Dataset Information

Cost-Effectiveness of Cervical Cancer Screening in Women Living With HIV in South Africa: A Mathematical Modeling Study.

ABSTRACT:

Background

Women with HIV face an increased risk of human papillomavirus (HPV) acquisition and persistence, cervical intraepithelial neoplasia, and invasive cervical cancer. Our objective was to determine the cost-effectiveness of different cervical cancer screening strategies among women with HIV in South Africa.

Methods

We modified a mathematical model of HPV infection and cervical disease to reflect coinfection with HIV. The model was calibrated to epidemiologic data from HIV-infected women in South Africa. Clinical and economic data were drawn from in-country data sources. The model was used to project reductions in the lifetime risk of cervical cancer and incremental cost-effectiveness ratios (ICERs) of Pap and HPV DNA screening and management algorithms beginning at HIV diagnosis, at 1-, 2-, or 3-year intervals. Strategies with an ICER below South Africa's 2016 per capita gross domestic product (US$5270) were considered "cost-effective."

Results

HPV testing followed by treatment (test-and-treat) at 2-year intervals was the most effective strategy that was also cost-effective, reducing lifetime cancer risk by 56.6% with an ICER of US$3010 per year of life saved. Other cost-effective strategies included Pap (referral threshold: HSIL+) at 1-, 2-, and 3-year intervals, and HPV test-and-treat at 3-year intervals. Pap (ASCUS+), HPV testing with 16/18 genotyping, and HPV testing with Pap or visual triage of HPV-positive women were less effective and more costly than alternatives.

Conclusions

Considering per capita gross domestic product as the benchmark for cost-effectiveness, HPV test-and-treat is optimal in South Africa. At lower cost-effectiveness benchmarks, Pap (HSIL+) would be optimal.

SUBMITTER: Campos NG

PROVIDER: S-EPMC6143200 | biostudies-literature | 2018 Oct

REPOSITORIES: biostudies-literature

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Publications

Cost-Effectiveness of Cervical Cancer Screening in Women Living With HIV in South Africa: A Mathematical Modeling Study.

Campos Nicole G NG Lince-Deroche Naomi N Chibwesha Carla J CJ Firnhaber Cynthia C Smith Jennifer S JS Michelow Pam P Meyer-Rath Gesine G Jamieson Lise L Jordaan Suzette S Sharma Monisha M Regan Catherine C Sy Stephen S Liu Gui G Tsu Vivien V Jeronimo Jose J Kim Jane J JJ

Journal of acquired immune deficiency syndromes (1999) 20181001 2

<h4>Background</h4>Women with HIV face an increased risk of human papillomavirus (HPV) acquisition and persistence, cervical intraepithelial neoplasia, and invasive cervical cancer. Our objective was to determine the cost-effectiveness of different cervical cancer screening strategies among women with HIV in South Africa.<h4>Methods</h4>We modified a mathematical model of HPV infection and cervical disease to reflect coinfection with HIV. The model was calibrated to epidemiologic data from HIV-i ...[more]

PMID: 29916959

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Project description:ObjectiveTo determine the costs and health effects of interventions to combat breast, cervical, and colorectal cancers in order to guide resource allocation decisions in developing countries.SettingTwo World Health Organization sub-regions of the world: countries in sub-Saharan Africa with very high adult and high child mortality (AfrE); and countries in South East Asia with high adult and high child mortality (SearD).DesignCost effectiveness analysis of prevention and treatment strategies for breast, cervical, and colorectal cancer, using mathematical modelling based on a lifetime population model.Data sourcesDemographic and epidemiological data were taken from the WHO mortality and global burden of disease databases. Estimates of intervention coverage, effectiveness, and resource needs were based on clinical trials, treatment guidelines, and expert opinion. Unit costs were taken from the WHO-CHOICE price database.Main outcome measuresCost per disability adjusted life year (DALY) averted, expressed in international dollars ($Int) for the year 2005.ResultsIn both regions certain interventions in cervical cancer control (screening through cervical smear tests or visual inspection with acetic acid in combination with treatment) and colorectal cancer control (increasing the coverage of treatment interventions) cost <$Int2000 per DALY averted and can be considered highly cost effective. In the sub-Saharan African region screening for colorectal cancer (by colonoscopy at age 50 in combination with treatment) costs $Int2000-6000 per DALY averted and can be considered cost effective. In both regions certain interventions in breast cancer control (treatment of all cancer stages in combination with mammography screening) cost $Int2000-6000 per DALY averted and can also be considered cost effective. Other interventions, such as campaigns to eat more fruit and vegetable or subsidies in colorectal cancer control, are not cost effective according to the criteria defined.ConclusionHighly cost effective interventions to combat cervical and colorectal cancer are available in the African and Asian sub-regions. In cervical cancer control, these include screening through smear tests or visual inspection in combination with treatment. In colorectal cancer, increasing treatment coverage is highly cost effective (screening through colonoscopy is cost effective in the African sub-region). In breast cancer control, mammography screening in combination with treatment of all stages is cost effective.

