Costs were estimated from the provider perspective using micro-costing between June 2013-April 2014. HPV DNA results were received later and were not used to determine whether colposcopic biopsy would be done. This analysis offers insight regarding the costs of three screening alternatives; however, ultimately the budget and priorities within the health system must dictate the methods selected. HPV DNA testing is also highly sensitive and offers greater specificity than the Pap 2 option, but it was also very expensive under the study conditions. The Pap test looks only for abnormal cervical cells (in most cases these abnormal changes are caused by HPV). The HPV vaccine covers those strains of the virus that are most likely to cause cancer. recommended test to check for early signs of cervical cancer. However, in some cases, an HPV infection persists and results in either warts or precancerous lesions. However, the doctor may also charge you the cost of a clinic or office visit. 9 In many cases, the reporting of HPV genotypes with the screening test result could improve risk stratification and support risk-based patient … About 90% of HPV infections cause no symptoms and resolve spontaneously within two years. Early screening for cervical cancer allows for diagnosis of abnormalities at a pre-invasive and treatable stage. Free shipping included. Various studies have shown that the prevalence of HPV infection in Southern Africa varies per province or district; age group, gender, immunocompetence, e.g. Affiliation https://doi.org/10.1371/journal.pone.0141969.t003. Globally, cervical cancer is the fourth most common cancer affecting women and accounts for 12% of all cancers among women in resource-limited settings [1]. Women with inadequate smears must be called back for a repeat test, presenting an opportunity for loss to follow up. In contrast, VIA, which involves the application of dilute acetic acid to the cervix to visually identify lesions, can result in an immediate diagnosis (i.e. In the threshold analysis, with a 71% reduction in the costs of the lab component of the HPV DNA screening cost, this approach became a competitive alternative as compared to the Pap 2 approach. Most existing studies of the cost-effectiveness of cervical cancer screening rely on models that draw input parameters from multiple and disparate sources [18–20]. recently validated the sensitivity and specificity of conventional cytology, VIA, and HPV DNA testing for detection of cervical intra-epithelial lesion grade two or higher (CIN 2+) among HIV-positive women taking ARV treatment at an HIV clinic in Johannesburg, South Africa [13]. Following generally recommended methods [24], capital costs were annualized to obtain the equivalent annual cost using a discount rate of 3% and depreciation periods recommended for various categories of equipment by the South Africa Revenue Service [25]. Because a primary HPV test may not be an option everywhere, a co-test every 5 years or a Pap test every 3 years are still good options. In consideration of the potential for its introduction, threshold analysis was used to determine the necessary reduction in costs required to make this novel approach competitive with the currently offered conventional cytology service. For those not covered by health insurance, a conventional Pap test usually costs $25 to $40 and a liquid-based Pap test -- sometimes referred to by the brand name ThinPrep -- costs $45 to $60, according to the University of Pittsburgh Medical Center. South Africa is set to start school-based HPV vaccination campaigns n 2014. Credit: UNICEF. The cost of this training is also not included. The VIA service included painting and viewing the cervix. However, cervical cancer is largely preventable when early screening and treatment are available. Positive Pap results were defined in two ways in the validation study. Performed the experiments: NLD JP CF. Chat to your doctor or nurse about the availability of the vaccine for your daughter or yourself. Capital costs were annualized using a discount rate of 3%. 21 February 2019 - Wits University The Wits Reproductive Health and HIV Institute will evaluate the impact of HPV vaccine schedules on the prevalence of this virus on SA adolescent girls. Medical officers reviewed all Pap results when received from the NHLS and provided instruction on whether to call back the women for follow up. In South Africa, according to national guidelines, all women should have access to free cervical cancer screenings with conventional cytology in the public sector at ten year intervals from age 30 to 50 [16]; HIV-positive women are allowed screening upon diagnosis and then annually or three-yearly depending on the results of the initial and subsequent screens [17]. To our knowledge, the work presented here is the only full micro-costing of cervical cancer screening in South Africa. All three screening services were offered by professional nurses who had received study-related training. HPV DNA lab costs were particularly high at US$ 51.74 (38.80–64.67) per test, or 95.2% of the total procedural cost. HPV is a group of more than 150 related viruses. Alternatively, shifting to either a more conservative definition for triaging Pap results (i.e. HPV in South Africa. 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. As indicated in Table 4, given this prevalence and the published sensitivity and specificity information, using the Pap 2 definition, cytology would have identified 888 positive cases (i.e. After the age of 30 years, HPV testing is recommended.