Community-based HPV self-collection versus visual inspection with acetic acid in Uganda: a cost-effectiveness analysis of the ASPIRE trial

Abstract

BackgroundCervical cancer is the leading cause of cancer death for women in Uganda, despite the potential for prevention through organised screening. Community-based self-collected human papillomavirus (HPV) testing has been proposed to reduce barriers to screening.ObjectiveOur objective was to evaluate the cost-effectiveness of the Advances in Screening and Prevention of Reproductive Cancers (ASPIRE) trial, conducted in Kisenyi, Uganda in April 2014 (n=500). The trial compared screening uptake and compliance with follow-up in two arms: (1) community-based (ie, home or workplace) self-collected HPV testing (facilitated by community health workers) with clinic-based visual inspection with acetic acid (VIA) triage of HPV-positive women (‘HPV-VIA’) and (2) clinic-based VIA (‘VIA’). In both arms, VIA was performed at the local health unit by midwives with VIA-positive women receiving immediate treatment with cryotherapy.DesignWe informed a Monte Carlo simulation model of HPV infection and cervical cancer with screening uptake, compliance and retrospective cost data from the ASPIRE trial; additional cost, test performance and treatment effectiveness data were drawn from observational studies. The model was used to assess the cost-effectiveness of each arm of ASPIRE, as well as an HPV screen-and-treat strategy (‘HPV-ST’) involving community-based self-collected HPV testing followed by treatment for all HPV-positive women at the clinic.Outcome measuresThe primary outcomes were reductions in cervical cancer risk and incremental cost-effectiveness ratios (ICERs), expressed in dollars per year of life saved (YLS).ResultsHPV-ST was the most effective and cost-effective screening strategy, reducing the lifetime absolute risk of cervical cancer from 4.2% (range: 3.8%–4.7%) to 3.5% (range: 3.2%–4%), 2.8% (range: 2.4%–3.1%) and 2.4% (range: 2.1%–2.7%) with ICERs of US$130 (US$110–US$150) per YLS, US$240 (US$210–US$280) per YLS, and US$470 (US$410–US$550) per YLS when performed one, three and five times per lifetime, respectively. Findings were robust across sensitivity analyses, unless HPV costs were more than quadrupled.ConclusionsCommunity-based self-collected HPV testing followed by treatment for HPV-positive women has the potential to be an effective and cost-effective screening strategy.

The role of community health workers in cervical cancer screening in low-income and middle-income countries: a systematic scoping review of the literature

“…At the end of the screening process, 15 peer-reviewed studies remained for inclusion in the final review, of which one originated from snowball sampling, and one from the grey literature 5 22–35…”

“…Different modalities of screening were used across the 15 studies. Pap smears were the most common modality offered (n=6),5 24–27 34 followed by dual or mixed screening modalities (using a combination of Pap smears, VIA or HPV-DNA) (n=5),23 29 32 33 35 HPV-DNA sampling only (n=3),22 30 31 and VIA only (n=1) 28…”

“…The most common role for CHWs was to carry out education, outreach, or awareness raising activities (n=14) 5 22 24–35. Home-based community outreach programmes were described in studies in El Salvador and Iran 22 25.…”

“…In five studies, CHWs played a role in the actual cervical screening process, either through performing cervical screening or in assisting specialist medical staff 5 23 32 34 35. In Nigeria, CHWs were trained to carry out screening using VIA under supervision, and link positive cases for cryotherapy 23.…”

“…In the remaining studies, CHWs had roles in assisting the specialist medical staff who carried out the process. These included helping women undress and dress and supporting them during the screening procedure,34 assisting the nurse by cleaning equipment,34 or transporting HPV-DNA samples to the laboratory for sequencing 32…”