The Cost-Effectiveness of Visual Triage of Human Papillomavirus–Positive Women in Three Low- and Middle-Income Countries

Abstract

World Health Organization guidelines support human papillomavirus (HPV) testing alone (followed by treatment with cryotherapy) or in conjunction with visual inspection with acetic acid (VIA) triage testing. Our objective was to determine the cost-effectiveness of VIA triage for HPV-positive women in low-resource settings. We calibrated mathematical simulation models of HPV infection and cervical cancer to epidemiologic data from India, Nicaragua, and Uganda. Using cost and test performance data from the START-UP demonstration projects, we assumed screening took place either once or three times in a lifetime between ages 30 and 40 years. Strategies included (i) HPV alone, followed by cryotherapy for all eligible HPV-positive women; and (ii) HPV testing with VIA triage for HPV-positive women, followed by cryotherapy for eligible women who were also VIA-positive (HPV-VIA). Model outcomes included lifetime risk of cervical cancer and incremental cost-effectiveness ratios (ICERs; international dollars/year of life saved). In all three countries, HPV alone was more effective than HPV-VIA. In Nicaragua and Uganda, HPV alone was also less costly than HPV-VIA; ICERs associated with screening three times in a lifetime (HPV alone) were below per capita GDP. In India, both HPV alone and HPV-VIA had ICERs below per capita GDP. VIA triage of HPV-positive women is not likely to be cost-effective in settings with high cervical cancer burden. HPV alone followed by treatment may achieve greater health benefits and value for public health dollars. This study provides early evidence on the cost-effectiveness of HPV testing followed by VIA triage versus an HPV screen-and-treat strategy. .

Evaluation of human-papillomavirus testing and visual inspection for cervical cancer screening in Rwanda

“…Although this approach will treat some women without disease, it will also destroy cells from the cervical squamocolumnar junction where most HPV-related neoplastic lesions originate [ 36 ]. Indeed, in a modelling exercise, even with re-screening at one year of HPV-positives, 2-visit VIA-triage of HPV positive women was not a cost effective approach in comparison to treating all HPV-positive women [ 37 ].…”

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

“… 11 , 12 Our modeling approach assumes similarities in the natural history of HPV regardless of setting but allows for differences in HPV incidence (due to sexual behavior) and type-specific immunity. To reflect the greater risk of HPV infection and progression (to CIN and cancer) and the decreased likelihood of HPV clearance and CIN regression in HIV-infected women, as well as parameter uncertainty, we modified the previously described natural history model by setting plausible ranges for factors to apply to baseline transition probabilities derived from longitudinal studies, guided by previous work modeling HPV infection in the general population of women in several low- and middle-income countries with a low burden of HIV 12 , 20 and published hazard and risk ratios in HIV-infected versus HIV-uninfected women. 21 The model underwent repeated model simulations in the absence of any intervention, and for each simulation, single random values from a uniform distribution spanning the plausible range for each factor were selected and applied to the relevant baseline probability to create a unique natural history input parameter set.…”

Potential effectiveness of a therapeutic HPV intervention campaign in Uganda

“…9,10 Given existing barriers to accessing care, strategies that reduce the number of visits needed for diagnosis and treatment are generally cost-effective relative to traditional cytology approaches in which multiple follow-up visits are needed. 11,12 In Uganda, lifetime screen rates are estimated to be between 5% and 30% and typically relies on visual inspection with acetic acid (VIA) followed by treatment with cryotherapy for women with identified precancerous lesions. 10,13 New developments in delivery of cervical cancer screening seek to reduce costs and increase accessibility to treatment by reducing complexity and resource burden of traditional screening strategies.…”