title: Cost-effectiveness analysis of human papillomavirus vaccination in South Africa accounting for human immunodeficiency virus prevalence.
abstract: BACKGROUND
  This study aims at evaluating the cost-effectiveness of a 2-dose schedule human papillomavirus (HPV) vaccination programme of HPV and human immunodeficiency virus (HIV) naïve 12-year-old girls, in addition to cervical cancer (CC) screening alone, in South Africa. The study aims to account for both the impact of the vaccine among girls who are HIV-positive (HIV+) as well as HIV-negative (HIV-) population.
  
  
  METHODS
  A previously published Markov cohort model was adapted to assess the impact and cost-effectiveness of a HPV vaccination programme in girls aged 12 years (N = 527 900) using the AS04-adjuvanted HPV-16/18 vaccine from a public payer perspective. Two subpopulations were considered: HIV- and HIV+ women. Each population followed the HPV natural history with different transition probabilities. Model input data were obtained from the literature, local databases and Delphi panel. Costs and outcomes were discounted at 5 %. Extensive sensitivity analyses were conducted to assess the robustness of the evaluation.
  
  
  RESULTS
  Implementation of the AS04-adjuvanted HPV-16/18 vaccine in combination with current cytological screening in South African girls could prevent up to 8 869 CC cases and 5 436 CC deaths over the lifetime of a single cohort. Without discounting, this HPV vaccine is dominant over screening alone; with discounting, the incremental cost-effectiveness ratio is ZAR 81 978 (South African Rand) per quality-adjusted life years (QALY) gained. HPV vaccination can be considered cost-effective based on World Health Organization (WHO) recommended threshold (3 x gross domestic product/capita = ZAR 200 293). In a scenario with a hypothetical targeted vaccination in a HIV+ subpopulation alone, the modelled outcomes suggest that HPV vaccination is still cost-effective, although the incremental cost-effectiveness ratio increases to ZAR 102 479. Results were sensitive to discount rate, vaccine efficacy, HIV incidence and mortality rates, and HPV-related disease transition probabilities.
  
  
  CONCLUSIONS
  The AS04-adjuvanted HPV-16/18 vaccine can be considered cost-effective in a South African context although the cost-effectiveness is expected to be lower in the HIV+ subpopulation than in the overall female population. With improved access to HIV treatment, the HIV mortality and incidence rates are likely to be reduced, which could improve cost-effectiveness of the vaccination programme in South Africa.
authors.affiliation: Health Economics, GSK Vaccines, Avenue Fleming 20, 1300, Wavre, Belgium. xiao.x.li@gsk.com.
authors.forename: Xiao
authors.initials: X
authors.lastname: Li
authors.affiliation: Health Economic Research, HEXOR (Pty) Ltd, Block J, Central Park, 400 16th Road, Midrand, Republic of South Africa. tienies@hexor.co.za.
authors.forename: Martinus P
authors.initials: MP
authors.lastname: Stander
authors.affiliation: Health Economics, GSK Vaccines, Avenue Fleming 20, 1300, Wavre, Belgium. georges.m.van-kriekinge@gsk.com.
authors.forename: Georges
authors.initials: G
authors.lastname: Van Kriekinge
authors.affiliation: Health Economics, GSK Vaccines, Avenue Fleming 20, 1300, Wavre, Belgium. nadia.x.demarteau@gsk.com.
authors.forename: Nadia
authors.initials: N
authors.lastname: Demarteau
mesh_terms: D000276:Adjuvants, Immunologic / Q000627:therapeutic use; D002648:Child; D003362:Cost-Benefit Analysis; D005260:Female; D015658:HIV Infections / Q000150:complications / Q000175:diagnosis / Q000453:epidemiology; D052162:Human papillomavirus 16 / Q000276:immunology; D052161:Human papillomavirus 18 / Q000276:immunology; D006801:Humans; D015994:Incidence; D008390:Markov Chains; D008962:Models, Theoretical; D030361:Papillomavirus Infections / Q000150:complications / Q000191:economics* / Q000517:prevention & control; D053918:Papillomavirus Vaccines / Q000276:immunology*; D015995:Prevalence; D013019:South Africa / Q000453:epidemiology; D015996:Survival Rate; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis / Q000401:mortality / Q000517:prevention & control; D014611:Vaccination / Q000191:economics*
chemical_list: D000276:Adjuvants, Immunologic; D053918:Papillomavirus Vaccines