services in low- and middle-income countries.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Cost analysis of genital inflammation screening as a predictor of sexually transmitted infections and bacterial vaginosis in women: evidence from the GIFT study in Madagascar, South Africa, and Zimbabwe\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-11-28 12:09:45\",\"doi\":\"10.21203/rs.3.rs-8120784/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2025-12-23T09:41:33+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-12-21T07:43:34+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-12-15T18:21:15+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"133275361695121842868406383964673825898\",\"date\":\"2025-12-12T06:42:47+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-12-10T00:45:59+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"268591940192555200949261557309481637967\",\"date\":\"2025-12-01T10:43:19+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"166286326674915228392583279364497126739\",\"date\":\"2025-11-25T15:02:47+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2025-11-25T00:41:42+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-11-20T05:01:23+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-11-19T14:11:27+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Women's Health\",\"date\":\"2025-11-19T14:08:21+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-womens-health\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bmwh\",\"sideBox\":\"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/bmwh/default.aspx\",\"title\":\"BMC Women's Health\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"8b4db2c9-8234-4e52-b8c7-58257c4495ad\",\"owner\":[],\"postedDate\":\"November 28th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-03-24T09:39:03+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-11-28 12:09:45\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8120784\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8120784\",\"identity\":\"rs-8120784\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}