Sexually Transmitted Diseases in America: How Many Cases and at What Cost?

Part 3

Estimates Of The Direct Medical Costs Of STDs In The United States

The ASHA panel reviewed published data on the economic costs of individual STDs and estimated the direct medical costs of STD treatment for all estimated cases per year. Direct medical costs are dollars actually spent within the health care system treating STDs and their complications. The direct costs presented here - $8.4 billion - are only one part of the total economic burden of the STD epidemic. These estimates do not include nonmedical indirect costs (lost wages and productivity due to STD-related illness), out-of-pocket costs, or the costs incurred when STDs are transmitted to infants, which can result in significant lifelong expenditures. In addition, many STD cases result in an office visit but are not diagnosed as STDs. Finally, these estimates do not include the cost of STD prevention and screening.

It is useful to look at the costs for treating bacterial and viral STDs separately, because the nature of these infections is quite different (see tables 3 and 4). Treatment of bacterial STDs most often results in a cure; the course of therapy is limited and relatively inexpensive. By far the greatest costs associated with bacterial STDs result from complications of untreated chlamydia and gonorrhea, which can lead to pelvic inflammatory disease (PID). Viral STDs, in contrast, cannot be cured and may require treatment over a period of years. The greatest costs associated with viral STDs result from treatment of precancerous cervical lesions caused by HPV infection, and treatment of sexually transmitted HIV/AIDS.

In addition to the economic impact of STDs, the panel noted that STDs have a high human cost in terms of pain, suffering and grief. Complications of chlamydia and gonorrhea can lead to chronic pain, infertility and tubal pregnancies, which can affect a woman's health and well-being throughout her lifetime. The harmful impact of STDs on infants leads to long-term emotional suffering and stress for families, which cannot be captured in dollar terms. Unlike other diseases, STDs often cause stigma and feelings of shame for patients diagnosed with these infections. According to a 1998 Kaiser Family Foundation/Glamour survey of adults, almost half of men (44%) and women (47%) say if they were in a new relationship and discovered their partner had an STD, they would be "a lot less likely" to continue the relationship, with another third saying they would be "somewhat less likely" (30% men, 29% women). Most say they would feel "angry" at the person they got it from if they found out they had an STD, though women (87%) are more likely than men (74%) to say so.

Table 3. Estimated Annual Medical Costs of the Major Curable STDs in the United States
STD	Total Costa ($ millions)
Chlamydiab	$ 374.6
Gonorrheac	56.0
Pelvic inflammatory diseased	1,125.2
Trichomoniasise	375.0
Syphilisf	43.8
Total costs, bacterial STDs	$1,974.6

1. All cost figures are adjusted to 1997 dollars using the Consumer Price Index, which includes medical expenses along with other consumer costs for urban consumers (approximately 87% of the U.S. population), from the U.S. Department of Labor's Bureau of Labor Statistics.
2. Source: Washington E, Johnson R, Sanders L. Chlamydia trachomatis infections in the United States: what are they costing us? JAMA 1987; 257: 2070-2, as cited in Eng TR, Butler WT, eds, The Hidden Epidemic: Confronting Sexually Transmitted Diseases, Washington, DC, National Academy Press, 1997, p 59. Note: Estimated cost is of acute infection only, and excludes treatment costs of sequelae, i.e., pelvic inflammatory disease (PID) (see below).
3. Source: Begley CE, McGill L, Smith PB. The incremental cost of screening, diagnosis and treatment of gonorrhea and chlamydia in a family planning clinic. Sexually Transmitted Diseases 1989; 16: 63-7, as cited in Eng TR, Butler WT, eds, The Hidden Epidemic: Confronting Sexually Transmitted Diseases, Washington, DC, National Academy Press, 1997, p 59. This assumes the average cost per case is $80 excluding screening costs (1994 dollars). Note: Estimated cost includes acute infection only; and excludes treatment costs of the major sequelae, i.e., PID (see below).
4. Source: Rein D, Kassler W, Rabiee L. Decreasing, but still substantial: The direct medical cost of pelvic inflammatory disease and its sequelae chronic pelvic pain, ectopic pregnancy and infertility for the year 1998 (August 1998 in press). Note: This estimate of the annual incidence of PID and its major sequelae assumes that 80% of acute PID cases are STD-related, and that 50% of ectopic pregnancies, 20% of chronic pelvic pain, and 11-30% of infertility are PID-related; a midpoint of 20% infertility is assumed in this report.
5. No reliable cost estimates are available. The cost of treatment is comparable to that for chlamydia and gonorrhea (conservatively, approximately $75 per course of treatment); if all cases are treated, the annual direct cost for treatment would be approximately $375 million.
6. Source: Chesson HW, Rein D, Kassler WJ, Irwin KL, Carande-Kulis V, Schmid GP, Pinkerton SD. Direct medical costs of syphilis in the United States: The potential for a cost-saving national elimination program. Abstract, 1998 National STD Prevention Conference, Dallas, Texas, forthcoming. This estimate is based on $1,386 per case for the 31,564 primary and secondary and early latent cases in 1996 and includes future sequelae costs for these cases. It does not include present sequelae costs of syphilis cases that occurred in the past. It does not include costs for congenital syphilis.

