Abstract
With the availability of a low-cost HPV DNA test that can be administered by either a healthcare provider or a woman herself, programme planners require information on the costs and cost-effectiveness of implementing cervical cancer screening programmes in low-resource settings under different models of healthcare delivery. Using data from the START-UP demonstration project and a micro-costing approach, we estimated the health and economic impact of once-in-a-lifetime HPV self-collection campaign relative to clinic-based provider-collection of HPV specimens in Uganda. We used an individual-based Monte Carlo simulation model of the natural history of HPV and cervical cancer to estimate lifetime health and economic outcomes associated with screening with HPV DNA testing once in a lifetime (clinic-based provider-collection vs a self-collection campaign). Test performance and cost data were obtained from the START-UP demonstration project using a micro-costing approach. Model outcomes included lifetime risk of cervical cancer, total lifetime costs (in 2011 international dollars [I$]), and life expectancy. Cost-effectiveness ratios were expressed using incremental cost-effectiveness ratios (ICERs). When both strategies achieved 75% population coverage, ICERs were below Uganda’s per capita GDP (self-collection: I$80 per year of life saved [YLS]; provider-collection: I$120 per YLS). When the self-collection campaign achieved coverage gains of 15–20%, it was more effective than provider-collection, and had a lower ICER unless coverage with both strategies was 50% or less. Findings were sensitive to cryotherapy compliance among screen-positive women and relative HPV test performance. The primary limitation of this analysis is that self-collection costs are based on a hypothetical campaign but are based on unit costs from Uganda. Once-in-a-lifetime screening with HPV self-collection may be very cost-effective and reduce cervical cancer risk by > 20% if coverage is high. Demonstration projects will be needed to confirm the validity of our logistical, costing and compliance assumptions.
Highlights
Cervical cancer is caused by persistent infection with one or more oncogenic human papillomavirus (HPV) types
We found that an HPV self-collection campaign would be an effective and very cost-effective alternative to clinic-based provider-collection in Uganda, at high coverage levels (i.e. 75% and above) and when self-collection is associated with greater coverage of screening-eligible women than provider-collection
We explored the impact of several uncertain assumptions and inputs, including community health workers (CHWs) delivering screening results by text message, rather than home visits; reducing cryotherapy compliance in the self-collection campaign strategy from 85 to 70%; decreasing or increasing prototypical district size for purposes of programmatic cost allocation; improving test performance of selfcollection to mirror provider-collection, to reflect the similar performance of PCR-based tests regardless of collection method; and adding comparable programmatic costs to clinic-based providercollection
Summary
Cervical cancer is caused by persistent infection with one or more oncogenic human papillomavirus (HPV) types. Despite the potential for prevention through organized screening programmes that detect and treat precancerous lesions, cervical cancer is a leading cause of cancer death among women worldwide (Ferlay et al 2013). Routine screening with Pap smear testing has reduced the burden of cervical cancer in high-income countries (Kitchener et al 2006), but the implementation of Pap-based screening programmes has not been feasible in low-resource settings due to a lack of healthcare delivery infrastructure and limited health budgets. Despite the challenges of implementing and scaling cervical cancer screening programmes in low-resource settings, several clinical and economic studies have suggested that a screen-and-treat approach using VIA or HPV DNA testing can be feasible, beneficial, and cost-effective (Sankaranarayanan et al 2009; Shastri et al 2014; Campos et al 2015a,b). The decrement in test sensitivity associated with self-collection of vaginal samples poses a trade-off between the potential for increased uptake with self-sampling vs the enhanced lesion detection associated with provider-collection of cervical samples (Arbyn et al 2014)
Sign-in/Register to view highlights & summary Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
