Better access to cervical cancer testing and treatment could prevent thousands of HIV-positive women dying
Expanding access to even the most basic form of cervical cancer screening and treatment could prevent thousands of deaths among women living with HIV in Kenya.
A modelling study from Kenya finds that even low cost strategies to screen women for cervical cancer will result in significant population-level health gains. Four different cervical cancer screening and treatment strategies were assessed, by modelling their scale up to reach 70% of HIV positive women on antiretroviral treatment (ART) over the next 20 years.
One scenario assessed the impact of providing the least costly screening method, known as visual inspection with acetic acid (VIA), plus same-day treatment using cryotherapy.
A second scenario offered VIA and cryotherapy, plus a treatment called a loop excision electrical procedure (LEEP). This is a small electrical wire loop that is used to treat more advanced precancerous lesions and must be carried out by a specialist clinic.
A third scenario assessed the impact of offering human papillomavirus (HPV)-DNA testing, which is the preferred screening method due to its sensitivity. This requires someone to visit a clinic twice, once for testing and once for their results. Treatment under this scenario was same-day cryotherapy or LEEP on referral.
A fourth scenario offered same-day HPV-DNA testing or digitally enhanced VIA, which is more sensitive than traditional VIA. Treatment was either same-day cryotherapy or LEEP on referral, depending on need.
The study estimated that, between 2020 and 2040, around 86,100 women living with HIV who are on ART will get cervical cancer, and 44,700 will die from it. They found that introducing any of these four screening and treatment strategies would result in significant declines in both cases and deaths of cervical cancer.
However, the fourth strategy of offering same-day testing and treatment using a range of methods was found to be the most effective, averting 50% (43,200) of cervical cancer cases and 40% (11,800) of deaths.
The results of the other three scenarios were likely to be similar to each other: averting 33% (28,000) of cervical cancer cases and 27% (7,700) of deaths.
The similarity between these three approaches is due to various factors. Although VIA screening is less sensitive than HPV-DNA testing, because its results are immediate people can be treated on the same day. By contrast, while HPV-DNA testing is highly sensitive, it requires people to return for treatment, and because some will not do so their risk of cervical cancer increases.
The study estimated that the number of women living with HIV on ART will increase from 0.91 million in 2020 to 1.73 million in 2040. Due to the protective effect of ART, the prevalence of HPV, which can lead to cervical cancer, was predicted to decrease from 55.8% to 47.7%, while cervical cancer itself is likely to fall from 7.6% to 4%.
A cost-benefit analysis found that yearly re-screening, regardless of the technology used, will place a large burden on Kenya’s health system, but that this could be reduced without undermining impact if screening was provided every three years.
The study is limited by the assumption that women living with HIV who are on ART for more than two years will have the same level of HPV-related disease as HIV-negative women. The study also did not model the effects of HIV treatment failure.
Despite this, its results suggest that even expanding access to more basic cervical cancer screening and treatment for women living with HIV would greatly reduce the number of women developing and dying from cervical cancer.