Lifetime effects, costs, and cost effectiveness of testing for human papillomavirus to manage low grade cytological abnormalities: results of the NHS pilot studies

Cost effectiveness of strategies for cervical cancer prevention in India

The establishment of link between high-risk human papillomavirus (HPV) infection and occurrence of cervical cancer has resulted in development of various HPV related control strategies for the prevention of cervical cancer. The objective of the present study was to assess the cost effectiveness of various screening strategies for cervical cancer and human papilloma virus (HPV) vaccination in India. A Markov model based on societal perspective was designed to estimate the lifetime costs and consequences of screening (with either visual inspect with acetic acid (VIA), Papanicolaou test or HPV DNA test at various time intervals) in a hypothetical cohort of 30-65 years age women or vaccination among adolescent girls. Diagnostic accuracy of the screening strategies, efficacy of HPV vaccination and data on transition probabilities was based on the results of the existing meta-analyses. Primary data was collected for assessing per person cost of screening, cost of treating cervical cancer and quality of life. We found that introduction of different screening strategies leads to reduction in lifetime occurrence of cervical cancer cases caused by HPV 16/18 from 20% to 61%, and cervical cancer deaths from 28% to 70%, as compared to no screening. Among various screening strategies, screening with both VIA 5 yearly and VIA 10 yearly came out to be cost effective at 1-time per capita GDP, with VIA every 5 years providing greater health benefits as compared to VIA 10 years. Hence, screening with VIA 5 years at an incremental cost of US$ 829 (INR 54,881) per QALY gained is the recommended strategy for India. Further, with regards to HPV vaccination, it leads to 60% reduction in cancer cases and mortality caused by HPV 16/18 as compared to no vaccination. Moreover, when this vaccinated cohort of adolescent girls is also screened later in their life (with VIA every 10 years and VIA 5 years), it leads to 69%-76% reduction in cancer cases and 71%-81% reduction in cancer deaths. As compared to no vaccination and no screening, both HPV vaccination alone and vaccination plus screening (with VIA every 5 yearly and VIA 10 yearly) appears to be cost effective with ICERs in the range of US$ 86 (INR 5,693) to US$ 476 (INR 31,511) per QALY gained. In the long run, when the cohort of adolescent girls, who were immunized for HPV, reach the age of 30 years, the screening frequency using VIA should be determined based on the coverage of HPV vaccination in that cohort.

Public awareness of human papillomavirus

Objectives

The main objective of this study was to review the evidence relating to the level of awareness of human papillomavirus (HPV) in the general population and the implications for the potential introduction of HPV vaccination and HPV testing as part of screening.

Methods

PubMed search performed on terms: ‘HPV education’, ‘HPV awareness’ ‘Genital Warts Awareness’

Results

Public awareness of HPV is generally very low, particularly with respect to its relation to abnormal smears and cervical cancer although knowledge levels vary to some extent according to sociodemographic characteristics. There is also much confusion around which types cause warts and the types that can cause cancer. The sexually transmissible nature of the infection is of major concern and confusion to women.

Conclusions

Due to the lack of current awareness of HPV, significant education initiatives will be necessary should HPV vaccination and/or HPV testing be introduced. Organized edification of healthcare workers and the media, who constitute the two most preferred sources of information, will be crucial.

Beware of Kinked Frontiers: A Systematic Review of the Choice of Comparator Strategies in Cost-Effectiveness Analyses of Human Papillomavirus Testing in Cervical Screening

OBJECTIVES

To systematically review the choice of comparator strategies in cost-effectiveness analyses (CEAs) of human papillomavirus testing in cervical screening.

METHODS

The PubMed, Web of Knowledge, and Scopus databases were searched to identify eligible model-based CEAs of cervical screening programs using human papillomavirus testing. The eligible CEAs were reviewed to investigate what screening strategies were chosen for analysis and how this choice might have influenced estimates of the incremental cost-effectiveness ratio (ICER). Selected examples from the reviewed studies are presented to illustrate how the omission of relevant comparators might influence estimates of screening cost-effectiveness.

