Are intersectoral costs considered in economic evaluations of interventions relating to sexually transmitted infections (STIs)? A systematic review
BMC Public Health volume 22, Article number: 2180 (2022)
Sexually transmitted infections (STIs) not only have an impact on the health sector but also the private resources of those affected, their families and other sectors of society (i.e. labour, education). This study aimed to i) review and identify economic evaluations of interventions relating to STIs, which aimed to include a societal perspective; ii) analyse the intersectoral costs (i.e. costs broader than healthcare) included; iii) categorise these costs by sector; and iv) assess the impact of intersectoral costs on the overall study results.
Seven databases were searched: MEDLINE (PubMed), EMBASE (Ovid), Web of Science, CINAHL, PsycINFO, EconLit and NHS EED. Key search terms included terms for economic evaluation, STIs and specific infections. This review considered trial- and model-based economic evaluations conducted in an OECD member country. Studies were included that assessed intersectoral costs. Intersectoral costs were extracted and categorised by sector using Drummond’s cost classification scheme (i.e. patient/family, productivity, costs in other sectors). A narrative synthesis was performed.
Twenty-nine studies qualified for data extraction and narrative synthesis. Twenty-eight studies applied a societal perspective of which 8 additionally adopted a healthcare or payer perspective, or both. One study used a modified payer perspective. The following sectors were identified: patient/family, informal care, paid labour (productivity), non-paid opportunity costs, education, and consumption. Patient/family costs were captured in 11 studies and included patient time, travel expenses, out-of-pocket costs and premature burial costs. Informal caregiver support (non-family) and unpaid help by family/friends was captured in three studies. Paid labour losses were assessed in all but three studies. Three studies also captured the costs and inability to perform non-paid work. Educational costs and future non-health consumption costs were each captured in one study. The inclusion of intersectoral costs resulted in more favourable cost estimates.
This systematic review suggests that economic evaluations of interventions relating to STIs that adopt a societal perspective tend to be limited in scope. There is an urgent need for economic evaluations to be more comprehensive in order to allow policy/decision-makers to make better-informed decisions.
Sexually transmitted infections (STIs) continue to rise worldwide and generate important impacts on society . STIs and their sequelae are shown to not only have an impact on the health sector but also the private resources of those affected, their families and other sectors of society . Living with an STI can, for instance, affect an individual’s productivity and participation in the labour market [3,4,5]. It can also have a considerable impact on an individual’s mental health (i.e. stigma, depression), compromising an individual’s overall quality of life [6,7,8]. The wider societal impacts spilling over to other non-health sectors are also referred to as societal , multisectoral  or intersectoral costs and benefits (or consequences) [11, 12]. This review will use the term intersectoral costs.
Interventions relating to STIs are essential but complex in nature (like many other public health problems). This complexity can, in part, be explained by the aforementioned wide-ranging, intersectoral impacts of public health programmes, and this can create challenges in adequately capturing them in economic evaluations [12, 13]. The study perspective (or viewpoint) adopted in an economic evaluation ultimately determines the costs and benefits included in the analysis. A societal perspective is increasingly being advocated for economic evaluations of public health interventions as it is expected to capture all relevant costs and benefits associated with an intervention both within and beyond health [14, 15]. Depending on the study objective and stakeholder interests, it may be appropriate to assess costs and benefits from other perspectives (i.e. when estimating the financial costs of an intervention to a specific healthcare system or provider).
Even though a societal perspective has been advocated in methodological guidelines for some time , it is not always adopted or, if attempted, tends to be incomplete [17,18,19,20,21]. As indicated above, this can be due to the methodological challenges associated with quantifying the intersectoral impacts of public health interventions . However, evidence suggests that the societal costs associated with STI-related interventions can substantially contribute to the total economic cost burden [2, 3]. This implies that excluding intersectoral costs from analyses could severely underestimate the total cost burden and present incomplete economic information to policy/decision-makers, potentially leading to suboptimal decision-making (i.e. inefficient allocation of resources) [18, 19, 23]. Hence, more comprehensive economic evidence is needed that will allow policy/decision-makers to better understand the total cost burden associated with STIs.
Given the importance placed on the societal perspective and the potential for suboptimal policy decisions in the absence of a comprehensive evaluation, a systematic review of published economic evaluations which adopted a societal perspective was undertaken. The review aimed to explore the intersectoral costs considered under a societal perspective in economic evaluations of interventions relating to STIs, and the impact of including intersectoral costs on the overall study results. The specific objectives of this review were to i) identify economic evaluations of interventions relating to STIs which aimed to include a societal perspective; ii) analyse the intersectoral costs (i.e. costs broader than healthcare) included; iii) categorise these costs by sector (i.e. patient/family, productivity, other); and iv) assess the impact of intersectoral costs on the overall study results.
A protocol for this review was published in PROSPERO, the International Prospective Register of Systematic Reviews database (CRD42019130940). The review systematically followed the Centre for Review and Dissemination (CRD) guidance for undertaking reviews in health care  and a five-step approach on how to prepare a systematic review of economic evaluations for informing evidence-based healthcare decisions [25,26,27]. The PRISMA guidelines were followed for the reporting of this review  (supplemental file 1).
