Abstract:
While the incidence of cervical cancer has dropped in high-income countries due to
organized cytology-based screening programs, it remains the leading cause of cancer
death among women in Eastern Africa. Therefore, the World Health Organization
(WHO) now urges providers to transition from widely prevalent but low-performance
visual inspection with acetic acid (VIA) screening to primary human papillomavirus
(HPV) DNA testing. Due to high HPV prevalence, effective triage tests are needed to
identify those lesions likely to progress and so avoid over-treatment. To identify the
optimal cost-effective strategy, we compared the VIA screen-and-treat approach to
primary HPV DNA testing with p16/Ki67 dual-stain cytology or VIA as triage. We
used a Markov model to calculate the budget impact of each strategy with incremental quality-adjusted life years and incremental cost-effectiveness ratios (ICER) as the
main outcome. Deterministic cost-effectiveness analyses show that the screen-andtreat approach is highly cost-effective (ICER 2469 Int$), while screen, triage, and
treat with dual staining is the most effective with favorable ICER than triage with VIA
(ICER 9943 Int$ compared with 13,177 Int$). One-way sensitivity analyses show that
the results are most sensitive to discounting, VIA performance, and test prices. In the
probabilistic sensitivity analyses, the triage option using dual stain is the optimal
choice above a willingness to pay threshold of 7115 Int$ being cost-effective as per
WHO standards. The result of our analysis favors the use of dual staining over VIA as
triage in HPV-positive women and portends future opportunities and necessary
research to improve the coverage and acceptability of cervical cancer screening
programs
