Cost-effectiveness analysis of human papillomavirus vaccination in South Africa accounting for human immunodeficiency virus prevalence

Abstract

BackgroundThis 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.MethodsA 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.ResultsImplementation 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.ConclusionsThe 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.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-015-1295-z) contains supplementary material, which is available to authorized users.

Cancer prevention: cervical cancer

“…The randomised trials on cervical cancer screening have all been conducted in India, and have documented the efficacy of visual inspection, cytology screening and HPV-screening [18–21]. Numerous epidemiological studies have consistently documented that in countries where the resources exist to ensure high-quality and good coverage of the population, cytology screening contributes to decreasing the incidence of advanced-stage cancers and mortality associated with cervical cancer [22–24].…”

Cervical Cancer Prevention and Control

“…The randomized trial studies done in different places on cervical cancer screening have shown the efficacy of visual inspection, cytology screening and HPV screening [22][23][24]. Many studies have acknowledged that in countries where the resources exist to confirm high value and good coverage of the people, cytology screening provides to decreasing the incidence of advanced stage cancers and death related with cervical cancer [25][26][27].…”

Malignancies in women with HIV infection

“…In 2014 only 58 countries had incorporated HPV vaccination into national immunization campaigns and mostly in high-income settings [27]. More recently, countries in SSA have begun to implement HPV vaccination nationwide with support from global health programs [29], which may have significant cost efficacy [30]. Unfortunately, the details of real-world vaccination uptake in HIV-infected girls and women remain difficult to accomplish [31].…”