title: Cervical cancer screening among HIV-infected women: an economic evaluation in a middle-income country.
abstract: Due to the recent widespread availability of highly active antiretroviral therapy (HAART) in middle-income countries, there has been an increase in life expectancy for women on HAART, but no corresponding decrease in cervical cancer incidence. This study evaluates the optimal cervical cancer screening strategy for HIV-infected women in a middle-income country. We developed a mathematical model, which simulates the natural history of the HPV infection, as well as the HIV-mediated immunosupression among women in Brazil. Our model was calibrated using data from the IPEC/FIOCRUZ Women's HIV-infected cohort. The model compares the lifetime effects, costs and cost-effectiveness of strategies combining cytology, HPV DNA test and colposcopy at different screening intervals for different CD4 count strata (27 strategies in total). We found that the strategy with the best cost-effectiveness profile (cost-effectiveness ratio-U$4,911/year of life saved [YLS] and probability of being cost-effective-86%) was HPV testing followed by cytology triage every year for all HIV infected women, considering a very cost-effective threshold given by Brazil's GDP per capita (US$8,625/YLS). The results were robust to changes in the input parameters as demonstrated in one-way, scenario, threshold and probabilistic sensitivity analysis. Our study indicates that annual HPV testing followed by cytology triage for all HIV-infected women is likely to be very cost-effective in a middle-income country like Brazil. The results reflect the synergic effect of using a highly sensitive screening test (HPV DNA test) in sequence with a highly specific test (cytology).
authors.affiliation: Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom. tazio.vanni@lshtm.ac.uk
authors.forename: Tazio
authors.initials: T
authors.lastname: Vanni
authors.forename: Paula Mendes
authors.initials: PM
authors.lastname: Luz
authors.forename: Beatriz
authors.initials: B
authors.lastname: Grinsztejn
authors.forename: Valdilea G
authors.initials: VG
authors.lastname: Veloso
authors.forename: Anna
authors.initials: A
authors.lastname: Foss
authors.forename: Marco
authors.initials: M
authors.lastname: Mesa-Frias
authors.forename: Rosa
authors.initials: R
authors.lastname: Legood
mesh_terms: D001938:Brazil / Q000453:epidemiology; D003127:Colposcopy / Q000191:economics; D003362:Cost-Benefit Analysis; D004279:DNA, Viral / Q000032:analysis; D055088:Early Detection of Cancer / Q000191:economics* / Q000379:methods; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000453:epidemiology; D006801:Humans; D008390:Markov Chains; D008403:Mass Screening / Q000191:economics; D015233:Models, Statistical; D030361:Papillomavirus Infections / Q000150:complications / Q000175:diagnosis* / Q000453:epidemiology; D002583:Uterine Cervical Neoplasms / Q000150:complications / Q000175:diagnosis* / Q000191:economics* / Q000517:prevention & control; D014626:Vaginal Smears / Q000191:economics
chemical_list: D004279:DNA, Viral