Direct cost analysis of diagnostic pathways for acute vulvovaginal candidiasis in Uganda: a modelling study
Jonani Bwambale, Nakitende Patricia Peace, Ssebunya Enock, Gerald Mboowa, Anita Kisakye, Abel W Walekhwa, Felix Ocom, Alex R Ario, Betty Kivumbi NannyongaAbstract
Background
Vulvovaginal candidiasis (VVC) is commonly managed syndromically or investigated using fungal culture. This study compared direct medical costs of three diagnostic pathways for acute VVC in Uganda.
Methods
A decision-analytic cost model compared syndromic management, culture-based diagnosis, and microscopy-based diagnosis in a hypothetical cohort of 1,000 symptomatic women. The proportion classified by the microscopy-based framework as meeting the model criteria for antifungal treatment (10.1%) was derived from 447 high vaginal swab records at Sebbi Hospital (2022-2025). Laboratory and antifungal costs were obtained from procurement records and Uganda Joint Medical Stores prices. The culture-based pathway incorporated a return-visit consultation fee. One-way sensitivity analyses were conducted and a societal-perspective scenario assessed cost differences between pathways.
Results
Total direct costs per 1,000 women were USD 10,761 for syndromic management, USD 35,565 for culture-based diagnosis, and USD 14,996 for microscopy-based diagnosis. Culture-based diagnosis was the costliest pathway under every condition examined, exceeding microscopy-based diagnosis by USD 20,568 and syndromic management by USD 24,804. Microscopy-based diagnosis did not generate net savings over syndromic management at base-case public sector antifungal prices. The cost difference was most sensitive to the unit cost of microscopy and antifungal treatment. Selective fungal culture increased the cost of the microscopy-based pathway in a separate scenario analysis. For the base-case microscopy-based pathway, without selective fungal culture, the break-even antifungal unit price was USD 6.01 per treatment episode.
Conclusion
Under the modelled assumptions, microscopy-based diagnosis becomes less costly than syndromic management when the antifungal treatment price exceeded the base-case break-even threshold.