RESULTS

The search identified 30 eligible CEAs. The omission of relevant comparator strategies appears likely in 18 studies. The ICER estimates in these cases are probably lower than would be estimated had more comparators been included. Five of the 30 studies restricted relevant comparator strategies to sensitivity analyses or other subanalyses not part of the principal base-case analysis. Such exclusion of relevant strategies from the base-case analysis can result in cost-ineffective strategies being identified as cost-effective.

CONCLUSIONS

Many of the CEAs reviewed appear to include insufficient comparator strategies. In particular, they omit strategies with relatively long screening intervals. Omitting relevant comparators matters particularly if it leads to the underestimation of ICERs for strategies around the cost-effectiveness threshold because these strategies are the most policy relevant from the CEA perspective. Consequently, such CEAs may not be providing the best possible policy guidance and lead to the mistaken adoption of cost-ineffective screening strategies.

Human papillomavirus testing in young women: clinical outcomes of human papillomavirus triage in a UK cervical screening program

BACKGROUND

In the United Kingdom, human papillomavirus (HPV) testing is used to triage women with borderline cytology or mild dyskaryosis; however, in young women, the value of triage is limited by the high HPV prevalence rate. The current study examined the impact of HPV triage on colposcopy referral, colposcopy procedures, and patient outcome in a cervical screening population that included women aged < 25 years.

METHODS

Women aged 18 to 65 years attending for cervical screening in Northern Ireland were tested for HPV if their cytology result demonstrated borderline cytology or mild dyskaryosis. Of the 866 women eligible for HPV triage, those who tested negative for HPV were returned to routine screening and women who tested positive were referred to colposcopy.

RESULTS

HPV prevalence was 82.07% in women aged < 25 years and 54.69% in women aged ≥ 25 years. Colposcopy referrals increased by 42.67%. The odds of undergoing a large loop excision of the transformation zone (LLETZ) compared with punch biopsy increased by 0.056 per year above the age of 31 years. LLETZ performed in women aged ≥ 25 years and those aged < 25 years yielded rates of cervical intraepithelial neoplasia of type 2 or higher (≥ CIN2) of 57.04% and 80.00%, respectively. The positive predictive value of HPV triage for detecting ≥ CIN2 was 29.92% in women aged < 25 years and 27.51% in the older age group.

CONCLUSIONS

HPV triage substantially increased colposcopy referrals. The positive predictive value of a positive HPV test to detect ≥ CIN2 was not affected by age. LLETZ performed in women aged < 25 years yielded higher rates of ≥ CIN2 compared with the older age group.

ABC3 Part I: a review of the guidelines for terminology, classification and management of cervical cytology in England

The provision of guidance on cytology reporting and evaluation, first outlined in 1995 with the publication of Achievable Standards, Benchmarks for Reporting, and Criteria for Evaluating Cervical Cytopathology (ABC), and subsequently revised and expanded in a second edition in 2000, has been pivotal to the success of the National Health Service Cervical Screening Programme (NHSCSP), ensuring that standards are upheld, and that rigorous evaluation and quality assurance take place. In the last decade, major changes to the NHSCSP, notably the adoption of revised age ranges and screening intervals for all women in England, implementation of liquid-based cytology and, most recently, the decision to introduce high-risk human papillomavirus (HR-HPV) testing for triage of low-grade and borderline (equivalent to 'atypical') cytological abnormalities and test of cure after treatment of cervical intraepithelial neoplasia (CIN) determined that an updated version of ABC was required. The third edition of ABC recommends adoption, with minor modification, of the revised British Society for Clinical Cytology terminology and provides guidance on the management of abnormal cytology results linked to this terminology taking account of HR-HPV testing. To accommodate these changes, expanded result codes, which are electronic codes used to transfer management information to central computers for follow-up, call and recall of individual women, have been developed. Further guidance on specimen adequacy is also provided. Revised performance indicators are described and explained in a separate article by R. Blanks in this issue of Cytopathology. All the changes in ABC3 are designed to support the mission statement of the NHSCSP that 'the objective of cervical screening is to reduce cervical cancer incidence and mortality by screening with a high sensitivity for the detection of CIN2 or worse, whilst maintaining a high specificity'.

