Potential Impact of Antiretroviral Therapy and Screening on Cervical Cancer Mortality in HIV-Positive Women in Sub-Saharan Africa: A Simulation

Evan Myers,Julius Atashili,Beatriz Grinsztejn,Adaora A Adimora,Joseph Eron,William C Miller,Jennifer S Smith

doi:10.1371/journal.pone.0018527

Abstract

BackgroundDespite having high cervical cancer incidence and mortality rates, screening for cervical precancerous lesions remains infrequent in sub-Saharan Africa. The need to screen HIV-positive women because of the higher prevalence and faster progression of cervical precancerous lesions may be heightened by the increased access to highly-active antiretroviral therapy (HAART). Policymakers need quantitative data on the effect of HAART and screening to better allocate limited resources. Our aim was to quantify the potential effect of these interventions on cervical cancer mortality.Methods and FindingsWe constructed a Markov state-transition model of a cohort of HIV-positive women in Cameroon. Published data on the prevalence, progression and regression of lesions as well as mortality rates from HIV, cervical cancer and other causes were incorporated into the model. We examined the potential impact, on cumulative cervical cancer mortality, of four possible scenarios: no HAART and no screening (NHNS), HAART and no screening (HNS), HAART and screening once on HAART initiation (HSHI), and HAART and screening once at age 35 (HS35). Our model projected that, compared to NHNS, lifetime cumulative cervical cancer mortality approximately doubled with HNS. It will require 262 women being screened at HAART initiation to prevent one cervical cancer death amongst women on HAART. The magnitudes of these effects were most sensitive to the rate of progression of precancerous lesions.ConclusionsScreening, even when done once, has the potential of reducing cervical cancer mortality among HIV-positive women in Africa. The most feasible and cost-effective screening strategy needs to be determined in each setting.

Highlights

Cervical cancer is one of the leading causes of cancer death among women in sub-Saharan Africa [1]
We hypothesize that the increased survival that is expected to result from increased access to highly-active antiretroviral therapy (HAART) may be large enough to allow for lesions to progress to invasive cervical cancer and is likely to be followed by an increase in cervical cancer incidence and mortality
The baseline model projected a lifetime cumulative cervical cancer mortality of 25.4 per 1000 HIVpositive women who were infected at age 25 and neither received HAART nor were screened for cervical cancer (Table 2)

Summary

Introduction

Cervical cancer is one of the leading causes of cancer death among women in sub-Saharan Africa [1]. Death from cervical cancer would prevent further progression of HIV disease and, prior to the advent of highly active antiretroviral therapy (HAART), the progression of cervical precancerous lesions to cancer was largely averted by early death from AIDS and other opportunistic infections. We hypothesize that the increased survival that is expected to result from increased access to HAART may be large enough to allow for lesions to progress to invasive cervical cancer and is likely to be followed by an increase in cervical cancer incidence and mortality. Despite having high cervical cancer incidence and mortality rates, screening for cervical precancerous lesions remains infrequent in sub-Saharan Africa. The need to screen HIV-positive women because of the higher prevalence and faster progression of cervical precancerous lesions may be heightened by the increased access to highly-active antiretroviral therapy (HAART). Our aim was to quantify the potential effect of these interventions on cervical cancer mortality

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