A search strategy was developed in PubMed for MEDLINE together with an information specialist before adapting for use in other databases (supplemental file 2). Seven electronic databases were searched (1999–2019): MEDLINE (via PubMed), EMBASE (via Ovid), Web of Science (Core Collection), CINAHL, PsycINFO, EconLit and NHS EED. The search strategy was updated for 2020–21 in Medline (PubMed) only. The year 1999 was initially chosen as a starting year to reflect the inception of the United Kingdom (UK) National Institute of Health and Care Excellence (NICE) and their implementation of guidance statements for the conduct of health economic evaluations. Key search terms included terms for economic evaluation and STIs including specific infections.
This review considered both trial- and model-based economic evaluations of any intervention relating to STIs that were conducted in an Organisation for Economic Co-operation and Development (OECD) member country. OECD member countries were chosen due to their similarities in terms of health(care) systems and to better compare the methodology of studies concerned with similar health(care) systems. It focused on full economic evaluations that adopted a societal perspective, including cost-effectiveness analyses (CEA), cost-utility analyses (CUA) and cost-benefit analyses (CBA). The methods of CEA, CUA and CBA have varying theoretical foundations and outcomes are expressed differently. A CEA measures assesses outcomes (effects) in natural units, whereas a CUA assesses outcomes in health utilities such as quality-adjusted life years (QALYs). A CBA assesses both costs and outcomes in monetary values. No restrictions were placed on the type of comparator or outcomes. Participants in an intervention had to be at least 10 years of age to reflect international definitions of the start of adolescence (a period during which individuals establish sexual maturation and sexual activity)  (the PICO model is shown in supplemental file 3).
Screening of data and data extraction
Search results were exported into EndNote X9. Citations were de-duplicated following the guidelines by Bramer and colleagues . The study selection was performed by two reviewers (LS, LJ). A systematic process was adopted to guide the screening of studies for inclusion . Stage I: title screening (LS), stage II: abstract screening and categorisation of selected studies by study type and disease group (LS), and stage III: full-text screening (LS). This process was checked by a second reviewer (LJ) and discrepancies were discussed. A standardised data extraction sheet was utilised to record data on study characteristics, intersectoral costs and cost-effectiveness estimates for those studies that adopted a societal perspective in addition to a healthcare and/or provider perspective (to illustrate the difference in study results for each perspective) . Corresponding authors of selected studies were contacted for clarification where it was not clear what types of costs were considered. A PRISMA flowchart illustrates the selection process (Fig. 1).
Data were recorded using Microsoft Excel and Word. Intersectoral costs were identified, extracted and categorised by sector using Drummond’s sector-specific cost classification scheme  (Table 1). Drummond and colleagues categorise costs into (i) healthcare, (ii) patient and family, (iii) productivity, and (iv) costs in other sectors such as informal care, educational costs, costs in the criminal justice system, household and/or leisure costs . The reported intersectoral costs were converted to US Dollars and the year 2021, adjusting the values by inflation. This was done using an online inflation tool  and a currency converter . A narrative synthesis was performed following CRD guidelines .
The search strategy generated 23,895 studies after duplicates were removed. Studies were further limited to those published from 2009 onwards, excluding 6483. Though this was due to a high number of records identified in the databases, the publication date reflects the period of time during which intersectoral costs and benefits have gained more prominence [13, 22, 34]. Titles and then abstracts were screened, and a total of 572 economic evaluations were identified. Studies were further screened to exclude evaluations that considered healthcare or intervention costs only. In total, 48 studies were identified for full text screening and 29 studies were taken forward for data extraction and narrative synthesis (see supplemental file 4 for excluded studies).
Of the 29 studies identified, the majority focused on HPV (n = 11), HIV (n = 8) and chlamydia (n = 7, of which two focused on both chlamydia and gonorrhoea) (Table 2). The remaining studies were concerned with gonorrhoea (n = 1), hepatitis B (n = 1) and hepatitis C (n = 1). The countries of interest in the selected studies included the United States of America (USA) (n = 10), The Netherlands (n = 8), Canada (n = 3), Sweden (n = 3), Germany (n = 2), Australia (n = 1), Austria (n = 1) and Israel (n = 1). The overwhelming approach adopted was a CEA (considering the study authors’ definition of their study as a CEA and CUA). However, not all studies explicitly stated whether they applied a CEA or CUA approach. Only three out of the 29 studies explicitly reported to have undertaken a CUA [35,36,37] and one study was explicit about having conducted both a CEA and CUA . Modelling was used in all but two studies, which were trial-based [36, 37]. Most of the modelling studies applied a (dynamic) transmission model, which is the preferred method when evaluating infectious diseases [39,40,41,42,43,44,45,46,47]. Twenty-eight studies applied a societal perspective of which 8 additionally adopted a healthcare or payer perspective, or both [37, 39, 40, 44, 47,48,49]. One study used a modified payer perspective . More information is presented in Table 2.