Table 4. Estimated Annual Medical Costs of the Major Viral STDs in the United States
STD	Total Costa ($ millions)
Genital herpesb	$ 208.0
HPVc	1,622.8
hepatitis Bd	51.4
HIVe	4,540.0
Total costs, viral STDs	$6,422.2

1. All cost figures are adjusted to 1997 dollars using the Consumer Price Index, which includes medical expenses along with other consumer costs for urban consumers (approximately 87% of the U.S. population), from the U.S. Department of Labor's Bureau of Labor Statistics.
2. Source: Tao G, Kassler W, Rein D. Medical expenditures for genital herpes in the United States. Division of STD Prevention, National Center for HIV, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA 30333 (in press). Costs are estimated based on genital herpes-related clinical visits and pharmacy claims.
3. Includes direct annual costs of treatment for genital warts, precancerous lesions, carcinoma in situ and cervical cancer. Genital warts: Source of data on incidence: Stone KM. Epidemiological aspects of HPV infection, Clinical Obstetrics & Gynecology 1989; 32:112-3. Source of data on costs: Kassler W. Division of STD Prevention, National Center for HIV, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA 30333 ($446 per episode). Note: Annual costs assume that 75% of genital warts are treated (20-30% resolve without treatment.) Precancerous lesions, carcinoma in situ, and cervical cancer: Source of data: Preventing emerging infectious diseases: A strategy for the 21st century," Morbidity and Mortality Weekly Report 1998;47:RR-15. Note: Estimates for precancerous lesions, carcinoma in situ and cervical cancer assume that 82% of cases are attributable to HPV.
4. Source: Margolis H, Coleman P, Brown R, Mast E, Sheingold S, Arevalo J. Prevention of Hepatitis B virus transmission by immunization. JAMA 1995; 274:1201-8. Based on the data in the above report, the following assumptions were made in deriving the direct costs of treatment for acute hepatitis B infection and the major sequelae (chronic liver disease, comprising chronic active hepatitis, chronic persistent hepatitis, cirrhosis and primary hepatocellular carcinoma): Approximately 60% of initial adult/adolescent infections are asymptomatic and are assumed not to require treatment (Margolis, personal communication) and 40% of initial infections are symptomatic, of which approximately 88% require outpatient treatment estimated at $210 per case ($1993). Approximately 12% of symptomatic cases require hospitalization at $6,240 per case ($1993). Approximately 6% of adult/adolescent infections become chronic cases, of which approximately 15% develop chronic liver disease (CLD). Assuming that the four major components of CLD are equally distributed, the average cost of a case of CLD is estimated to be $45,800 ($1993). Conservatively, this lifetime cost figure can be discounted at 3% per annum assuming an average latency of onset of 20 years to $25,400. The average annual cost per case of infection is therefore approximately $668 in $1997.
5. Source: Bozzette S, Berry S, Duan N, Frankel MR, Keesey J, Lefkowitz D, Shapiro MF. Characteristics of HIV-infected patients receiving regular care in the U.S.: Results from the HIV Cost and Services Utilization Study (HCSUS). XII International Conference on AIDS. Geneva; 1998. Poster # 13229.

