Economic Evaluation of Screening Strategies Combined with HPV Vaccination of Preadolescent Girls for the Prevention of Cervical Cancer in Vientiane, Lao PDR

Abstract

BackgroundSeveral approaches to reduce the incidence of invasive cervical cancers exist. The approach adopted should take into account contextual factors that influence the cost-effectiveness of the available options.ObjectiveTo determine the cost-effectiveness of screening strategies combined with a vaccination program for 10-year old girls for cervical cancer prevention in Vientiane, Lao PDR.MethodsA population-based dynamic compartment model was constructed. The interventions consisted of a 10-year old girl vaccination program only, or this program combined with screening strategies, i.e., visual inspection with acetic acid (VIA), cytology-based screening, rapid human papillomavirus (HPV) DNA testing, or combined VIA and cytology testing. Simulations were run over 100 years. In base-case scenario analyses, we assumed a 70% vaccination coverage with lifelong protection and a 50% screening coverage. The outcome of interest was the incremental cost per Disability-Adjusted Life Year (DALY) averted.ResultsIn base-case scenarios, compared to the next best strategy, the model predicted that VIA screening of women aged 30–65 years old every three years, combined with vaccination, was the most attractive option, costing 2 544 international dollars (I$) per DALY averted. Meanwhile, rapid HPV DNA testing was predicted to be more attractive than cytology-based screening or its combination with VIA. Among cytology-based screening options, combined VIA with conventional cytology testing was predicted to be the most attractive option. Multi-way sensitivity analyses did not change the results. Compared to rapid HPV DNA testing, VIA had a probability of cost-effectiveness of 73%. Compared to the vaccination only option, the probability that a program consisting of screening women every five years would be cost-effective was around 60% and 80% if the willingness-to-pay threshold is fixed at one and three GDP per capita, respectively.ConclusionsA VIA screening program in addition to a girl vaccination program was predicted to be the most attractive option in the health care context of Lao PDR. When compared with other screening methods, VIA was the primary recommended method for combination with vaccination in Lao PDR.

Factors Influencing the Cost-Effectiveness Outcomes of HPV Vaccination and Screening Interventions in Low-to-Middle-Income Countries (LMICs): A Systematic Review

“…The reviewed evidence shows that screening interventions may not be cost-effective at lower coverage but are cost-effective at 50% coverage and become very attractive options at a coverage of 70% of the population at risk. In addition, the findings reveal that organized cervical cancer prevention programmes achieve a higher coverage of the population at risk than opportunistic programmes and result in better cost-effectiveness outcomes than opportunistic interventions (28,34). respectively.…”

“…When the loss-to-follow-up is below 40%, HPV DNA testing appears to yield higher cost-effectiveness when compared with other methods (35). Otherwise, there is a 73% probability that VIA will be more cost-effective screening strategy in comparison with HPV DNA testing when implemented (28). The findings suggest that combining VIA screening and HPV vaccination could be the most cost-effective approach in reducing the lifetime risk for cervical neoplasms linked to HPV by 85.7% (28).…”

“…however, one study found otherwise but assumed a low coverage and a very high cost of vaccines (30). Regarding the number of doses required to achieve lifelong immunity against HPV, four studies assessed the effectiveness of vaccination with three doses (27,28,30,33).…”

“…Furthermore, the vaccine efficacy significantly influences cost-effectiveness outcomes for vaccination programmes (26,31,32 The number of visits required to complete a screening test is important because the associated loss-to-follow-up (LTFU) undermines the overall effectiveness of screening interventions. HPV DNA analysis appears to be less cost-effective whenever the LTFU exceeds 40% of the primary population (28,34). Notably, reducing the uptake of follow-up services may contribute to a higher mortality rate in comparison with low coverage with respect to screening interventions.…”

“…Otherwise, there is a 73% probability that VIA will be more cost-effective screening strategy in comparison with HPV DNA testing when implemented (28). The findings suggest that combining VIA screening and HPV vaccination could be the most cost-effective approach in reducing the lifetime risk for cervical neoplasms linked to HPV by 85.7% (28). Regarding the approach that could be most cost-efficacious between screening interventions and vaccination programmes, probabilistic sensitivity analyses of cost-effectiveness results revealed that five yearly screening had a 70-80% probability for better cost-effectiveness in comparison with HPV vaccination programmes (28).…”