The types of interventions varied widely. Vaccination and screening interventions dominated, and involved stand-alone vaccination [45, 50,51,52], vaccination in addition to screening [40, 53,54,55,56], vaccination of girls and boys [43, 47], sex-neutral vaccination , screening (stand-alone) [41, 57,58,59], screening in addition to testing  and screening after vaccination . Other interventions involved test and treat interventions including PrEP (Pre-Exposure Prophylaxis) [42, 62], testing and linkage to care  and opt-out testing strategy ; expedited partner treatment , population-level treatment expansion , (on-demand) PrEP [35, 63], treatment adherence interventions , guided internet-based behaviour intervention  and financial incentives .
Identification, exploration and categorisation of intersectoral costs
Different intersectoral costs were identified, relating to the following sectors: patient & family, informal care, paid labour (productivity), non-paid opportunity costs (productivity), education and consumption (Table 3).
Patient & family
Patient and family costs were captured in 14 studies and included patient time, travel expenses, out-of-pocket costs and premature burial costs. Four studies estimated patient time and travel to seek care as part of healthcare costs (i.e. screening, treatment, vaccination) [43, 53, 54, 60]; although it was not clear whether this time was equated to lost productivity. Nine studies included travel costs or expenses paid for by patients/families in their analyses [35, 37, 43, 48, 50, 54, 55, 59, 61]. Most of the studies evaluated travel costs associated with the intervention being evaluated, though this was not made explicit in all studies. Studies were also not always explicit about whether this referred to travel time or financial expenses such as travel fares. Out-of-pocket costs related to costs paid for by patients/families and was accounted for by two studies [39, 56]. Premature burial costs were considered in one study .
Caregiver support (non-family) and unpaid help by family/friends was captured in four studies [38, 42, 52, 56]. Two focused on informal care costs related to HIV/AIDS care [38, 42], one on caregiver time loss during treatment for cervical cancer patients  and one estimated the time taken by family members during patients’ palliative care due to hepatitis B-related cancer .
Paid labour (productivity)
Productivity costs in terms of paid labour losses were assessed in 24 studies. The majority of studies measured these in terms of absenteeism (time off work). Of those, one study estimated productivity losses in a sensitivity analysis only . Two of the studies measured productivity in utilities and captured these in quality-adjusted life year (QALY) estimates [42, 56]. Here, productivity was attributable to the HIV-related morbidity and mortality and lost income due to death or disability from hepatitis B-related sequelae, both chronic conditions. Presenteeism was only accounted for by two studies [36, 58]. Few studies estimated lost income [39, 51], lost revenue due to unemployment rate gap , fringe benefits , early retirement , avoided future production loss (in a sensitivity analysis)  and intervention-related productivity gains [44, 51].
Non-paid opportunity costs (productivity)
Only four studies explicitly reported capturing the costs associated with non-paid work (i.e. domestic tasks, voluntary work) [36, 38, 39, 52]. It was not clear if/how many studies equated non-paid opportunity costs (i.e. lost leisure time) to lost work hours (labour).
School absence was captured in one study only . It refers to an individual missing out on potential productivity and educational attainment, but no further characteristics were stated for those who missed school. School absence was calculated by adding a unit price (based on the Dutch minimum wage) per hour missed.
Future consumption costs unrelated to health were considered by one study . These consumption costs referred to national average age-specific expenditures outside of healthcare and were based on the U.S. Census Consumer Expenditures Survey. The study did not further specify what this entailed.
The impact of intersectoral costs on the study results
All studies that applied a societal perspective in addition to a healthcare and/or payer perspective presented more favourable cost-effectiveness results under the societal perspective (Table 4). Four studies reported that interventions were cost-saving from a societal perspective, whereas they were ‘only’ cost-effective under a healthcare or payer perspective [39, 40, 44, 64]. Two studies found the incremental cost-effectiveness ratios (ICERs) of their interventions decreased when applying a societal perspective in addition to a healthcare or payer perspective [47, 49]. One study found their intervention to be cost-effective from both the health system and societal perspective .
This study is the first to systematically review economic evaluations of interventions relating to STIs and explore and categorise the different types of intersectoral costs captured under a societal perspective. It also presents evidence that the inclusion of intersectoral costs has an impact on the overall study results.
This review found that the identified studies took a rather narrow approach to the societal perspective and only considered costs relating to a limited range of non-health sectors. For the majority of studies this meant primarily estimating paid labour losses. For others, this meant the inclusion of patient and family costs in their analyses. Very few studies considered informal care costs and other non-paid opportunity costs. Only one study included educational costs and another captured non-medical consumption costs. These findings indicate that even where a societal perspective is adopted, this may often be limited in scope, potentially omitting relevant costs from other sectors. The theoretical definition of a societal perspective, however, does not limit the potential scope to the aforementioned sectors .
Even though the inclusion of intersectoral costs was limited to a few cost sectors, where intersectoral costs were accounted for, this resulted in more favourable cost-effectiveness estimates.
Methodological challenges to the study perspective
A primary reason for studies applying a narrow societal perspective could be the methodological challenges associated with capturing these wider costs such as with data collection processes or unavailable data . The identification, measurement and valuation of intersectoral costs and benefits in economic evaluations is recognised as one of four methodological challenges when assessing public health interventions . This review highlights that despite methodological difficulties, it is important to be transparent and if a narrower societal perspective is applied, this needs to be explained and justified.
