Model-based impact and cost-effectiveness of cervical cancer prevention in sub-Saharan Africa

Abstract

Using population and epidemiologic data for 48 countries in sub-Saharan Africa, we used a model-based approach to estimate cervical cancer cases and deaths averted, disability-adjusted life years (DALYs) averted and incremental cost-effectiveness ratios (I$ (international dollar) per DALY averted) for human papillomavirus (HPV) vaccination of pre-adolescent girls. Additional epidemiologic data from Uganda and South Africa informed estimates of cancer risk reduction and cost-effectiveness ratios associated with pre-adolescent female vaccination followed by screening of women over age 30. Assuming 70% vaccination coverage, over 670,000 cervical cancer cases would be prevented among women in five consecutive birth cohorts vaccinated as young adolescents; over 90% of cases averted were projected to occur in countries eligible for GAVI Alliance support. There were large variations in health benefits across countries attributable to differential cancer rates, population size, and population age structure. More than half of DALYs averted in sub-Saharan Africa were in Nigeria, Tanzania, Uganda, the Democratic Republic of the Congo, Ethiopia, and Mozambique. When the cost per vaccinated girl was I$5 ($0.55 per dose), HPV vaccination was cost-saving in 38 sub-Saharan African countries, and cost I$300 per DALY averted or less in the remaining countries. At this vaccine price, pre-adolescent HPV vaccination followed by screening three times per lifetime in adulthood cost I$300 per year of life saved (YLS) in Uganda (per capita GDP I$1,140) and I$1,000 per YLS in South Africa (per capita GDP I$9,480). In nearly all countries assessed, HPV vaccination of pre-adolescent girls could be very cost-effective if the cost per vaccinated girl is less than I$25-I$50, reflecting a vaccine price being offered to the GAVI Alliance. In-country decision makers will need to consider many other factors, such as affordability, acceptability, feasibility, and competing health priorities, when making decisions about cervical cancer prevention. This article forms part of a regional report entitled "Comprehensive Control of HPV Infections and Related Diseases in the Sub-Saharan Africa Region" Vaccine Volume 31, Supplement 5, 2013. Updates of the progress in the field are presented in a separate monograph entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.

Keywords: Cost-effectiveness; HPV; Mathematical model; Sub-Saharan Africa.