² In South Africa, less The cobas® 4800 HPV test detects pooled high-risk HPV types a … Linking health interventions may achieve cost-effective ways ... Cervical cancer prevention in South Africa: HPV vaccination and screening both essential to achieve and maintain a reduction in incidence. Sensitivity and specificity were varied using the confidence interval boundaries provided in the published report from the validation study. This machine uses self-contained testing cartridges, and the manufacturer offers a range of options, including testing for sexually transmitted infections and HPV [34]. When last did you have a pap smear? Approximately 3 000 women die each year due to cervical cancer in South Africa. the hypothetical Pap 2 definition) or HPV DNA testing could improve case detection, but not without increased costs. HPV DNA testing resulted in detection of 750 positive cases (361 true positive, 389 false positive). https://doi.org/10.1371/journal.pone.0141969.t002. 6 HPV VACCINATION IN AFRICA: LESSONS LEARNED FROM A PILOT PROGRAM IN UGANDA Lessons learned: Training, community mobilization, and information and education HEALTH WORKER AND TEACHER TRAINING Lesson 7: Separate training of teachers and health workers allows for focus on their specific roles, complemented with a joint session for both groups to solidify collective In resource limited settings, results are usually only available days or weeks after the sample collection. No, Is the Subject Area "Human papillomavirus infection" applicable to this article? The perspective of the study did not include societal costs and HPV testing on LBC samples. However, if the lab costs for HPV DNA testing were reduced by roughly 75% to US$ 12.93 (resulting in a 71% reduction of the total screening cost to US$ 15.54), the average total cost per case detected would then be US$ 191.92, and HPV DNA testing would no longer be dominated by the hypothetical Pap 2 approach (Table 6). If nurses’ outcomes could be improved over time through practice and quality management efforts including a second review via digital cervicography [32], missed cases and overtreatment may be reduced. Increasing the sensitivity of HPV DNA screening to the higher bound of the confidence interval (i.e. Human papillomavirus infection (HPV infection) is an infection caused by human papillomavirus (HPV), a DNA virus from the Papillomaviridae family. Screening interventions currently available globally include conventional and liquid based cytology (or a Papanicolaou (Pap) smear), visual inspection with acetic acid (VIA), and HPV testing. In Firnhaber et al’s (2013) validation study, they present sensitivity and specificity data for VIA performed by nurses as well as doctors [13]. Further, the time horizon stops at identification of cases and does not consider the long term repercussions of missed cases, or false negatives. Marie Stopes South Africa has 17 HIV testing centres across South Africa, to make an appointment for an HIV test, STI screening or comprehensive sexual health screening book online or call us on 0800 11 77 85. HPV DNA testing was US$ 320.09 per case detected. Because HPV DNA testing is more sensitive and less specific than the Pap 1 approach, it results in more women undergoing colposcopic biopsy in this analysis. Conceived and designed the experiments: NLD CF. An HPV infection also causes cancer of the vagina and vulva in women and in men it is responsible for some cases of penile cancer. Find out which test is best for you, and choose between our paper-based and computer-delivered tests , which are both delivered in one of our official test centres. Method effectiveness was derived from a validation study completed at the clinic. Fast Facts. When the cost of colposcopic biopsy as a follow up for screen positive cases was added for Pap 1, Pap 2 and HPV DNA screening, the total cost for screening was highest for HPV DNA screening at US$ 115,610 for the analytic cohort of 1,193 women. The Study Statistics scenario uses the average number of procedures actually done per day per nurse or doctor during the validation study. , researchers examined the cost-effectiveness of several cancer screening strategies utilizing conventional cytology and HPV testing in South Africa . Table 1. Adult HIV prevalence is 17.9% [11], and HPV prevalence ranges from 20.4% among women with normal cytology to 83% in women with high-grade SIL [12]. Right to Care, Johannesburg, Gauteng, South Africa, This approach casts a “wide net” and identifies almost all of the true cases in the analytic cohort; however, many women also receive false positive diagnoses. We would also like to thank Bruce Larson for his contributions to the analysis. https://doi.org/10.1371/journal.pone.0141969.g001. Book and buy online 24/7. Funding: 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. Vaccine 2: also covers HPV strains 16 and 18 PLUS another two strains that cause genital warts. Abstract. The authors would like to thank Suann Bruce, Masangu Mulongo, Bridgette Goeiman, Graham Perkins, Sophie Williams, Ntombiyenkosi Rakhombe, and Sibongile Ramotshela for their contributions to the data collection process and Kate Schnippel for her insights throughout the evaluation. 99% of cervical cancers are associated with HPV. Ethics approval for all data collection and analysis was obtained from the Human Ethics Research Committee at the University of the Witwatersrand. The cost per case detected for Pap testing was US$ 130.63 using a conventional definition for positive results and US$ 187.52 using a more conservative definition. They determined that for five developing country locations, including South Africa, once in a lifetime screening with VIA or HPV DNA testing followed by immediate cryotherapy reduced lifetime risk of cancer by roughly 25–36% and cost less than $500 per life year saved [19]. The age-standardized rates of cervical cancer incidence and mortality for the general population are 31.7 and 18.0 per 100,000 respectively [1]. 