Classification of costs
This review’s cost classification scheme was established to assess whether (or not) and to what extent intersectoral costs were considered and reported explicitly and transparently. The findings suggest that there is considerable scope for exploring other wider societal costs in relation to interventions addressing STIs. This would help improve understanding of the wider societal impacts of STI-related interventions and inform the design of future, more comprehensive economic evaluations.
This review shows that informal care was rarely captured in the evaluations, but where it was considered, it related to chronic conditions including HIV/AIDS, HPV-related cervical cancer and hepatitis B-related cancer. Where (long-term) care is provided informally this makes the inclusion of such costs in economic evaluations crucial. If informal care is not considered (or discussed as a study limitation) this can omit important information and underestimate the total cost burden. Future research is needed to further investigate informal care costs related to STIs, particularly those that can have chronic impacts (i.e. HIV/AIDS, hepatitis B) and those with severe long-term sequelae (i.e. pelvic inflammatory disease, chronic pelvic pain).
Non-paid opportunity costs
This review also found that the costs associated with unpaid work remained largely excluded from economic evaluations relating to STIs. This was difficult to judge as not all studies were explicit about which cost components/resource items they accounted for when referring to productivity costs – i.e. paid labour, volunteering or household work. A number of study authors were approached to clarify whether productivity losses accounted for paid or unpaid labour, or both. The majority responded that only paid labour losses were included due to missing data or the methodological challenges of including unpaid productivity. These findings suggest that greater transparency is needed when a societal perspective is adopted to clarify which costs and benefits are included/excluded and the justification for these decisions.
School absence was only captured in one study. Absence from school due to an STI or seeking treatment for an STI can refer to potential productivity loss or loss of educational attainment. The study that captured absence from school valued each hour missed at school based on the national minimum wage, as informal care and domestic activities. No other costs relating to education were identified.
Where future consumption costs unrelated to health were accounted for it was not clear what this involved. Examples of non-medical consumption costs can include travel expenditures or future costs for housing and food . This adds to the call from this review that more transparency is needed in economic evaluations, in particular on the different cost components included (or not included), to increase consistency in terms of the costs captured and improve comparability of results across studies.
Distinct health impacts
Other potentially important distinct health impacts can include costs in the reproductive health and mental health sphere. However, these impacts were not captured in the selected studies. The prevention of STIs can reduce the risk of cervical cancer, pelvic inflammatory disease and infertility among women , which is often related to their sexual, reproductive and psychological health . This implies there might be intangible costs related to STIs and their sequelae such as pain, anxiety and psychological suffering that could have an impact on people’s overall quality of life and contribute to the cost burden. Research shows that intangible costs could potentially outweigh healthcare costs and its inclusion in economic evaluations potentially result in more favourable cost-effectiveness estimates . This study acknowledges there are difficulties associated with measuring and valuing intangible costs and the demonstration of attribution, and more research is needed in this area.
Comparison to other literature
Relatively few economic evaluations related to STIs have adopted a societal perspective. This is in line with recent findings by Bloch and colleagues  who assessed how costs and outcomes are measured in economic evaluations relating to interventions to control STIs. Their study revealed that multiple studies did not adopt a broader perspective to account for outcomes beyond health, despite national recommendations advocating to do so . The present review focused on those economic evaluations that did adopt a societal perspective and demonstrated that often this perspective is limited to certain cost sectors, predominantly the labour sector. Kim and colleagues similarly found that the CEAs they considered rarely captured impacts on sectors outside health, but if so, productivity losses were the most commonly estimated . Krol and colleagues’  findings also show that economic evaluations tend to predominantly assess paid labour costs . Unpaid work, in comparison, has tended to receive little attention . The present review confirms that non-paid work is almost entirely ignored, or not explicitly reported, in economic evaluations. As indicated above, sexual health is closely related to other sectors, including education. In 2010, Shepherd and colleagues found that school-based behavioural interventions for the prevention of STIs can improve knowledge and increase self-efficacy . Research by Chong and colleagues  showed that online sexual-health education have an impact on an individual’s knowledge and attitudes. Overall, it is evident that public health issues and interventions can impact other sectors of society, and that the application of a societal perspective is important. This has recently been highlighted using COVID-19 as an example and demonstrating the broader societal impacts of such disease on other sectors outside health .
A societal perspective is generally recommended to allow for all relevant costs and benefits to be considered and for an economic evaluation to be as comprehensive as possible. However, where economic studies adopt a societal perspective, but this only includes certain costs in certain sectors, relevant societal implications may be ignored. As a result, decisions based on an analysis with a limited scope might not be optimal . As shown in this review, adopting a societal perspective and capturing intersectoral costs relating to STIs resulted in more favourable cost-effectiveness estimates . Again, where diseases such as STIs can be prevented, treated or managed this can have an impact on an individual’s physical, mental and social health and wellbeing, their productivity as well as wider society . In order to improve information communicated to policy/decision-makers all potentially relevant intersectoral costs need to be included in analyses, and if a narrow societal perspective is adopted, the exclusion of relevant costs needs to be made transparent and justified.
