Modelling cervical cancer elimination using single‐visit screening and treatment strategies in the context of high HIV prevalence: estimates for KwaZulu‐Natal, South Africa

Abstract

Introduction In settings with high HIV prevalence, cervical cancer incidence rates are up to six‐fold higher than the global average of 13.1 cases per 100,000 women‐years. To inform strategies for global cervical cancer elimination, we used a dynamic transmission model to evaluate scalable screening and treatment strategies, accounting for HIV‐associated cancer risks and weighing prevention gains against overtreatment. Methods We developed a dynamic model of HIV‐HPV co‐infection and disease progression, which we calibrated to KwaZulu‐Natal, South Africa. Our baseline scenario reflects the current practice of HPV vaccination with a multi‐visit screening and treatment strategy involving cytology and colposcopy triage. We evaluated 13 comparator scenarios with increased vaccination coverage and one‐time, two‐time or repeat HIV‐targeted cervical cancer screening with the following single‐visit strategies: HPV DNA testing, HPV genotyping, automated visual evaluation (AVE) and HPV DNA with AVE triage. In all scenarios, HIV antiretroviral therapy, condom use and voluntary male medical circumcision continue at baseline levels. We simulated cancer incidence under each scenario from 2020 to 2120 using the 25 best‐fitting parameter sets. We present the median and range of model output from these simulations to account for parameter uncertainty. Results We estimate that cervical cancer incidence will decrease by 87% with the continuation of current cervical cancer and HIV prevention strategies, from an age‐standardized rate per 100,000 women of 80.4 (range 58.2, 112.1) in 2020 to 10.7 (4.2, 29.9) in 2120. Scenarios scaling up vaccination and single‐visit strategies resulted in near‐ and long‐term gains. With repeat HIV‐targeted screening, incidence rates were projected to be 29–34% lower in 2030 relative to the baseline scenario, and elimination (incidence <4/100,000) was achieved with HPV DNA testing in 2095 and with AVE in 2114. A strategy of HPV DNA with AVE triage optimized the tradeoff between cancer cases averted and overtreatment. Conclusions Single‐visit screening strategies could avert a substantial burden of cervical cancer and accelerate progress towards elimination in settings with a high burden of HIV. Increasing the screening frequency among women with HIV and reducing loss‐to‐follow‐up for treatment will be key components of a successful elimination strategy.

An audit of adherence to cervical cancer screening guidelines in a tertiary-level HIV clinic

“…Further studies are needed to evaluate if the establishment of a dedicated cervical screening service within our hospital for women at high risk would improve screening rates as it has in other studies. 16 , 17 , 18 Considering the prevalence of HIV in South Africa and the known links between HIV and cervical cancer, an HIV clinic serves as an ideal site for cervical cancer screening. Alternatively, an organised referral system to a dedicated screening facility would greatly improve the number of women referred for screening – this could be initiated through utilisation of currently available gynaecology services in our hospital.…”

Enhanced cervical cancer and HIV interventions reduce the disproportionate burden of cervical cancer cases among women living with HIV: A modeling analysis

“…We used the DRIVE (Data-driven Recommendations for Interventions against Viral InfEction) model [ 13 ], a dynamic, compartmental model of HIV and HPV transmission and disease progression, to project cervical cancer and HIV outcomes for the province of KwaZulu-Natal, South Africa between the years 2001 and 2071. The model population was stratified by age, gender, sexual activity risk group, and infection and disease status.…”

“…These differences, along with the heightened risk of cervical cancer among women living with HIV, highlight the importance of cervical cancer prevention and treatment guidelines tailored by HIV status. Recent modeling studies predicted that increasing vaccination or screening frequency for women living with HIV can significantly decrease near-term cervical cancer incidence [ 6 , 13 , 14 ]. A comparative modeling study additionally demonstrated reduced relative cancer incidence among women living with HIV with focused interventions, but assumed idealized coverage levels of precancer and cancer treatment and 100% precancer treatment efficacy [ 15 ].…”

Facility-Based Indicators to Manage and Scale Up Cervical Cancer Prevention and Care Services for Women Living With HIV in Sub-Saharan Africa: a Three-Round Online Delphi Consensus Method

“…1,3 To achieve the goal of the World Health Organization (WHO) of eliminating CC, countries in sub-Saharan Africa (SSA) must scale up access to primary, secondary, and tertiary prevention measures, especially for girls and WLHIV. [4][5][6] To improve CC control programs, clinicians, researchers, and policymakers need high-quality routine health facility data, 7,8 which can be collected by monitoring each step of the path that people take through the health system. To create a monitoring plan for cancer control, each sequential step through a complex health system must be quantified within the framework of a cascade 9 and indicators must be specified for each step.…”