Estimated Impact Of STDs State-By-State

Comprehensive state-level data on STD incidence and cost do not exist. Therefore the ASHA panel attempted to estimate the distribution of cases for each of the 50 states using population statistics as a rough proxy. Overall, total STD rates do not vary greatly by region. For the most common STDs, HPV and trichomoniasis, no regional distribution pattern has been seen. For genital herpes, only a slight regional variation has been found, with the highest distribution of cases in the West and the lowest in the Midwest. Thus it is possible to use the percentage of sexually active unmarried men and women ages 15-24 in each state to approximate the number of new STD infections each year by state. Table 5 shows this distribution of new STD cases by state for 1996, with associated costs.

Table 5: Estimated Annual Direct Costs of All STDs by State
STATES	Estimated annual new cases of STDs	Estimated annual direct medical costs, all STDs ($ millions)
ALL USA	15,300,000	$8,396.8
ALABAMA	240,700	132.1
ALASKA	28,300	15.6
ARIZONA	296,400	162.6
ARKANSAS	142,600	78.3
CALIFORNIA	1,857,000	1,019.1
COLORADO	267,600	146.9
CONNECTICUT	170,900	93.8
DELAWARE	45,400	24.9
D.C.	35,800	19.6
FLORIDA	719,900	395.1
GEORGIA	476,000	261.2
HAWAII	66,100	36.3
IDAHO	64,400	35.4
ILLINOIS	736,400	404.1
INDIANA	304,200	166.9
IOWA	154,800	85.0
KANSAS	149,500	82.0
KENTUCKY	208,700	114.5
LOUISIANA	291,300	159.9
MAINE	58,300	32.0
MARYLAND	310,900	170.6
MASSACHUSETTS	357,700	196.3
MICHIGAN	599,400	329.0
MINNESOTA	265,000	145.4
MISSISSIPPI	187,300	102.8
MISSOURI	276,500	151.7
MONTANA	51,300	28.1
NEBRASKA	94,700	52.0
NEVADA	84,200	46.2
NEW HAMPSHIRE	58,300	32.0
NEW JERSEY	456,500	250.5
NEW MEXICO	100,200	55.0
NEW YORK	1,146,000	628.9
NORTH CAROLINA	416,200	228.4
NORTH DAKOTA	41,500	22.8
OHIO	628,800	345.1
OKLAHOMA	167,800	92.1
OREGON	201,300	110.5
PENNSYLVANIA	619,000	339.7
RHODE ISLAND	42,800	23.5
SOUTH CAROLINA	258,900	142.1
SOUTH DAKOTA	39,900	22.0
TENNESSEE	266,100	146.0
TEXAS	1,127,600	618.8
UTAH	136,000	74.6
VERMONT	35,300	19.4
VIRGINIA	345,800	189.8
WASHINGTON	298,700	163.9
WEST VIRGINIA	92,000	50.5
WISCONSIN	253,500	139.1
WYOMING	26,500	14.5

NOTES: The incidence and prevalence for each of the major STDs were described by the ASHA Panel To Estimate STD Incidence and Cost (see table 2). The estimated distribution of STDs and STD costs by state was calculated using, as a proxy, the proportion of unmarried men and women ages 15- 24 who were estimated to be sexually active in 1997 (James Trussell, Office of Population Research, Princeton University). Data from the 1990 Census and the 1995 National Survey of Family Growth (females ages 15-24), the 1995 National Survey of Adolescent Males (males ages 15-19) and the 1991 National Survey of Men (males ages 20-24) were used to obtain estimates of the proportion of sexually active men and women by state in 1990; these figures were extrapolated to 1997 numbers using the March 1997 Current Population Survey. The estimated annual direct medical cost of all STDs is derived from tables 3 and 4 ("Estimated Annual Medical Costs of the Major Curable STDs in the United States" and "Estimated Annual Medical Costs of the Major Viral STDs in the United States"). These tables give estimated direct medical costs for all annual U.S. cases of STDs in 1997 dollars. Cost figures are adjusted to 1997 dollars using the Consumer Price Index, which includes medical expenses along with other consumer costs for urban consumers (approximately 87% of the U.S. population), from the U.S. Department of Labor's Bureau of Labor Statistics.

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