Direct Cost Analysis of Diagnostic Pathways for Acute Vulvovaginal Candidiasis in Uganda: A Modeling Study.

Background: Vulvovaginal candidiasis (VVC) is commonly managed syndromically or investigated using fungal culture. This study compared direct medical costs of 3 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 1000 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 used to assess cost differences between pathways. Results: Total direct costs per 1000 women were US dollar (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. Conclusions: Under the modeled assumptions, microscopy-based diagnosis becomes less costly than syndromic management when the antifungal treatment price exceeded the base-case break-even threshold.