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The Costs, Clinical Benefits, and Cost-Effectiveness of Screening for Cervical Cancer in HIV-Infected Women

Sue J. Goldie, MD, MPH; Milton C. Weinstein, PhD; Karen M. Kuntz, ScD; and Kenneth A. Freedberg, MD, MSc
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From Harvard University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Boston University School of Public Health, Boston, Massachusetts.

Ann Intern Med. 1999;130(2):97-107. doi:10.7326/0003-4819-130-2-199901190-00003
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Background: Women with HIV infection have a higher risk for cervical squamous intraepithelial lesions than do women without HIV infection, and the optimal regimen for cervical cancer screening in these women is uncertain.

Objective: To assess the net health consequences, costs, and cost-effectiveness of various screening strategies for cervical neoplasia and cancer in HIV-infected women.

Design: A cost-effectiveness analysis from a societal perspective done by using a state-transition Markov model. Values for incidence, progression, and regression of cervical neoplasia; efficacy of screening and treatment; progression of HIV disease; mortality from HIV infection and cancer; quality of life; and costs were obtained from the literature.

Setting: Simulated clinical practice in the United States.

Patients: HIV-infected women representative of the U.S. population.

Intervention: Six main screening strategies—no screening, annual Papanicolaou smears, annual Papanicolaou smears after two negative smears obtained 6 months apart (recommended by the Centers for Disease Control and Prevention), semiannual Papanicolaou smears, annual colposcopy, and semiannual colposcopy—were considered.

Measurements: Quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness.

Results: Annual Papanicolaou smear screening resulted in a 2.1-month gain in quality-adjusted life expectancy for an incremental cost of $12 800 per QALY saved. Annual Papanicolaou smear screening after two negative smears obtained 6 months apart provided an additional 0.04 QALYs at a cost of $14 800 per QALY saved. Semiannual Papanicolaou smear screening provided a further 0.17 QALYs at a cost of $27 600 per QALY saved. Annual colposcopy cost more but provided no additional benefit compared with that given by semiannual Papanicolaou smear screening, and semiannual colposcopy exceeded $375 000 per QALY saved. Results were most sensitive to the rate of progression of neoplasia to invasive cancer.

Conclusions: In HIV-infected women, cervical cancer screening with annual Papanicolaou smears after two negative smears obtained 6 months apart offers quality-adjusted life expectancy benefits at a cost comparable to that of other clinical preventive interventions.


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Figure 1.
Overview of the Markov model.SIL

The model has five broad categories of states: normal, low-grade squamous intraepithelial lesions ( ), high-grade SIL, cervical cancer, and death. Each cervical health state is stratified by CD4 cell count and history of cervical neoplasia. Cancer states are further stratified by stage of cervical cancer. Death may result from an acute or chronic AIDS-related condition, cervical cancer, or other causes.

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Figure 2.
Three-way sensitivity analysis of the incidence of squamous intraepithelial lesions (SIL), progression of SIL to cancer, and the acceptable cost-effectiveness threshold for the choice of semiannual Papanicolaou smear screening or the Centers for Disease Control and Prevention (CDC) screening strategy (annual Papanicolaou smear screening after two initial smears obtained 6 months apart).QALY

The lines show the incremental cost per quality-adjusted life-year ( ) gained necessary to use semiannual Papanicolaou smear screening ($20 000, $50 000, and $100 000 per QALY). For a particular cost-effectiveness threshold, points to the upper right of the line indicate that semiannual Papanicolaou smear screening is preferred; points to the lower left of the line indicate that the CDC screening strategy is preferred. Asterisk represents the base case.

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