title: Cost-effectiveness of screening for anal precancers in HIV-positive men.
abstract: OBJECTIVE
  To assess the cost-effectiveness of high-resolution anoscopy (HRA), anal cytology, and anal human papillomavirus (HPV) detection in screening for histologic high-grade anal intraepithelial neoplasia (AIN 2/3) in HIV-positive MSM.
  
  
  METHODS
  Participants were 401 HIV-positive MSM who were screened for anal cancer in a tertiary care HIV clinic.
  
  
  METHODS
  A decision analytical model was used to determine the cost-effectiveness of three anal cancer screening strategies: the direct use of HRA; HRA only if anal cytology was abnormal; and HRA only if oncogenic HPV was present. The model included the use of different thresholds for abnormal cytology and also combined cytology and HPV testing. The outcome was the number of AIN 2/3 cases detected. Costs were estimated from institutional data and sensitivity/specificity of cytology and HPV tests were obtained from the screening study.
  
  
  RESULTS
  The costs ($ US) per procedure for HRA, cytology, and HPV testing were $193, $90, and $95, respectively. The direct use of HRA was the most cost-effective strategy. It detected 98 individuals with AIN 2/3 and had a cost-effectiveness of $809 per AIN 2/3 case detected. Using probabilistic sensitivity analysis, three other strategies had similar costs per case detected and might be as cost-effective as HRA.
  
  
  CONCLUSIONS
  In HIV-infected MSM, the direct use of HRA is the most cost-effective strategy for detecting AIN 2/3. The higher cost per use for HRA was offset by the high sensitivity and low specificity of HPV and cytology testing.
authors.affiliation: University of Toronto, Toronto General Hospital, Canada.
authors.forename: Jonathan M C
authors.initials: JM
authors.lastname: Lam
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Hoch
authors.forename: Jill
authors.initials: J
authors.lastname: Tinmouth
authors.forename: Marie
authors.initials: M
authors.lastname: Sano
authors.forename: Janet
authors.initials: J
authors.lastname: Raboud
authors.forename: Irving E
authors.initials: IE
authors.lastname: Salit
mesh_terms: D000328:Adult; D001005:Anus Neoplasms / Q000175:diagnosis* / Q000191:economics / Q000821:virology; D003362:Cost-Benefit Analysis; D055088:Early Detection of Cancer / Q000191:economics*; D015658:HIV Infections / Q000150:complications* / Q000191:economics / Q000821:virology; D018451:Homosexuality, Male; D006801:Humans; D008297:Male; D027383:Papillomaviridae / Q000302:isolation & purification*; D030361:Papillomavirus Infections / Q000191:economics / Q000473:pathology* / Q000821:virology; D011230:Precancerous Conditions / Q000175:diagnosis* / Q000191:economics / Q000821:virology; D012680:Sensitivity and Specificity