title: Costs and Cost Effectiveness of Three Approaches for Cervical Cancer Screening among HIV-Positive Women in Johannesburg, South Africa.
abstract: BACKGROUND
  South Africa has high rates of HIV and HPV and high incidence and mortality from cervical cancer. However, cervical cancer is largely preventable when early screening and treatment are available. We estimate the costs and cost-effectiveness of conventional cytology (Pap), visual inspection with acetic acid (VIA) and HPV DNA testing for detecting cases of CIN2+ among HIV-infected women currently taking antiretroviral treatment at a public HIV clinic in Johannesburg, South Africa.
  
  
  METHODS
  Method effectiveness was derived from a validation study completed at the clinic. Costs were estimated from the provider perspective using micro-costing between June 2013-April 2014. Capital costs were annualized using a discount rate of 3%. Two different service volume scenarios were considered. Threshold analysis was used to explore the potential for reducing the cost of HPV DNA testing.
  
  
  RESULTS
  VIA was least costly in both scenarios. In the higher volume scenario, the average cost per procedure was US$ 3.67 for VIA, US$ 8.17 for Pap and US$ 54.34 for HPV DNA. Colposcopic biopsies cost on average US$ 67.71 per procedure. VIA was least sensitive but most cost-effective at US$ 17.05 per true CIN2+ case detected. The cost per case detected for Pap testing was US$ 130.63 using a conventional definition for positive results and US$ 187.52 using a more conservative definition. HPV DNA testing was US$ 320.09 per case detected. Colposcopic biopsy costs largely drove the total and per case costs. A 71% reduction in HPV DNA screening costs would make it competitive with the conservative Pap definition.
  
  
  CONCLUSIONS
  Women need access to services which meet their needs and address the burden of cervical dysplasia and cancer in this region. Although most cost-effective, VIA may require more frequent screening due to low sensitivity, an important consideration for an HIV-positive population with increased risk for disease progression.
authors.affiliation: Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa.
authors.forename: Naomi
authors.initials: N
authors.lastname: Lince-Deroche
authors.affiliation: Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa.
authors.forename: Jane
authors.initials: J
authors.lastname: Phiri
authors.affiliation: Cytology Unit, National Health Laboratory Service and Department of Anatomical Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa.
authors.forename: Pam
authors.initials: P
authors.lastname: Michelow
authors.affiliation: Department of Epidemiology, Gillings School of Public Health, University of North Carolina, Chapel Hill, NC, United States of America.|Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States of America.
authors.forename: Jennifer S
authors.initials: JS
authors.lastname: Smith
authors.affiliation: Right to Care, Johannesburg, Gauteng, South Africa.|Clinical HIV Research Unit, Department of Internal Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, Gauteng, South Africa.
authors.forename: Cindy
authors.initials: C
authors.lastname: Firnhaber
mesh_terms: D019342:Acetic Acid / Q000737:chemistry; D000293:Adolescent; D000328:Adult; D000368:Aged; D060085:Coinfection; D003127:Colposcopy / Q000191:economics; D003362:Cost-Benefit Analysis; D004279:DNA, Viral / Q000032:analysis; D055088:Early Detection of Cancer / Q000191:economics / Q000379:methods*; D005189:False Positive Reactions; D005260:Female; D015658:HIV Infections / Q000150:complications*; D017048:Health Care Costs; D006801:Humans; D008403:Mass Screening / Q000191:economics / Q000379:methods; D008875:Middle Aged; D065006:Papanicolaou Test / Q000191:economics*; D027383:Papillomaviridae / Q000235:genetics; D030361:Papillomavirus Infections / Q000150:complications / Q000175:diagnosis* / Q000191:economics; D013019:South Africa; D002583:Uterine Cervical Neoplasms / Q000150:complications / Q000175:diagnosis* / Q000191:economics; D014626:Vaginal Smears; D054928:Validation Studies as Topic; D055815:Young Adult; D002578:Uterine Cervical Dysplasia / Q000150:complications / Q000175:diagnosis / Q000191:economics
chemical_list: D004279:DNA, Viral; D019342:Acetic Acid