Implications for research
The costs considered and included under a societal perspective differed across studies, resulting in heterogeneity of study results. This highlights that there is a need for a clear understanding of which costs were included and excluded under any perspective when reviewing and synthesising the existing literature, or when combining results from different studies undertaken in different settings. This is particularly important because the different elements of costs (i.e. care practices, wages) can differ between countries and time points. When researchers adopt data from the existing literature for use in their own work, they need to carefully assess what costs were captured before the results can be relied on and utilised.
Strengths and limitations
The main strength of this review is that it followed a structured and rigorous process. To our knowledge, this is the first review in sexual health to apply a cost classification scheme in order to explore and categorise the intersectoral costs considered by sector. The classification scheme provides a valuable foundation for the critical appraisal of economic evaluations, in particular with regard to the consideration and identification of societal costs. The results of this study can inform the design of future, more comprehensive economic evaluations of public health interventions, building on the classification scheme presented. Another key strength of this review is the exhaustive search strategy that was developed in cooperation with an information specialist, searching nine databases and a wide range of key search terms relating to sexual health. It is however possible that some relevant search terms may have been missed. In addition, the update of the review focused on Medline only, which may have resulted in some studies being omitted, although this was mitigated by extensive hand searching. A potential weakness of the review is that because of the high volume of studies identified in the databases, an initial screening was undertaken to exclude studies where the abstract suggested that the study adopted a healthcare perspective only. This means that relevant studies could have been missed. Future research could review economic analyses that adopted a healthcare (system) perspective to assess in detail which costs these studies captured, i.e. direct medical costs, patient costs, or other costs. Another limitation of this review is that it focused on OECD member countries. Reviewing studies in non-OECD member countries could have identified other potentially relevant costs associated with interventions relating to STIs. Further, this review focused on STIs that are sexually transmitted and interventions related to infections transmitted other than sexually, could have revealed additional cost sectors.
Further research is needed to investigate wider intersectoral costs related to STIs that were not (sufficiently) captured in this review but that could be important to inform policy/decision-making. Such research could also help explore the intersectoral costs relating to other sexual health aspects beyond disease such as sexuality, sexual behaviour, and related areas. Given the complexity of sexual health future research could explore wider intersectoral costs relating to STIs that have been considered outside of the health economics literature such as in educational journals or journals relating to social services. Furthermore, future research could explore in greater depth the distinction between intersectoral consequences associated with the disease and the intersectoral costs incurred by the intervention being evaluated, as this was not always fully clear.
This systematic review suggests that economic evaluations of interventions relating to STIs that adopt a societal perspective tend to be limited in scope. This risks omitting potentially relevant intersectoral costs that could be important information for policy/decision-making. There is an urgent need for economic evaluations to be more comprehensive in order to allow policy/decision-makers to make better informed decisions.
Availability of data and materials
All data generated or analysed during this study are included in this published article [and its supplementary information files].
Acquired Immunodeficiency Syndrome
Consensus on Health Economic Criteria checklist
Centre for Review and Dissemination
Human Immunodeficiency Virus
Herpes Simplex Virus
Incremental Cost-Effectiveness Ratio
Organisation for Economic Co-operation and Development
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
The International Prospective Register of Systematic Reviews
Quality Adjusted Life Year
Sexually Transmitted Infection
United States of America
United States Dollar
Eng TR, Butler WT. Estimates of the economic burden of STDs: review of the literature with updates. The hidden epidemic: confronting sexually transmitted diseases. US: National Academies Press; 1997.
Mullins CD, Whitelaw G, Cooke JL, Beck EJ. Indirect cost of HIV infection in England. Clin Ther. 2000;22(11):1333–45.
Blandford JM, Gift TL. Productivity losses attributable to untreated chlamydial infection and associated pelvic inflammatory disease in reproductive-aged women. Sex Transm Dis. 2006;33(10):S117–S21.
Hutchinson AB, Farnham PG, Dean HD, Ekwueme DU, Del Rio C, Kamimoto L, et al. The economic burden of HIV in the United States in the era of highly active antiretroviral therapy: evidence of continuing racial and ethnic differences. J Acquir Immune Defic Syndr. 2006;43(4):451–7.
Hubben GAA, Bishai D, Pechlivanoglou P, Cattelan AM, Grisetti R, Facchin C, et al. The societal burden of HIV/AIDS in northern Italy: an analysis of costs and quality of life. AIDS Care. 2008;20(4):449–55.
World Health Organization (WHO). Global health sector strategy on sexually transmitted infections 2016–2021: toward ending STIs. Geneva: World Health Organization; 2016.
Passanisi A, Leanza V, Leanza G. The impact of sexually transmitted diseases on quality of life: application of three validated measures. G Ital Ostet Ginecol. 2013;35(6):722–7.
Darroch J, Myers L, Cassell J. Sex differences in the experience of testing positive for genital chlamydia infection: a qualitative study with implications for public health and for a national screening programme. Sex Transm Infect. 2003;79(5):372–3.
