Cost-effectiveness of cervical cancer screening in women living with HIV in South Africa: A mathematical modeling study

Fri, 15 Jun 2018 00:00:00 GMT-05:00 - Campos, Nicole G.; Lince-Deroche, Naomi; Chibwesha, Carla J.; Firnhaber, Cynthia; Smith, Jennifer S.; Michelow, Pam; Meyer-Rath, Gesine; Jamieson, Lise; Jordaan, Suzette; Sharma, Monisha; Regan, Catherine; Sy, Stephen; Liu, Gui; Tsu, Vivien; Jeronimo, Jose; Kim, Jane J.
ÅéóáãùãÞ: Women with HIV face an increased risk of human papillomavirus (HPV) acquisition and persistence, cervical intraepithelial neoplasia, and invasive cervical cancer. Our objective was to determine the cost-effectiveness of different cervical cancer screening strategies among women with HIV in South Africa.
ÌÝèïäïé: We modified a mathematical model of HPV infection and cervical disease to reflect co-infection with HIV. The model was calibrated to epidemiologic data from HIV-infected women in South Africa. Clinical and economic data were drawn from in-country data sources. The model was used to project reductions in the lifetime risk of cervical cancer and incremental cost-effectiveness ratios (ICERs) of Pap and HPV DNA screening and management algorithms beginning at HIV diagnosis, at one-, two-, or three-year intervals. Strategies with an ICER below South Africa’s 2016 per capita GDP (US$5,270) were considered ‘cost-effective.’
ÁðïôåëÝóìáôá: HPV testing followed by treatment (test-and-treat) at two-year intervals was the most effective strategy that was also cost-effective, reducing lifetime cancer risk by 56·6% with an ICER of US$3,010 per year of life saved (YLS). Other cost-effective strategies included Pap (referral threshold: HSIL+) at one-, two-, and three-year intervals, and HPV test-and-treat at three-year intervals. Pap (ASCUS+), HPV testing with 16/18 genotyping, and HPV testing with Pap or visual triage of HPV-positive women were less effective and more costly than alternatives.
ÓõìðÝñáóìá: Considering per capita GDP as the benchmark for cost-effectiveness, HPV test-and-treat is optimal in South Africa. At lower cost-effectiveness benchmarks, Pap (HSIL+) would be optimal. This is an open access article distributed under the terms of the Creative Commons Attribution License 4.0 (CC BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Corresponding author: Nicole G. Campos, Center for Health Decision Science, 718 Huntington Avenue, Boston, MA 02115; Phone: 617-432-2019; Fax: 617-432-0190; E-mail: ncampos@hsph.harvard.edu Conflicts of Interest and Source of Funding: This study was funded by the US National Cancer Institute (U01CA199334) and The Bill & Melinda Gates Foundation (OPP1086544). The funders had no role in study design; data collection, analysis, or interpretation; decision to publish; or preparation of the manuscript. The costing work that preceded this study was made possible by the generous support of the American people through the United States Agency for International Development (USAID), award number AID-674-A-12-00029. The contents are the responsibility of the Health Economics and Epidemiology Research Office, a Division of the Wits Health Consortium (Pty) Ltd and do not necessarily reflect the views of USAID or the United States Government. NGC reports grants from the Bill & Melinda Gates Foundation during the conduct of the study. NLD has nothing to disclose. CJC has nothing to disclose. CF has nothing to disclose. JSS has nothing to disclose. PM has nothing to disclose. GMR has nothing to disclose. LJ has nothing to disclose. SJ has nothing to disclose. MS has nothing to disclose. CR reports grants from the Bill & Melinda Gates Foundation during the conduct of the study. SS reports grants from the Bill & Melinda Gates Foundation during the conduct of the study. GL has nothing to disclose. VT reports grants from the Bill & Melinda Gates Foundation during the conduct of the study. JJ was a consultant for Qiagen Inc. and Global Good Fund I, LLC; he was the co-owner and Deputy Manager of Onco Prev International, a Peruvian company, from 2012 through March 2017. Onco Prev International offers cervical cancer screening services and in 2016 also began positioning for distribution of medical devices including colposcopes and the Liger thermocoagulator. Onco Prev International did not commercialize any medical instrument during the time JJ was part of the company. JJK reports grants from the Bill & Melinda Gates Foundation during the conduct of the study. - © 2018

Attrition across the HIV cascade of care among a diverse cohort of women living with HIV in Canada

Fri, 15 Jun 2018 00:00:00 GMT-05:00 - Kerkerian, Genevieve; Kestler, Mary; Carter, Allison; Wang, Lu; Kronfli, Nadine; Sereda, Paul; Roth, Eric; Milloy, M-J; Pick, Neora; Money, Deborah; Webster, Kath; Hogg, Robert S; de Pokomandy, Alexandra; Loutfy, Mona; Kaida, Angela
ÅéóáãùãÞ: In North America, women have lower engagement across the HIV cascade of care compared with men. Among women living with HIV (WLWH) in Canada, we measured the prevalence and correlates of attrition across cascade stages overall, and by key sub-populations.
ÌÝèïäïé: We analyzed baseline survey data regarding six nested stages of the HIV cascade among 1,424 WLWH enrolled in the Canadian HIV Sexual and Reproductive Health Cohort Study (CHIWOS), including: linked to care, retained in care, initiated antiretroviral therapy (ART), current ART use, ART adherence (≥90%), and viral suppression (<50 copies/mL). Logistic regression identified factors associated with attrition at each stage.
ÁðïôåëÝóìáôá: Overall, 98% of WLWH were linked to care; 96% retained; 88% initiated ART; 83% were currently on ART; and, among those on ART, 68% were adherent and 72% were virally suppressed, with substantial variability by sub-population (49%-84%). The largest attrition occurred between current ART use and adherence (-17%), with the greatest losses among Indigenous women (-25%), women who use illicit drugs (-32%), and women incarcerated in the past year (-45%). Substantial attrition also occurred between linkage to care and ART initiation (-11%), with the greatest losses among women 16-29 years (-20%) and with unstable housing (-27%). Factors independently associated with attrition at viral suppression included household annual income, racial discrimination, incarceration history, age, and resilience.
ÓõìðÝñáóìá: Overall, 28% of WLWH were lost across the HIV care cascade, with significant differences by stage, sub-population, and social inequities. Targeted interventions are needed to improve women’s retention across the cascade. Corresponding Author: Dr. Angela Kaida Associate Professor Faculty of Health Sciences, Simon Fraser University Blusson Hall Room 10522, 8888 University Drive, Burnaby, B.C. V5A 1S6. Email:kangela@sfu.ca. Tel: +1 (778) 782-9068. Fax: 778.782.5927. The authors report no conflicts of interest related to this work. δ Additional research team members are listed at the end and should be hyperlinked as authors Meeting at Which the Data were Presented: Parts of the data were presented as a poster presentation at the 21st International AIDS Conference (AIDS 2016) in Durban, South Africa, on July 18-22 2016. Funding: CHIWOS is funded by the Canadian Institutes of Health Research (CIHR, MOP111041); the CIHR Canadian HIV Trials Network (CTN 262); the Ontario HIV Treatment Network (OHTN); and the Academic Health Science Centres (AHSC) Alternative Funding Plans (AFP) Innovation Fund. AC and KS received support through a Doctoral Research Award from the CIHR HIV/AIDS Research Initiative and the Canadian Association for HIV Research (CAHR). NO and AdP received support from Fonds de Recherche du Quebéc – Santé (FRQS). AK received salary support through a Tier 2 Canada Research Chair in Global Perspectives on HIV and Sexual and Reproductive Health. - © 2018