Cost-Effectiveness of Cervical Cancer Screening in Women Living With HIV in South Africa: A Mathematical Modeling Study

Campos, Nicole G.; Lince-Deroche, Naomi; Chibwesha, Carla J.; Firnhaber, Cynthia; Smith, Jennifer S.; Michelow, Pam; Meyer‐Rath, Gesine; Jamieson, Lise; Jordaan, Suzette; Regan, Catherine; Sy, Stephen; Gui, Liu; Tsu, Vivien; Jerónimo, José; Kim, Jane J.

doi:10.1097/qai.0000000000001778

Cited by 24 publications

(29 citation statements)

References 35 publications

(37 reference statements)

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“…Our results are in line with previous evidence suggesting that integrated CC screening and treatment services into HIV care can be life-saving and that the added benefits of HPV-DNA tests, compared with VIA, depend on ensuring LTFU is minimised 26 27. These and our results highlight key implications for health systems of SSA that, like Kenya, are looking to scale up CC screening coverage and respond to the WHO’s call to eliminate CC.…”

Section: Discussionsupporting

confidence: 90%

“…We believe these results are applicable to other high-HIV burden countries and the directionality of the results to be applicable to HIV-negative populations. Previous models of CC among WHIV in SSA have focused on cohort approaches to produce key contributions to the cost-effectiveness literature of CC screening strategies 26 27 36. However, population-level health outcomes have not been at the core of these studies, and simulated strategies have been outside of those recommended by national guidelines (eg, once in a lifetime) and/or targeted idealised cohorts (where infection with HIV and treatment with ART happens statically at an early age).…”

Section: Discussionmentioning

confidence: 99%

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The impact of scaling up cervical cancer screening and treatment services among women living with HIV in Kenya: a modelling study

et al. 2020

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IntroductionWe aimed to quantify health outcomes and programmatic implications of scaling up cervical cancer (CC) screening and treatment options for women living with HIV in care aged 18–65 in Kenya.MethodsMathematical model comparing from 2020 to 2040: (1) visual inspection with acetic acid (VIA) and cryotherapy (Cryo); (2) VIA and Cryo or loop excision electrical procedure (LEEP), as indicated; (3) human papillomavirus (HPV)-DNA testing and Cryo or LEEP; and (4) enhanced screening technologies (either same-day HPV-DNA testing or digitally enhanced VIA) and Cryo or LEEP. Outcomes measured were annual number of CC cases, deaths, screening and treatment interventions, and engaged in care (numbers screened, treated and cured) and five yearly age-standardised incidence.ResultsAll options will reduce CC cases and deaths compared with no scale-up. Options 1–3 will perform similarly, averting approximately 28 000 (33%) CC cases and 7700 (27%) deaths. That is, VIA screening would yield minimal losses to follow-up (LTFU). Conversely, LTFU associated with HPV-DNA testing will yield a lower care engagement, despite better diagnostic performance. In contrast, option 4 would maximise health outcomes, averting 43 200 (50%) CC cases and 11 800 (40%) deaths, given greater care engagement. Yearly rescreening with either option will impose a substantial burden on the health system, which could be reduced by spacing out frequency to three yearly without undermining health gains.ConclusionsBeyond the specific choice of technologies to scale up, efficiently using available options will drive programmatic success. Addressing practical constraints around diagnostics’ performance and LTFU will be key to effectively avert CC cases and deaths.

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Section: Discussionsupporting

confidence: 90%

Section: Discussionmentioning

confidence: 99%

The impact of scaling up cervical cancer screening and treatment services among women living with HIV in Kenya: a modelling study

et al. 2020

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“…Among the most notable results of our study was that the participants expressed a strong preference for same‐day HPV testing and treatment. Although this strategy is thought to be cost‐effective in the context of low‐income and middle‐income countries, including those with generalized HIV epidemics, few programs in South Africa have previously used the single‐visit strategy . The local standard of care follows a multivisit paradigm in which abnormal Papanicolaou smear test results are followed by diagnostic biopsy and excisional treatment if biopsy confirms the presence of high‐grade precancerous lesions .…”

Section: Discussionmentioning

confidence: 99%

Exploring women's preferences for HPV‐based cervical cancer screening in South Africa