Aranda-Reneo I, Rodríguez-Sánchez B, Peña-Longobardo LM, Oliva-Moreno J, López-Bastida J. Can the consideration of societal costs change the recommendation of economic evaluations in the field of rare diseases? An empirical analysis Value Health. 2020;24(3):431–42.
Remme M, Martinez-Alvarez M, Vassall A. Cost-effectiveness thresholds in global health: taking a multisectoral perspective. Value Health. 2017;20(4):699–704.
Drost R, Paulus A, Ruwaard D, Evers S. Inter-sectoral costs and benefits of mental health prevention: towards a new classification scheme. J Ment Health Policy Econ. 2013;16(4):179–86.
Edwards RT, Charles JM, Lloyd-Williams H. Public health economics: a systematic review of guidance for the economic evaluation of public health interventions and discussion of key methodological issues. BMC Public Health. 2013;13(1):1001.
Drummond M, Weatherly H, Claxton K, Cookson R, Ferguson B, Godfrey C, et al. Assessing the challenges of applying standard methods of economic evaluation to public health interventions. York: Public Health Research Consortium; 2007.
Weinstein MC, Russell LB, Gold MR, Siegel JE. Cost-effectiveness in health and medicine. New York: Oxford University Press; 1996.
Sanders GD, Neumann PJ, Basu A, Brock DW, Feeny D, Krahn M, et al. Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: second panel on cost-effectiveness in health and medicine. JAMA. 2016;316(10):1093–103.
Drummond MF, Sculpher MJ, Claxton K, Stoddart GL, Torrance GW. Methods for the economic evaluation of health care programmes. Oxford: Oxford University Press; 2015.
Drost RM, Paulus AT, Evers SM. Five pillars for societal perspective. Int J Technol Assess Health Care. 2020;36(2):72–4.
Kim DD, Silver MC, Kunst N, Cohen JT, Ollendorf DA, Neumann PJ. Perspective and costing in cost-effectiveness analysis, 1974–2018. Pharmacoeconomics. 2020;38(10):1135–45.
Krol M, Papenburg J, Tan SS, Brouwer W, Hakkaart L. A noticeable difference? Productivity costs related to paid and unpaid work in economic evaluations on expensive drugs. Eur J Health Econ. 2016;17(4):391–402.
Neumann PJ. Costing and perspective in published cost-effectiveness analysis. Med Care. 2009;47(7):28–32.
Trapero-Bertran M, Oliva-Moreno J. Economic impact of HIV/AIDS: a systematic review in five European countries. Heal Econ Rev. 2014;4(1):1–16.
Weatherly H, Drummond M, Claxton K, Cookson R, Ferguson B, Godfrey C, et al. Methods for assessing the cost-effectiveness of public health interventions: key challenges and recommendations. Health Policy. 2009;93(2–3):85–92.
Chesson HW. Cost effectiveness of one to one STI prevention interventions. Med Soc Study Vener Dis. 2007;83(6):423–4.
Centre for Reviews and Dissemination UoY. Systematic reviews: CRD’s guidance for undertaking reviews in health care. York: Centre for Reviews and Dissemination, University of York; 2009.
van Mastrigt GA, Hiligsmann M, Arts JJ, Broos PH, Kleijnen J, Evers SM, et al. How to prepare a systematic review of economic evaluations for informing evidence-based healthcare decisions: a five-step approach (part 1/3). Expert Rev Pharmacoecon Outcomes Res. 2016;16(6):689–704.
Thielen F, Van Mastrigt G, Burgers L, Bramer W, Majoie H, Evers S, et al. How to prepare a systematic review of economic evaluations for clinical practice guidelines: database selection and search strategy development (part 2/3). Expert Rev Pharmacoecon Outcomes Res. 2016;16(6):705–21.
Wijnen B, Van Mastrigt G, Redekop W, Majoie H, De Kinderen R, Evers S. How to prepare a systematic review of economic evaluations for informing evidence-based healthcare decisions: data extraction, risk of bias, and transferability (part 3/3). Expert Rev Pharmacoecon Outcomes Res. 2016;16(6):723–32.
Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Syst Rev. 2021;10(1):89.
World Health Organization. Adolescent health. Available from: https://www.who.int/health-topics/adolescent-health#tab=tab_1.
Bramer WM, Giustini D, de Jonge GB, Holland L, Bekhuis T. De-duplication of database search results for systematic reviews in EndNote. J Med Libr Assoc. 2016;104(3):240.
Roberts T, Henderson J, Mugford M, Bricker L, Neilson J, Garcia J. Antenatal ultrasound screening for fetal abnormalities: a systematic review of studies of cost and cost effectiveness. BJOG. 2002;109(1):44–56.
Inflation Tool [Available from: https://www.inflationtool.com/.
Currency Converter [Available from: https://www.xe.com/.
National Institute for Health and Care Excellence (NICE). Guide to the methods of technology appraisal 2013. United Kingdom: National Institute for Health and Care Excellence; 2013.
