Condoms at bathhouses and syphilis: a cost-effectiveness analysis of providing condoms to reduce the spread of syphilis at bathhouses in Toronto, Canada
University of Toronto, Health Policy, Management and Evaluation, Toronto, Canada
Background: Though there is a long history of mass distribution of condoms; there is a lack of research to support planning and evaluation of condom distribution programs. Oral sex and sex at bathhouses have been implicated in the current syphilis outbreak among men who have sex with men (MSM) in Toronto, Canada. The syphilis outbreak could be an important facet of the unstable HIV epidemic among MSM in Ontario; among syphilis cases in Toronto in 2008, 45% were HIV-positive.
Methods: A cost-effectiveness analysis was conducted to determine the cost per syphilis case averted. The distribution of condoms to bathhouses was evaluated in terms of the cost to Toronto Public Health (TPH) and the impact of this program on reducing syphilis related to oral sex in bathhouses in Toronto in 2007. Estimates of behaviours were collected from the literature; these were discussed and verified with local sources. Estimates of syphilis cases averted were derived by mathematical modelling. Sensitivity analyses were conducted.
Results: A conservative estimate of the cost effectiveness of TPH’s provision of free condoms in bathhouses is US$158/syphilis case averted. If the program was assumed to be least effective under plausible conditions, the cost remained relatively low at US$450/syphilis case averted.
Conclusions: The cost associated with treating syphilis in Toronto is unknown; however, literature from the US suggests that the average directs cost per case of syphilis is US$572. While this study had several limitations, it does suggest that even if the provision of free condoms in bathhouses is having a very small effect on the increase of condom use during oral sex it is relatively cost-effective. Effective responses to the syphilis outbreaks among men who have sex with men in urban areas may provide insight and additional information as to how to prevent the spread of HIV amongst this high risk population.