1 Cervical Cancer is the number 1 ranked cancer in women aged 15 to 44 in Southern Africa and one of the leading female cancer death causes in South Africa. 5 743 new cases are reported each year. The total cost of screening, i.e. [2,3] A school-based introduction was suggested for SA. In the sensitivity analysis, the comparison of total costs and ranking of methods did not change when the costs for each screening procedure varied by 25 percent higher or lower or for the different service volume scenarios. The resources required to provide screening are summarized in Table 1. However, it is important to note that the Pap 2 option is currently not allowed within the national screening guidelines. That will make your overall bill higher. Competing interests: The authors have the following competing interests: 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. The nurse also photographed the cervix, and in a weekly quality control meeting the photographs and diagnoses were reviewed by a team of nurses and doctors. 9 August 2015, a citizen of South Africa (we’ll call her Sarah) sent the following questions about HPV vaccines to CANSA, the Cancer Association of South Africa. VIA offers the ability for same day diagnosis and treatment, minimizing loss to follow up. This does not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials, as detailed online in the guide for authors. Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States of America, Affiliations HPV and Cervical Cancer Screening The purpose of HPV and screening of your cervix is to detect changes to the cells before they become cancerous and to test for the presence of HPV … Recent important studies have shown that HPV testing can detect precancerous changes of the cervix earlier and more accurately than the Pap test. However, HIV infection is a major risk factor for persistent HPV infection and abnormal cytological findings [7–10]. Screening for cervical cancer, whether it be through a pap smear or a HPV test, has saved millions of lives around the world. VIA was least sensitive but most cost-effective at US$ 17.05 per true CIN2+ case detected. The cost is: $90. To address the potential for increased risk of progression to disease among HIV-positive women infected with HPV, a second definition (Pap 2) was created for the validation study. The funders had no role in the study design, data collection, analysis or decision to publish this manuscript. SI Tables contains further detail. Yes If the cervical sample has not yet been collected– Your patients can choose to pay for this test online on our website using their credit card by visiting our order now page. It is the single biggest cause of cervical cancer in women. Almost all cases of cervical cancer are caused by HPV infection. A 71% reduction in HPV DNA screening costs would make it competitive with the conservative Pap definition. Perform the sample collection discreetly at home. The Nurx test, for example, costs $49 if you have insurance or $79 without it. An average time per procedure and average supply and equipment usage were then calculated using the three responses unless there were large discrepancies in the reported information. For example, the time spent each day gathering the necessary supplies, setting up and cleaning the clinic rooms, and filling out the necessary paperwork was constant regardless of the number of procedures performed. Get-Tested today! The hypothetical Pap 2 alternative (i.e. The difference was in the interpretation of the results only. of factors such as the initial high costs of both vaccines, poor community knowledge of cervical cancer and the causal relationship between HPV and cervical cancer, and lack of population experience with and acceptance of vaccines targeting adolescents. An HPV vaccine is now available in South Africa, and is offered to girls aged nine and up. Fig 2 illustrates the strategies considered. There are two types of the HPV vaccine available in South Africa: Vaccine 1: covers the most dangerous HPV strains 16 and 18. In South African women cervical cancer is responsible for the most cancer-related deaths and is … The base case results and a range representing 25% higher and lower costs are presented for personnel, supplies, equipment, lab and total costs. Comparing the incremental cost effectiveness of the four approaches, HPV DNA screening was “dominated” by Pap 2 in that HPV DNA testing offered fewer true cases while costing more overall. NB: The line represents the cost-effectiveness threshold, or frontier. You can get HPV by having vaginal, anal, or oral sex with someone who has the virus. PLoS ONE 10(11): Pap 2 was put forward in the validation study as a hypothetical, alternative screening approach for HIV-positive women on ARV treatment. careHPV screening once every 5 years with vaccination is the most cost-effective strategy for cervical cancer prevention in China. Using the outcomes estimated in the validation study, the average cost per case of CIN2+ detected by each screening strategy was calculated and compared taking into consideration both the costs for the screening method alone and for colposcopic biopsy if required for women with positive screening outcomes. Contributed reagents/materials/analysis tools: NLD. This is not the case in South Africa’s public sector. In many resource limited settings, improving