Costs and cost-effectiveness of LEEP versus cryotherapy for treating cervical dysplasia among HIV-positive women in Johannesburg, South Africa
Public Deposited- Creator
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Lince-Deroche, N.
- Other Affiliation: University of the Witwatersrand
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Van Rensburg, C.
- Other Affiliation: University of the Witwatersrand
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Roseleur, J.
- Other Affiliation: University of the Witwatersrand
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Sanusi, B.
- Affiliation: Gillings School of Global Public Health
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Phiri, J.
- Other Affiliation: University of the Witwatersrand
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Michelow, P.
- Other Affiliation: University of Witwatersrand
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Smith, J.S.
- Affiliation: Gillings School of Global Public Health
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Firnhaber, C.
- Other Affiliation: University of Witwatersrand
- Abstract
- Background Cervical cancer incidence is significant in countries, such as South Africa, with high burdens of both HIV and human papillomavirus (HPV). Cervical cancer is largely preventable if dysplasia is diagnosed and treated early, but there is debate regarding the best approaches for screening and treatment, especially for low-resource settings. Currently South Africa provides Pap smears followed by colposcopic biopsy and LEEP if needed in its public health facilities. We estimated the costs and cost-effectiveness of two approaches for treating cervical intraepithelial neoplasia grade 2 or higher (CIN2+) among HIV-infected women, most of whom were taking antiretroviral treatment, at a public HIV treatment facility in Johannesburg, South Africa. Methods Method effectiveness was derived from an intention-to-treat analysis of data gathered in a clinical trial completed previously at the study facility. In the trial, women who were diagnosed with CIN2+ and eligible for cryotherapy were randomized to cryotherapy or LEEP. If women were CIN2+ at six months as determined via Pap smear and colposcopic biopsy, all women-regardless of their original treatment assignment-received LEEP. "Cure" was then defined as the absence of disease at 12 months based on Pap smear and colposcopic biopsy. Health service costs were estimated using micro-costing between June 2013 and April 2014. Capital costs were annualized using a discount rate of 3%. Two different service volume scenarios were considered, and results from an as-treated analysis were considered in sensitivity analysis. Results In total, 166 women with CIN2+ were enrolled (86 had LEEP; 80 had cryotherapy). At 12 months, cumulative loss to follow-up was 12.8% (11/86) for the LEEP group and 13.8% (11/80) for cryotherapy. Based on the unadjusted intention-to-treat analysis conducted for this economic evaluation, there was no significant difference in efficacy. At 12 months, 83.8% (95% CI 73.8-91.1) of women with CIN2+ at baseline and randomized to cryotherapy were free of CIN2+ disease. In contrast, 76.7% (95% CI 66.4-85.2) of women assigned to LEEP were free from disease. On average, women initially treated with cryotherapy were less costly per patient randomized at US $ 118.00 (113.91-122.10), and per case "cured" at US$ 140.90 (136.01-145.79). Women in the LEEP group cost US$ 162.56 (157.90-167.22) per patient randomized and US$ 205.59 (199.70-211.49) per case cured. In the as-treated analysis, which was based on trial data, LEEP was more efficacious than cryotherapy; however, the difference was not significant. Cryotherapy remained more cost-effective than LEEP in all sensitivity and scenario analyses. Conclusions For this cost-effectiveness analysis, using an intention-to-treat approach and taking into consideration uncertainty in the clinical and cost outcomes, a strategy involving cryotherapy plus LEEP if needed at six months was dominant to LEEP plus LEEP again at six months if needed for retreatment. However, compared to other studies comparing LEEP and cryotherapy, the efficacy results were low in both treatment groups-possibly due to the HIV-positivity of the participants. Further research is needed, but at present choosing the "right" treatment option may be less important than ensuring access to treatment and providing careful monitoring of treatment outcomes.
- Date of publication
- 2018
- Keyword
- health care cost
- Middle Aged
- electrosurgery
- South Africa
- colposcopy
- economics
- randomization
- complication
- Article
- vagina smear
- major clinical study
- Papanicolaou test
- human
- Survival Analysis
- health care access
- female
- procedures
- endometrium biopsy
- Adult
- Humans
- Female
- clinical trial
- Combined Modality Therapy
- Colposcopy
- controlled study
- intention to treat analysis
- Cost-Benefit Analysis
- Vaginal Smears
- uterine cervix dysplasia
- highly active antiretroviral therapy
- Young Adult
- comparative study
- health care facility
- papillomavirus infection
- cost effectiveness analysis
- economic evaluation
- Random Allocation
- young adult
- Papillomavirus Infections
- treatment outcome
- loop electrosurgical excision procedure
- aged
- intermethod comparison
- cost benefit analysis
- middle aged
- Antiretroviral Therapy, Highly Active
- Papanicolaou Test
- uterine cervix carcinoma in situ
- cryotherapy
- Treatment Outcome
- cohort analysis
- survival analysis
- Human immunodeficiency virus infected patient
- Electrosurgery
- adult
- multimodality cancer therapy
- Cryotherapy
- Cervical Intraepithelial Neoplasia
- randomized controlled trial
- human tissue
- antiretroviral therapy
- DOI
- Identifier
- Resource type
- Article
- License
- Attribution 4.0 International
- Journal title
- PLoS ONE
- Journal volume
- 13
- Journal issue
- 10
- Language
- English
- Version
- Publisher
- ISSN
- 1932-6203
- Publisher
- Public Library of Science
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