To expand coverage, or increase frequency: Quantifying the tradeoffs between equity and efficiency facing cervical cancer screening programs in low-resource settings

Abstract

Cervical cancer is a leading cause of cancer death worldwide, with 85% of the disease burden residing in less developed regions. To inform evidence‐based decision‐making as cervical cancer screening programs are planned, implemented, and scaled in low‐ and middle‐income countries, we used cost and test performance data from the START‐UP demonstration project in Uganda and a microsimulation model of HPV infection and cervical carcinogenesis to quantify the health benefits, distributional equity, cost‐effectiveness, and financial impact of either (1) improving access to cervical cancer screening or (2) increasing the number of lifetime screening opportunities for women who already have access. We found that when baseline screening coverage was low (i.e., 30%), expanding coverage of screening once in a lifetime to 50% can yield comparable reductions in cancer risk to screening two or three times in a lifetime at 30% coverage, lead to greater reductions in health disparities, and cost 150 international dollars (I$) per year of life saved (YLS). At higher baseline screening coverage levels (i.e., 70%), screening three times in a lifetime yielded greater health benefits than expanding screening once in a lifetime to 90% coverage, and would have a cost‐effectiveness ratio (I$590 per YLS) below Uganda's per capita GDP. Given very low baseline coverage at present, we conclude that a policy focus on increasing access for previously unscreened women appears to be more compatible with improving both equity and efficiency than a focus on increasing frequency for a small subset of women.

Uptake and correlates of cervical cancer screening among HIV-infected women attending HIV care in Uganda

“…Despite the reduction from three to two doses of HPV vaccine, which was intended to reduce costs and ease administration, uptake of HPV vaccine has remained low owing to cost and lack of knowledge [10]. Cervical cancer screening remains very low across several countries in SSA because of low levels of awareness, challenges with health-seeking behavior, and health system barriers [11]. A study in two districts in Eastern Uganda found that only 4.8% of women aged between 25 and 49 years had ever been screened for cervical cancer, and most had been screened owing to symptoms which they associated with cervical cancer [12].…”

Evidence‐based policy choices for efficient and equitable cervical cancer screening programs in low‐resource settings

“…For each of these challenges, we summarize the tradeoffs between resource utilization and programmatic attributes. We then highlight opportunities for efficient and equitable prevention programming, with supporting evidence from recent mathematical modeling analyses informed by data from the PATH demonstration projects in India, Nicaragua, and Uganda .…”

The health and economic impact of scaling cervical cancer prevention in 50 low‐ and lower‐middle‐income countries

“…To account for herd immunity benefits, HPV transmission models informed by sexual behavior data are needed. We have not explored the impact of varying coverage, vaccine efficacy, screening test performance, or visit compliance here, but have described elsewhere the importance of these parameters in estimating the cost‐effectiveness of cervical cancer prevention …”