Project description:BackgroundMobile HIV screening may facilitate early HIV diagnosis. Our objective was to examine the cost-effectiveness of adding a mobile screening unit to current medical facility-based HIV testing in Cape Town, South Africa.Methods and findingsWe used the Cost Effectiveness of Preventing AIDS Complications International (CEPAC-I) computer simulation model to evaluate two HIV screening strategies in Cape Town: 1) medical facility-based testing (the current standard of care) and 2) addition of a mobile HIV-testing unit intervention in the same community. Baseline input parameters were derived from a Cape Town-based mobile unit that tested 18,870 individuals over 2 years: prevalence of previously undiagnosed HIV (6.6%), mean CD4 count at diagnosis (males 423/µL, females 516/µL), CD4 count-dependent linkage to care rates (males 31%-58%, females 49%-58%), mobile unit intervention cost (includes acquisition, operation and HIV test costs, $29.30 per negative result and $31.30 per positive result). We conducted extensive sensitivity analyses to evaluate input uncertainty. Model outcomes included site of HIV diagnosis, life expectancy, medical costs, and the incremental cost-effectiveness ratio (ICER) of the intervention compared to medical facility-based testing. We considered the intervention to be "very cost-effective" when the ICER was less than South Africa's annual per capita Gross Domestic Product (GDP) ($8,200 in 2012). We projected that, with medical facility-based testing, the discounted (undiscounted) HIV-infected population life expectancy was 132.2 (197.7) months; this increased to 140.7 (211.7) months with the addition of the mobile unit. The ICER for the mobile unit was $2,400/year of life saved (YLS). Results were most sensitive to the previously undiagnosed HIV prevalence, linkage to care rates, and frequency of HIV testing at medical facilities.ConclusionThe addition of mobile HIV screening to current testing programs can improve survival and be very cost-effective in South Africa and other resource-limited settings, and should be a priority.

