Background The burden of congenital syphilis remains high in many low-income countries, despite the availability of preventive therapy. Rapid syphilis tests (RSTs) could improve access to and cost-effectiveness of syphilis screening programs in low resource settings. The objective of this study was to inform programs how best to use RSTs based on relative efficiency, cost-effectiveness and access considerations.

Methods Incremental costs for RST screening in existing antenatal care settings in Tanzania were collected from nine health facilities varying in size, remoteness, and scope of services provided. The number of DALYs averted was modelled from project outputs. Economic costs per: woman tested, treated, and DALY were calculated for each facility. A sensitivity analysis was constructed to determine the impact of parameter and model uncertainty.

Results In surveyed facilities a total 6362 women were tested with RSTs over a costing period of 9 months, as compared with just 224 tested with RPR over a similar time period the previous year. Total economic costs for RST screening ranged from $1758 to $6375. Unit costs ranged from $1.90 to $6.06 per woman screened, $17.76–$63.19 per woman treated, and $1.20–$4.26 per DALY. Larger facilities had lower unit costs, suggesting that economies of scale exist in screening services. Results were sensitive to assumptions regarding supply wastage, frequency of supervision, and program duration.

Conclusion RST screening costs fall well below the WHO threshold for ‘highly attractive’ cost-effectiveness. Although RST costs are slightly higher than those for RPR, the number of women reached by screening services was increased under RSTs. Results suggest that RSTs can overcome critical barriers to antenatal syphilis testing and treatment. Through removal of supply chain barriers, RSTs enable the realisation of economies of scale in screening services. This suggests that larger facilities will benefit from implementation of RSTs. RSTs further allow for screening where a lack of infrastructure prevents consistent RPR testing. Therefore, in the effort to increase equity in access to screening, roll-out is also recommended in facilities not able to provide RPR screening. RSTs are currently being expanded throughout the country in the effort to increase access to syphilis screening in antenatal care. This could facilitate control of congenital syphilis and prevent countless unnecessary fetal and infant deaths.