Human papillomavirus testing versus repeat cytology for triage of minor cytological cervical lesions

BACKGROUND

Atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intra-epithelial lesions (LSIL) are minor lesions of the cervical epithelium, detectable by cytological examination of cells collected from the surface of the cervix of a woman.Usually, women with ASCUS and LSIL do not have cervical (pre-) cancer, however a substantial proportion of them do have underlying high-grade cervical intra-epithelial neoplasia (CIN, grade 2 or 3) and so are at increased risk for developing cervical cancer. Therefore, accurate triage of women with ASCUS or LSIL is required to identify those who need further management.This review evaluates two ways to triage women with ASCUS or LSIL: repeating the cytological test, and DNA testing for high-risk types of the human papillomavirus (hrHPV) - the main causal factor of cervical cancer.

OBJECTIVES

Main objective To compare the accuracy of hrHPV testing with the Hybrid Capture 2 (HC2) assay against that of repeat cytology for detection of underlying cervical intraepithelial neoplasia of grade 2 or worse (CIN2+) or grade 3 or worse (CIN3+) in women with ASCUS or LSIL. For the HC2 assay, a positive result was defined as proposed by the manufacturer. For repeat cytology, different cut-offs were used to define positivity: Atypical squamous cells of undetermined significance or worse (ASCUS+), low-grade squamous intra-epithelial lesions or worse (LSIL+) or high-grade squamous intra-epithelial lesions or worse (HSIL+).Secondary objective To assess the accuracy of the HC2 assay to detect CIN2+ or CIN3+ in women with ASCUS or LSIL in a larger group of reports of studies that applied hrHPV testing and the reference standard (coloscopy and biopsy), irrespective whether or not repeat cytology was done.

SEARCH METHODS

We made a comprehensive literature search that included the Cochrane Register of Diagnostic Test Accuracy Studies; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE (through PubMed), and EMBASE (last search 6 January 2011). Selected journals likely to contain relevant papers were handsearched from 1992 to 2010 (December). We also searched CERVIX, the bibliographic database of the Unit of Cancer Epidemiology at the Scientific Institute of Public Health (Brussels, Belgium) which contains more than 20,000 references on cervical cancer.More recent searches, up to December 2012, targeted reports on the accuracy of triage of ASCUS or LSIL with other HPV DNA assays, or HPV RNA assays and other molecular markers. These searches will be used for new Cochrane reviews as well as for updates of the current review.

SELECTION CRITERIA

Studies eligible for inclusion in the review had to include: women presenting with a cervical cytology result of ASCUS or LSIL, who had undergone both HC2 testing and repeat cytology, or HC2 testing alone, and were subsequently subjected to reference standard verification with colposcopy and colposcopy-directed biopsies for histologic verification.

DATA COLLECTION AND ANALYSIS

The review authors independently extracted data from the selected studies, and obtained additional data from report authors.Two groups of meta-analyses were performed: group I concerned triage of women with ASCUS, group II concerned women with LSIL. The bivariate model (METADAS-macro in SAS) was used to assess the absolute accuracy of the triage tests in both groups as well as the differences in accuracy between the triage tests.

MAIN RESULTS

The pooled sensitivity of HC2 was significantly higher than that of repeat cytology at cut-off ASCUS+ to detect CIN2+ in both triage of ASCUS and LSIL (relative sensitivity of 1.27 (95% CI 1.16 to 1.39; P value < 0.0001) and 1.23 (95% CI 1.06 to 1.4; P value 0.007), respectively. In ASCUS triage, the pooled specificity of the triage methods did not differ significantly from each other (relative specificity: 0.99 (95% CI 0.97 to 1.03; P value 0.98)). However, the specificity of HC2 was substantially, and significantly, lower than that of repeat cytology in the triage of LSIL (relative specificity: 0.66 (95% CI 0.58 to 0.75) P value < 0.0001).