existing Pap services is a goal for addressing this need, which is particularly urgent among HIV-positive women. HPV is so common that nearly all men and women get it at some point in their lives. After screening and diagnosis all women were followed up using study guidelines and local standards of care. We estimate the costs and cost-effectiveness of conventional cytology (Pap), visual inspection with acetic acid (VIA) and HPV DNA testing for detecting cases of CIN2+ among HIV … Baseline values and ranges for model variables. The “true prevalence” of CIN2+ in the study population, calculated based on colposcopic biopsy results, was 32.94% (95% confidence interval 30.01–36.01) or 393 cases [13]. Colposcopic biopsy costs largely drove the total and per case costs. In a separate modelling exercise from 2005, Goldie et al recommended HPV DNA testing again followed by same day treatment [35], and in 2009, Vijayaraghavan et al recommended conventional cytology followed by HPV DNA testing for triaging rather than colposcopic biopsy [20]. Firnhaber et al. All costs were collected in South African Rand (R), inflated to 2013 prices (where necessary) using the South African Consumer Price Index [26], and are reported here in 2013 US dollars using an average exchange rate for 2013 of 9.65 Rands per dollar [27]. Could you please let me know why CANSA is supporting the use of the hpv vaccines when these are now proven to be deadly? South Africa’s HIV and HPV infection rates are among the highest globally. No, PLOS is a nonprofit 501(c)(3) corporation, #C2354500, based in San Francisco, California, US, https://doi.org/10.1371/journal.pone.0141969, http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx, http://www.unaids.org/en/regionscountries/countries/southafrica/, https://www.imf.org/external/pubs/ft/weo/2014/02/weodata/index.aspx, http://www.cepheid.com/en/cepheid-solutions-uk/clinical-ivd-tests/sexual-health/xpert-hpv. However, at the time the commercial HPV vaccine was not available, so it was not included in the study. Also, this analysis stops at diagnosis of CIN2+ and does not consider the cost of treating women with dysplasia or cervical cancer or the potential for cancer-related mortality. Second, VIA is also less sensitive for CIN2+ detection than the other three approaches, resulting in more missed cases. Colposcopic biopsy was performed by a medical officer with assistance from a staff nurse. Yes Cytology and HPV testing require collection of a sample of cells and “reading” or testing of the sample in a laboratory [14]. - ... it's likely that the testing kits would be free once they come out. No, Is the Subject Area "Cancer treatment" applicable to this article? We have tests for the commonest STIs including chlamydia, gonorrhea, HIV and herpes as well as customized bundles to test for health and cancers For HIV-positive women with increased risk of disease progression, perhaps the “wide net” approach is acceptable to avoid missing cases. * An HPV vaccine dose costs R542, excluding VAT (standard price set by Health Department), though it can cost between R700 and R1 000 in private sector clinics. Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa, Affiliation Use of screening approaches varies globally and is often based on resource availability and perceived cost effectiveness. Cytology slides and histology specimens were sent to the NHLS as per standard of care for processing. Despite these limitations, our results are similar to other published cost-effectiveness analyses from South Africa in that strategies which eliminate or reduce the need for follow up visits and/or expensive colposcopy seem most competitive. The digene HPV Test, using Hybrid Capture 2 technology, provides an accurate, cost-effective, user-friendly method by achieving reliable and reproducible detection.. Benefits of HC2: Full-length probe for reliable senstivity and specificity with no risk due to deletions ; Unmatched cervical intraepithelial neoplasia (CIN) 2+ sensitivity the cost of the initial screening method plus the colposcopic biopsy for screen positive cases, was US$ 38,915 for Pap 1, US$ 69,865 for Pap 2, and US$ 115,610 for HPV DNA testing. [4] HPV demonstration project in KwaZulu-Natal An HPV demonstration project was conducted among 963 female In 2005, Goldie et al, used modelling to determine that screening strategies requiring fewer visits and less opportunity for loss to follow up were most cost-effective when considering lifetime risk of cancer, years of life saved, lifetime costs, and cost-effectiveness ratios. At-home HPV tests could change that. For women who do receive a positive, or abnormal, Pap result, many do not return for colposcopic biopsy. Sexually active, HIV-negative women, aged 16–22 years recruited from Soweto (n = 143) and Cape Town (n = 148) were tested for cervical HPV and other genital infections. The Consolidated Health Economics Evaluation Reporting checklist, a standardized, internationally recognized tool, was used in the preparation of this manuscript [29]. Pap 1 was US$ 130.63 per case; Pap 2 was US$ 187.52 per case; and HPV DNA screening was most costly at US$ 320.09 per case. The virus can cause changes to the cells in a woman's cervix. Men and women can get cancer of the mouth/ throat, and anus/rectum from the virus. In the validation study, which preceded the study presented here, all women were screened with all methods. As indicated in Table 4, the cost of screening this population with the initial screening method only was US$ 4,383 with VIA, US$ 9,750 for Pap and US$ 64,826 with HPV DNA testing. 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