Oberlin

Pasipamire

Chibwesha

2019

Intl J Gynecology & Obste

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Objective To determine preferences for HPV‐based cervical cancer screening among South African women. Methods A discrete choice experiment survey was conducted among 298 women who attended two public‐sector clinics in South Africa from February 1 to May 31, 2018. Participants chose between hypothetical screening scenarios: method of swab collection (self or provider); timing of treatment (same day or return visit); type of clinic (static or mobile); cost of services (US $0 or US $4); and time spent at the clinic (30, 60, or 120 minutes). A logistic regression model was generated to evaluate the importance of each attribute. A market simulation analysis was performed to determine potential uptake of the various screening strategies. Results The participants expressed strong preferences for free services (β=0.50; P<0.001) and same‐day HPV testing and treatment (β=0.40; P<0.001). The market simulation indicated that 83.8% of women would be willing to undergo screening if services were free; the swab was collected by the provider; and treatment was offered at a return visit. Including same‐day testing and treatment in the model increased uptake to 96.4%. Conclusion Offering same‐day HPV testing and treatment could substantially improve uptake of cervical cancer screening in the South African public healthcare sector.

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“…Personnel, consumables, equipment and laboratory costs were included, but building costs were excluded. We obtained costs incurred by patients for screening and pre-cancer treatment as well as cervical cancer treatment from a separate cost-effectiveness study comparing cervical cancer screening and treatment for HIV-positive women in South Africa (18). Patient costs include both direct costs, such as travel costs, as well as the opportunity cost of lost time, valued as the median income of the sample.…”

Section: Comparison Strategiesmentioning

confidence: 99%

“…For the CEA, we used a Monte Carlo simulation model previously developed to t the natural history of HPV infection and cervical cancer among HIV-infected women in South Africa (18). Girls entered the model at 9 years of age, were assumed to be infected with HIV at 20 years and diagnosed at age 25 years.…”

Section: 3 Economic Evaluationmentioning

confidence: 99%

The Value of Different Types of Economic and Budget Analysis for Informing Real World Decision Making: the Case of Cervical Cancer Screening in South Africa

Rensburg

Meyer‐Rath

Campos

et al. 2020

Preprint

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Objectives South Africa recently updated its cervical cancer screening policy, which we used as a case study to compare the outcomes of different methods of economic evaluation and their potential contributions to decision making.Methods We applied three evaluation methods – cost-effectiveness analysis (CEA), budget impact analysis (BIA) and multi-criteria decision analysis (MCDA) – to six strategies for screening and treatment of cervical pre-cancer lesions in HIV-positive women. Strategies included screening with visual inspection with acetic acid (VIA); cytology, followed by colposcopic biopsy; and HPV DNA testing. Strategies also differed by number of visits for screening and management, and treatment (cryotherapy or LEEP). Results Ranking of strategies differed by evaluation method. HPV DNA testing with LEEP ranked highest in the CEA but had the largest budget impact. VIA 1- visit ranked highly across the methods. Cytology was dominated in the CEA but was more affordable than HPV DNA testing, and scored lowest on the MCDA despite being the method chosen in the policy for the scale up of services. Conclusions Standard economic evaluations often rely on CEA for priority setting. In our study, the difference in strategy rankings between the evaluation methods demonstrates the tension between CEA, budget constraints, and other decision-maker priorities. While MCDA may be best placed to offer multi-faceted input, it struggles to resolve this tension when policy decisions are made over a number of sequential steps.

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Cost-Effectiveness of Cervical Cancer Screening in Women Living With HIV in South Africa: A Mathematical Modeling Study

Abstract: Supplemental Digital Content is Available in the Text.

Cited by 24 publications

References 35 publications

The impact of scaling up cervical cancer screening and treatment services among women living with HIV in Kenya: a modelling study

The impact of scaling up cervical cancer screening and treatment services among women living with HIV in Kenya: a modelling study

Exploring women's preferences for HPV‐based cervical cancer screening in South Africa

The Value of Different Types of Economic and Budget Analysis for Informing Real World Decision Making: the Case of Cervical Cancer Screening in South Africa

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