Ginsberg G, Chemtob D. Cost utility analysis of HIV pre exposure prophylaxis among men who have sex with men in Israel. BMC Public Health. 2020;20(1):1–14.
van Luenen S, Kraaij V, Garnefski N, Spinhoven P, van den Akker–van ME. Cost-utility of a guided internet-based intervention in comparison with attention only for people with HIV and depressive symptoms: a randomized controlled trial. J Psychosom Res. 2019;118:34–40.
Zulliger R, Maulsby C, Solomon L, Baytop C, Orr A, Nasrullah M, et al. Cost-utility of HIV testing programs among men who have sex with men in the United States. AIDS Behav. 2017;21(3):619–25.
Wijnen BF, Oberjé EJ, Evers SM, Prins JM, Nobel H-E, van Nieuwkoop C, et al. Cost-effectiveness and cost-utility of the adherence improving self-management strategy in human immunodeficiency virus care: a trial-based economic evaluation. Clin Infect Dis. 2019;68(4):658–67.
Adamson B, El-Sadr W, Dimitrov D, Gamble T, Beauchamp G, Carlson JJ, et al. The cost-effectiveness of financial incentives for viral suppression: HPTN 065 study. Value Health. 2019;22(2):194–202.
Damm O, Horn J, Mikolajczyk RT, Kretzschmar ME, Kaufmann AM, Deleré Y, et al. Cost-effectiveness of human papillomavirus vaccination in Germany. Cost Eff Resour Allocation. 2017;15(1):1–19.
de Wit GA, Over EA, Schmid BV, van Bergen JE, van den Broek IV, van der Sande MA, et al. Chlamydia screening is not cost-effective at low participation rates: evidence from a repeated register-based implementation study in the Netherlands. Sex Transm Infect. 2015;91(6):423–9.
Drabo EF, Hay JW, Vardavas R, Wagner ZR, Sood N. A cost-effectiveness analysis of preexposure prophylaxis for the prevention of HIV among Los Angeles County men who have sex with men. Clin Infect Dis. 2016;63(11):1495–504.
Kim JJ, Goldie SJ. Cost effectiveness analysis of including boys in a human papillomavirus vaccination programme in the United States. BMJ. 2009;339:b3884
Nosyk B, Min J, Lima V, Hogg R, Montaner J. Modelling the cost-effectiveness of population-level HAART expansion in British Columbia. Lancet HIV. 2015;2(9):e393.
Owusu-Edusei K Jr, Chesson HW, Gift TL, Brunham RC, Bolan G. Cost-effectiveness of Chlamydia vaccination programs for young women. Emerg Infect Dis. 2015;21(6):960.
Owusu-Edusei K Jr, Hoover KW, Gift TL. Cost-effectiveness of opt-out Chlamydia testing for high-risk young women in the US. Am J Prev Med. 2016;51(2):216–24.
Zechmeister I, de Blasio BF, Garnett G, Neilson AR, Siebert U. Cost-effectiveness analysis of human papillomavirus-vaccination programs to prevent cervical cancer in Austria. Vaccine. 2009;27(37):5133–41.
Gift TL, Kissinger P, Mohammed H, Leichliter JS, Hogben M, Golden MR. The cost and cost-effectiveness of expedited partner therapy compared with standard partner referral for the treatment of chlamydia or gonorrhea. Sex Transm Dis. 2011;38(11):1067–73.
Wolff E, Elfström KM, Cange HH, Larsson S, Englund H, Sparén P, et al. Cost-effectiveness of sex-neutral HPV-vaccination in Sweden, accounting for herd-immunity and sexual behaviour. Vaccine. 2018;36(34):5160–5.
Campos NG, Scarinci IC, Tucker L, Peral S, Li Y, Regan MC, et al. Cost-effectiveness of offering cervical cancer screening with HPV self-sampling among African-American women in the Mississippi Delta. Cancer Epidemiol Prev Biomark. 2021;30(6):1114–21.
Régnier SA, Huels J. Potential impact of vaccination against Neisseria meningitidis on Neisseria gonorrhoeae in the United States: results from a decision-analysis model. Hum Vaccin Immunother. 2014;10(12):3737–45.
Mahumud RA, Alam K, Dunn J, Gow J. The cost-effectiveness of controlling cervical cancer using a new 9-valent human papillomavirus vaccine among school-aged girls in Australia. PLoS One. 2019;14(10):e0223658.
de Kok IM, van Ballegooijen M, Habbema JDF. Cost-effectiveness analysis of human papillomavirus vaccination in the Netherlands. J Natl Cancer Inst. 2009;101(15):1083–92.
Kim JJ, Ortendahl J, Goldie SJ. Cost-effectiveness of human papillomavirus vaccination and cervical cancer screening in women older than 30 years in the United States. Ann Intern Med. 2009;151(8):538–45.
Rogoza R, Westra T, Ferko N, Tamminga J, Drummond M, Daemen T, et al. Cost-effectiveness of prophylactic vaccination against human papillomavirus 16/18 for the prevention of cervical cancer: adaptation of an existing cohort model to the situation in the Netherlands. Vaccine. 2009;27(35):4776–83.
Rossi C, Schwartzman K, Oxlade O, Klein MB, Greenaway C. Hepatitis B screening and vaccination strategies for newly arrived adult Canadian immigrants and refugees: a cost-effectiveness analysis. PLoS One. 2013;8(10):e78548.
