Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
PATH, Reproductive Health Program, Seattle, Washington.
Cancer Epidemiol Biomarkers Prev. 2017 Oct;26(10):1500-1510. doi: 10.1158/1055-9965.EPI-16-0787. Epub 2017 Jul 14.
World Health Organization guidelines support human papillomavirus (HPV) testing alone (followed by treatment with cryotherapy) or in conjunction with visual inspection with acetic acid (VIA) triage testing. Our objective was to determine the cost-effectiveness of VIA triage for HPV-positive women in low-resource settings. We calibrated mathematical simulation models of HPV infection and cervical cancer to epidemiologic data from India, Nicaragua, and Uganda. Using cost and test performance data from the START-UP demonstration projects, we assumed screening took place either once or three times in a lifetime between ages 30 and 40 years. Strategies included (i) HPV alone, followed by cryotherapy for all eligible HPV-positive women; and (ii) HPV testing with VIA triage for HPV-positive women, followed by cryotherapy for eligible women who were also VIA-positive (HPV-VIA). Model outcomes included lifetime risk of cervical cancer and incremental cost-effectiveness ratios (ICERs; international dollars/year of life saved). In all three countries, HPV alone was more effective than HPV-VIA. In Nicaragua and Uganda, HPV alone was also less costly than HPV-VIA; ICERs associated with screening three times in a lifetime (HPV alone) were below per capita GDP. In India, both HPV alone and HPV-VIA had ICERs below per capita GDP. VIA triage of HPV-positive women is not likely to be cost-effective in settings with high cervical cancer burden. HPV alone followed by treatment may achieve greater health benefits and value for public health dollars. This study provides early evidence on the cost-effectiveness of HPV testing followed by VIA triage versus an HPV screen-and-treat strategy. .
世界卫生组织指南支持单独进行人乳头瘤病毒（HPV）检测（随后用冷冻疗法进行治疗）或与醋酸视觉检查（VIA）联合进行筛查检测。我们的目标是确定在资源匮乏环境中对 HPV 阳性女性进行 VIA 分流检测的成本效益。我们对 HPV 感染和宫颈癌的数学模拟模型进行了校准，以匹配来自印度、尼加拉瓜和乌干达的流行病学数据。利用 START-UP 示范项目的成本和检测性能数据，我们假设筛查在 30 至 40 岁之间的一生中进行一次或三次。策略包括（i）单独进行 HPV 检测，对所有符合条件的 HPV 阳性女性进行冷冻治疗；（ii）对 HPV 阳性女性进行 HPV 检测联合 VIA 分流检测，对同时也是 VIA 阳性（HPV-VIA）的符合条件女性进行冷冻治疗。模型结果包括宫颈癌的终生风险和增量成本效益比（ICER；国际元/年生命挽救）。在所有三个国家，单独进行 HPV 检测均比 HPV-VIA 更有效。在尼加拉瓜和乌干达，单独进行 HPV 检测也比 HPV-VIA 更具成本效益；一生中筛查三次（单独进行 HPV 检测）的关联 ICER 低于人均 GDP。在印度，单独进行 HPV 检测和 HPV-VIA 的 ICER 均低于人均 GDP。在宫颈癌负担较高的环境中，对 HPV 阳性女性进行 VIA 分流检测不太可能具有成本效益。单独进行 HPV 检测后进行治疗可能会带来更大的健康效益和对公共卫生资金的价值。本研究提供了 HPV 检测后进行 VIA 分流检测与 HPV 筛查和治疗策略相比的成本效益的早期证据。
