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. 2011 Apr 4;6(4):e18527.
doi: 10.1371/journal.pone.0018527.

Potential impact of antiretroviral therapy and screening on cervical cancer mortality in HIV-positive women in sub-Saharan Africa: a simulation

Julius Atashili  1 , Jennifer S Smith, Adaora A Adimora, Joseph Eron, William C Miller, Evan Myers
Affiliations

Potential impact of antiretroviral therapy and screening on cervical cancer mortality in HIV-positive women in sub-Saharan Africa: a simulation

Julius Atashili et al. PLoS One. .

Abstract

Background: Despite having high cervical cancer incidence and mortality rates, screening for cervical precancerous lesions remains infrequent in sub-Saharan Africa. The need to screen HIV-positive women because of the higher prevalence and faster progression of cervical precancerous lesions may be heightened by the increased access to highly-active antiretroviral therapy (HAART). Policymakers need quantitative data on the effect of HAART and screening to better allocate limited resources. Our aim was to quantify the potential effect of these interventions on cervical cancer mortality.

Methods and findings: We constructed a Markov state-transition model of a cohort of HIV-positive women in Cameroon. Published data on the prevalence, progression and regression of lesions as well as mortality rates from HIV, cervical cancer and other causes were incorporated into the model. We examined the potential impact, on cumulative cervical cancer mortality, of four possible scenarios: no HAART and no screening (NHNS), HAART and no screening (HNS), HAART and screening once on HAART initiation (HSHI), and HAART and screening once at age 35 (HS35). Our model projected that, compared to NHNS, lifetime cumulative cervical cancer mortality approximately doubled with HNS. It will require 262 women being screened at HAART initiation to prevent one cervical cancer death amongst women on HAART. The magnitudes of these effects were most sensitive to the rate of progression of precancerous lesions.

Conclusions: Screening, even when done once, has the potential of reducing cervical cancer mortality among HIV-positive women in Africa. The most feasible and cost-effective screening strategy needs to be determined in each setting.

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Conflict of interest statement

Competing Interests: JA has previously received honoraria from GSK and research supplies from Digene. JSS has received research grants, honoraria, or consulting fees during the last three years from GSK, Digene and GenProbe. ERM has received research funding and done consulting for Merck & Co.

Figures

Figure 1
Figure 1. Summary of states in the Markov model.
Adapted from an original depiction by Goldie et al, 1999 .
Figure 2
Figure 2. Cumulative mortality by intervention in a cohort of HIV positive women getting infected at age 25.
A. Cumulative mortality from cervical cancer. B. Cumulative mortality from all causes (NHNS: No HAART No Screening; HNS: HAART but No Screening; HSHI: HAART and one screen at HAART initiation; HS35: HAART and one screen at age 35).
Figure 3
Figure 3. Sensitivity of cumulative cervical cancer mortality to model parameters.
A. Sensitivity to the relative effect of HAART in reducing HIV-mortality. B. Sensitivity to the progression rate of precancerous lesions. C. Sensitivity to cervical cancer mortality rate. The values on the x-axis refer to the ratio of each parameter compared to its value in the base model. (NHNS: No HAART No Screening; HNS: HAART but No Screening; HSHI: HAART and one screen at HAART initiation; HS35: HAART and one screen at age 35).
Figure 4
Figure 4. Sensitivity of cumulative cervical cancer mortality to baseline parameters.
A. Sensitivity to the prevalence of squamous intraepithelial lesions at beginning of cohort. B. Sensitivity to the proportion of lesions that are high grade squamous intraepithelial lesions at the beginning of cohort. C. Sensitivity to the initial age of cohort. (NHNS: No HAART No Screening; HNS: HAART but No Screening; HSHI: HAART and one screen at HAART initiation; HS35: HAART and one screen at age 35).
See this image and copyright information in PMC

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