Cervical Cancer Elimination with Single-Visit Screening and Treatment Strategies in South Africa: Modeled Estimates in the Context of High HIV Prevalence

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Background: In settings with high HIV prevalence, cervical cancer incidence rates are up to six-fold higher than the global average of 13.1/100,000 women-years. To achieve global cervical cancer elimination, it is critical to identify scalable prevention strategies that account for HIV-associated cancer risk and address barriers to healthcare while minimizing overtreatment. Methods: We developed a dynamic model of HIV-HPV co-infection and disease progression, which we calibrated to KwaZulu-Natal, South Africa. Our baseline scenario reflects current practice of HPV vaccination, cytology-based screening, and colposcopy triage. We evaluated nine comparator scenarios with increased vaccination coverage and one-time or repeat screening with single-visit strategies: HPV DNA testing, HPV genotyping, Automated Visual Evaluation (AVE), and HPV DNA with AVE triage. For each scenario, we simulated cancer incidence from 2021-2120 using the 25 best-fitting parameter sets. We present the median and range of model output. Findings: Continuing current cervical cancer and HIV prevention strategies is projected to decrease cervical cancer incidence by 87%, from an age-standardized rate per 100,000 women of 80.4 (range 58·2-112·1) to 10·7 (4·2-29·9) in 2120. Scaling up single-visit strategies result in incidence rates 29-34% lower in 2030 relative to the baseline scenario. Elimination (incidence <4/100,000) could be achieved with HPV DNA testing in 2095 and with AVE in 2114. HPV DNA with AVE triage optimizes the tradeoff between cancer cases averted and overtreatment. Interpretation: Single-visit screening strategies could avert a substantial burden of cervical cancer and accelerate progress towards elimination in high-burden settings. Funding: National Institutes of Health, World Health Organization. Declaration of Interest: NM receives research funding from Merck Ltd. RVB declares support from the National Institutes of Health and the Bill and Melinda Gates Foundation, and funding from Regeneron Pharmaceuticals for manuscript writing and abstract submission outside the submitted work. No authors have conflicts to declare.