Project description:BackgroundCervical cancer incidence is significant in countries, such as South Africa, with high burdens of both HIV and human papillomavirus (HPV). Cervical cancer is largely preventable if dysplasia is diagnosed and treated early, but there is debate regarding the best approaches for screening and treatment, especially for low-resource settings. Currently South Africa provides Pap smears followed by colposcopic biopsy and LEEP if needed in its public health facilities. We estimated the costs and cost-effectiveness of two approaches for treating cervical intraepithelial neoplasia grade 2 or higher (CIN2+) among HIV-infected women, most of whom were taking antiretroviral treatment, at a public HIV treatment facility in Johannesburg, South Africa.MethodsMethod effectiveness was derived from an intention-to-treat analysis of data gathered in a clinical trial completed previously at the study facility. In the trial, women who were diagnosed with CIN2+ and eligible for cryotherapy were randomized to cryotherapy or LEEP. If women were CIN2+ at six months as determined via Pap smear and colposcopic biopsy, all women-regardless of their original treatment assignment-received LEEP. "Cure" was then defined as the absence of disease at 12 months based on Pap smear and colposcopic biopsy. Health service costs were estimated using micro-costing between June 2013 and April 2014. Capital costs were annualized using a discount rate of 3%. Two different service volume scenarios were considered, and results from an as-treated analysis were considered in sensitivity analysis.ResultsIn total, 166 women with CIN2+ were enrolled (86 had LEEP; 80 had cryotherapy). At 12 months, cumulative loss to follow-up was 12.8% (11/86) for the LEEP group and 13.8% (11/80) for cryotherapy. Based on the unadjusted intention-to-treat analysis conducted for this economic evaluation, there was no significant difference in efficacy. At 12 months, 83.8% (95% CI 73.8-91.1) of women with CIN2+ at baseline and randomized to cryotherapy were free of CIN2+ disease. In contrast, 76.7% (95% CI 66.4-85.2) of women assigned to LEEP were free from disease. On average, women initially treated with cryotherapy were less costly per patient randomized at US$ 118.00 (113.91-122.10), and per case "cured" at US$ 140.90 (136.01-145.79). Women in the LEEP group cost US$ 162.56 (157.90-167.22) per patient randomized and US$ 205.59 (199.70-211.49) per case cured. In the as-treated analysis, which was based on trial data, LEEP was more efficacious than cryotherapy; however, the difference was not significant. Cryotherapy remained more cost-effective than LEEP in all sensitivity and scenario analyses.ConclusionsFor this cost-effectiveness analysis, using an intention-to-treat approach and taking into consideration uncertainty in the clinical and cost outcomes, a strategy involving cryotherapy plus LEEP if needed at six months was dominant to LEEP plus LEEP again at six months if needed for retreatment. However, compared to other studies comparing LEEP and cryotherapy, the efficacy results were low in both treatment groups-possibly due to the HIV-positivity of the participants. Further research is needed, but at present choosing the "right" treatment option may be less important than ensuring access to treatment and providing careful monitoring of treatment outcomes.

Project description:ObjectiveTo assess the comparative costs and effects of interventions to combat five neuropsychiatric conditions (schizophrenia, bipolar disorder, depression, epilepsy, and heavy alcohol use).DesignCost effectiveness analysis based on an epidemiological model.SettingTwo epidemiologically defined World Health Organization sub-regions of the world: countries in sub-Saharan Africa with very high adult and high child mortality (AfrE); and countries in South East Asia with high adult and high child mortality (SearD).Data sourcesPublished studies, costing databases.Main outcome measuresCost per capita and cost per disability adjusted life year (DALY) averted, expressed in international dollars ($Int) for the year 2005.ResultsAcross 44 assessed intervention strategies for the five neuropsychiatric conditions, cost effectiveness values differed by as much as two orders of magnitude (from $Int100-250 to $Int10,000-25,000 for a year of healthy life gained). In both sub-regions, inpatient based treatment of schizophrenia with newer antipsychotic drugs was the most costly and least cost effective strategy. The most cost effective strategies in the African sub-region related to population based alcohol control, while in the South East Asian sub-region the most cost effective intervention was drug treatment of epilepsy in primary care. The cumulative cost per capita of the most cost effective set of interventions covering all five conditions was estimated at $Int4.90-5.70. This package comprises interventions for epilepsy (older first line antiepileptic drugs); depression (generically produced newer antidepressants and psychosocial treatment); bipolar disorder (mood stabiliser drug lithium); schizophrenia (neuroleptic antipsychotic drugs and psychosocial treatment); and heavy alcohol use (increased taxation and its enforcement, reduced access, and, in the African sub-region, advertising bans and brief advice to heavy drinkers in primary care).ConclusionsReallocation of resources to cost effective intervention strategies would increase health gain, save money and help implement much needed expansion of services for neuropsychiatric conditions in low resource settings.

Dataset Information

Cost-Effectiveness of Cervical Cancer Screening in Women Living With HIV in South Africa: A Mathematical Modeling Study.

Background

Methods

Results

Conclusions

Publications

Cost-Effectiveness of Cervical Cancer Screening in Women Living With HIV in South Africa: A Mathematical Modeling Study.

Similar Datasets

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