Health and economic impact of HPV 16/18 vaccination and cervical cancer screening in Eastern Africa

Abstract

Eastern Africa has the world's highest cervical cancer incidence and mortality rates. We used epidemiologic data from Kenya, Mozambique, Tanzania, Uganda, and Zimbabwe to develop models of HPV-related infection and disease. For each country, we assessed HPV vaccination of girls before age 12 followed by screening with HPV DNA testing once, twice, or three times per lifetime (at ages 35, 40, 45). For women over age 30 we assessed only screening (with HPV DNA testing up to three times per lifetime or VIA at age 35). Assuming no waning immunity, mean reduction in lifetime cancer risk associated with vaccination ranged from 36-45%, and vaccination followed by screening once per lifetime at age 35 with HPV DNA testing ranged from 43-51%. For both younger and older women, the most effective screening strategy was HPV DNA testing three times per lifetime. Provided the cost per vaccinated girl was less than I$10 (I$2 per dose), vaccination had an incremental cost-effectiveness ratio (I$ [international dollars]/year of life saved [YLS]) less than the country-specific per capita GDP, a commonly cited heuristic for “very cost-effective” interventions. If the cost per vaccinated girl was between I$10 (I$2 per dose) and I$25 (I$5 per dose), vaccination followed by HPV DNA testing would save the most lives and would be considered good value for public health dollars. These results should be used to catalyze design and evaluation of HPV vaccine delivery and screening programs, and contribute to a dialogue on financing HPV vaccination in poor countries.

The comparative and cost-effectiveness of HPV-based cervical cancer screening algorithms in El Salvador

“…[8][9][10][11][12] The model was calibrated to epidemiologic data from El Salvador and used to compare screening with careHPV using two algorithms for the management of women who test HPV-positive, as well as Papbased screening for women aged 30-65 years.…”

“…Transportation time was included separately for both the CM and ST cohorts for the results visit, at which cryotherapy was performed. 12 Includes 150 min of wait time, 30 min of procedure time, and 180 min of round-trip transportation time. 13 Includes 150 min of wait time, 15 min of procedure time, and 180 min of round-trip transportation time.…”

Factors influencing Malawian women's willingness to self-collect samples for human papillomavirus testing

“…However, despite rolling out a national cervical cancer screening programme in Malawi using visual inspection with acetic acid (VIA) in 2004, access and utilisation remains limited with only 3% of women ever screened for cervical cancer 1. Cervical cancer screening programmes are rare in Malawi and other low-resource regions for many reasons, including lack of health delivery infrastructure and trained personnel, limited health budgets, and competing healthcare priorities 3 4. With recent advancements in testing for human papillomavirus (HPV), which is responsible for nearly all cases of cervical cancer,5 the establishment of more accessible screening programmes in conjunction with existing VIA programmes is now possible.…”

Comparison of Visual Inspection with Acetic Acid and the Pap Smear for Cervical Cancer Screening

“…Although opportunities for primary prevention now exist with the availability of 2 prophylactic vaccines efficacious against HPV types 16 and 18 (which cause approximately 70% of cervical cancers [15,16] ) and a recently approved 9-valent vaccine against 5 additional HPV types [17] , screening remains the only form of prevention for 2-3 generations of women beyond the adolescent target age for vaccination. Despite the difficulties of implementing and scaling up cervical cancer screening programs, demonstration projects and clinical studies of test performance suggest that 1-visit and 2-visit screen-and-treat approaches using VIA or HPV DNA testing could be feasible, beneficial, and cost-effective in resource-poor settings [18][19][20][21] . Moreover, the World Health Organization has recently recommended the use of HPV testing or VIA for cervical cancer screening in those regions and countries that have not already established an effective, high-coverage, Pap-based program [22] .…”