Abstract
BackgroundWhere resources are available, the World Health Organization recommends cervical cancer screening with human papillomavirus (HPV) DNA testing and subsequent treatment of HPV-positive women with timely cryotherapy. Newer technologies may facilitate a same-day screen-and-treat approach, but these testing systems are generally too expensive for widespread use in low-resource settings.MethodsTo assess the value of a hypothetical point-of-care HPV test, we used a mathematical simulation model of the natural history of HPV and data from the START-UP multi-site demonstration project to estimate the health benefits and costs associated with a shift from a 2-visit approach (requiring a return visit for treatment) to 1-visit HPV testing (i.e., screen-and-treat). We estimated the incremental net monetary benefit (INMB), which represents the maximum additional lifetime cost per woman that could be incurred for a new point-of-care HPV test to be cost-effective, depending on expected loss to follow-up between visits (LTFU) in a given setting.ResultsFor screening three times in a lifetime at 100% coverage of the target population, when LTFU was 10%, the INMB of the 1-visit relative to the 2-visit approach was I$13 in India, I$36 in Nicaragua, and I$17 in Uganda. If LTFU was 30% or greater, the INMB values for the 1-visit approach in all countries was equivalent to or exceeded total lifetime costs associated with screening three times in a lifetime. At a LTFU level of 70%, the INMB of the 1-visit approach was I$127 in India, I$399 in Nicaragua, and I$121 in Uganda.ConclusionsThese findings indicate that point-of-care technology for cervical cancer screening may be worthy of high investment if linkage to treatment can be assured, particularly in settings where LTFU is high.
Highlights
Where resources are available, the World Health Organization recommends cervical cancer screening with human papillomavirus (HPV) DNA testing and subsequent treatment of HPV-positive women with timely cryotherapy
The knowledge that cervical cancer is caused by persistent infection with one or more oncogenic human papillomavirus (HPV) types [2] has led to advances in screening technology, including HPV DNA tests that are highly sensitive to detect precancer and cancer [3]
As loss to follow-up between visits (LTFU) increased, reduction in cancer risk associated with the 1-visit strategy remained stable in each country, while the health impact of the 2-visit approach diminished substantially
Summary
The World Health Organization recommends cervical cancer screening with human papillomavirus (HPV) DNA testing and subsequent treatment of HPV-positive women with timely cryotherapy. The careHPV testing system is designed to be run in batch mode [8], with optimal use at 90 samples per batch; few clinics in low-resource settings can achieve this high screening volume in a single day. These processing time and batch size constraints hinder same-day results and treatment for HPV-positive women. Given the substantial barriers to returning to the health facility in many low-resource settings [9,10,11], the need for at least two visits (first, for administration of the screening test and second, for receiving results and treatment if screen-positive) signifies that many women in need of treatment might never receive it
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