Rours G, Smith-Norowitz TA, Ditkowsky J, Hammerschlag MR, Verkooyen R, de Groot R, et al. Cost-effectiveness analysis of Chlamydia trachomatis screening in Dutch pregnant women. Pathog Glob Health. 2016;110(7–8):292–302.
Krauth C, Rossol S, Ortsäter G, Kautz A, Krüger K, Herder B, et al. Elimination of hepatitis C virus in Germany: modelling the cost-effectiveness of HCV screening strategies. BMC Infect Dis. 2019;19(1):1–13.
van Wifferen F, Hoornenborg E, van der Loeff MFS, Heijne J, van Hoek AJ. Cost-effectiveness of two screening strategies for Chlamydia trachomatis and Neisseria gonorrhoeae as part of the PrEP programme in the Netherlands: a modelling study. Sex Transm Infect. 2021;97(8):607–12.
Fogelberg S, Clements MS, Pedersen K, Sy S, Sparén P, Kim JJ, et al. Cost-effectiveness of cervical cancer screening with primary HPV testing for unvaccinated women in Sweden. PLoS One. 2020;15(9):e0239611.
Coupé VM, de Melker H, Snijders PJ, Meijer CJ, Berkhof J. How to screen for cervical cancer after HPV16/18 vaccination in the Netherlands. Vaccine. 2009;27(37):5111–9.
Deogan CL, Hansson Bocangel MK, Wamala SP, Månsdotter AM. A cost-effectiveness analysis of the Chlamydia Monday-a community-based intervention to decrease the prevalence of chlamydia in Sweden. Scand J Public Health. 2010;38(2):141–50.
Ouellet E, Durand M, Guertin JR, LeLorier J, Tremblay CL. Cost effectiveness of ‘on demand’HIV pre-exposure prophylaxis for non-injection drug-using men who have sex with men in Canada. Can J Infect Dis Med Microbiol. 2015;26(1):23–9.
Owusu-Edusei K, Roby TM, Chesson HW, Gift TL. Productivity costs of nonviral sexually transmissible infections among patients who miss work to seek medical care: evidence from claims data. Sex Health. 2013;10(5):434–7.
Weatherly H. Assessing the challenges of applying standard methods of economic evaluation to public health interventions. 2009. Available at SSRN 991835.
Drummond M, Weatherly H, Ferguson B. Economic evaluation of health interventions. BMJ. 2008;337.
de Vries LM, van Baal PH, Brouwer WB. Future costs in cost-effectiveness analyses: past, present, future. Pharmacoeconomics. 2019;37(2):119–30.
Vlassoff M, Singh S, Darroch JE, Carbone E, Bernstein S. Assessing costs and benefits of sexual and reproductive health interventions; 2004.
Newton D, Bayly C, Fairley C, Chen M, Williams H, Keogh L, et al. The impact of pelvic inflammatory disease on sexual, reproductive and psychological health. BMJ Publishing Group Limited. 2011;8:233.
Bloch SC, Jackson LJ, Frew E, Ross JD. Assessing the costs and outcomes of control programmes for sexually transmitted infections: a systematic review of economic evaluations. Sex Transm Infect. 2021;97(5):334–44.
Krol M, Brouwer W, Rutten F. Productivity costs in economic evaluations: past, present, future. Pharmacoeconomics. 2013;31(7):537–49.
Shepherd J, Kavanagh J, Picot J, Cooper K, Harden A, Barnett-Page E, et al. The effectiveness and cost-effectiveness of behavioural interventions for the prevention of sexually transmitted infections in young people aged 13-19: a systematic review and economic evaluation. Health Technol Assess. 2010;14(7):1–206 iii-iv.
Chong A, Gonzalez-Navarro M, Karlan D, Valdivia M. Effectiveness and spillovers of online sex education: evidence from a randomized evaluation in Colombian public schools. NBER Working Pap Ser. 2013:18776.
Schnitzler L, Janssen LM, Evers SM, Jackson LJ, Paulus AT, Roberts TE, et al. The broader societal impacts of COVID-19 and the growing importance of capturing these in health economic analyses. Int J Technol Assess Health Care. 2021;37(1):E43.
Bonanni P, Picazo JJ, Rémy V. The intangible benefits of vaccination–what is the true economic value of vaccination? J Market Access Health Policy. 2015;3(1):26964.
The authors would like to thank Gregor H.L.M. Franssen, Clinical Librarian at the Maastricht University Library, Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands, for his support in developing the search strategy.
The first and corresponding author (LS) is supported by a PhD Studentship, which is funded jointly by the University of Birmingham and the University of Maastricht. None of the other authors received any specific funding for the study. The funders had no role in the study design or analysis, nor in the preparation of the manuscript.
Ethics approval and consent to participate
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Schnitzler, L., Evers, S.M.A.A., Jackson, L.J. et al. Are intersectoral costs considered in economic evaluations of interventions relating to sexually transmitted infections (STIs)? A systematic review. BMC Public Health 22, 2180 (2022). https://doi.org/10.1186/s12889-022-14484-z