AUTHORS' CONCLUSIONS

HPV-triage with HC2 can be recommended to triage women with ASCUS because it has higher accuracy (significantly higher sensitivity, and similar specificity) than repeat cytology. When triaging women with LSIL, an HC2 test yields a significantly higher sensitivity, but a significantly lower specificity, compared to a repeat cytology. Therefore, practice recommendations for management of women with LSIL should be balanced, taking local circumstances into account.

Adjunctive colposcopy technologies for examination of the uterine cervix--DySIS, LuViva Advanced Cervical Scan and Niris Imaging System: a systematic review and economic evaluation

BACKGROUND

Women in England (aged 25-64 years) are invited for cervical screening every 3-5 years to assess for cervical intraepithelial neoplasia (CIN) or cancer. CIN is a term describing abnormal changes in the cells of the cervix, ranging from CIN1 to CIN3, which is precancerous. Colposcopy is used to visualise the cervix. Three adjunctive colposcopy technologies for examination of the cervix have been included in this assessment: Dynamic Spectral Imaging System (DySIS), the LuViva Advanced Cervical Scan and the Niris Imaging System.

OBJECTIVE

To determine the clinical effectiveness and cost-effectiveness of adjunctive colposcopy technologies for examination of the uterine cervix for patients referred for colposcopy through the NHS Cervical Screening Programme.

DATA SOURCES

Sixteen electronic databases [Allied and Complementary Medicine Database (AMED), BIOSIS Previews, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Database of Abstracts of Reviews of Effects (DARE), EMBASE, Health Management Information Consortium (HMIC), Health Technology Assessment (HTA) database; Inspec, Inside Conferences, MEDLINE, NHS Economic Evaluation Database (NHS EED), PASCAL, Science Citation Index Expanded (SCIE) and Science Citation Index (SCI) - Conference Proceedings], and two clinical trial registries [ClinicalTrials.gov and Current Controlled Trials (CCT)] were searched to September-October 2011.

REVIEW METHODS

Studies comparing DySIS, LuViva or Niris with conventional colposcopy were sought; a narrative synthesis was undertaken. A decision-analytic model was developed, which measured outcomes in terms of quality-adjusted life-years (QALYs) and costs were evaluated from the perspective of the NHS and Personal Social Services with a time horizon of 50 years.

RESULTS

Six studies were included: two studies of DySIS, one study of LuViva and three studies of Niris. The DySIS studies were well reported and had a low risk of bias; they found higher sensitivity with DySIS (both the DySISmap alone and in combination with colposcopy) than colposcopy alone for identifying CIN2+ disease, although specificity was lower with DySIS. The studies of LuViva and Niris were poorly reported and had limitations, which indicated that their results were subject to a high risk of bias; the results of these studies cannot be considered reliable. The base-case cost-effectiveness analysis suggests that both DySIS treatment options are less costly and more effective than colposcopy alone in the overall weighted population; these results were robust to the ranges tested in the sensitivity analysis. DySISmap alone was more costly and more effective in several of the referral groups but the incremental cost-effectiveness ratio (ICER) was never higher than £1687 per QALY. DySIS plus colposcopy was less costly and more effective in all reasons for referral. Only indicative analyses were carried out on Niris and LuViva and no conclusions could be made on their cost-effectiveness.

LIMITATIONS

The assessment is limited by the available evidence on the new technologies, natural history of the disease area and current treatment patterns.

CONCLUSIONS

DySIS, particularly in combination with colposcopy, has higher sensitivity than colposcopy alone. There is no reliable evidence on the clinical effectiveness of LuViva and Niris. DySIS plus colposcopy appears to be less costly and more effective than both the DySISmap alone and colposcopy alone; these results were robust to the sensitivity analyses undertaken. Given the lack of reliable evidence on LuViva and Niris, no conclusions on their potential cost-effectiveness can be drawn. There is some uncertainty about how generalisable these findings will be to the population of women referred for colposcopy in the future, owing to the introduction of the human papillomavirus (HPV) triage test and uptake of the HPV vaccine.

Cost and logistics of alternative roll-out options for implementing human papillomavirus testing as a triage in cervical screening: results of the sentinel sites study

Background:

Previous studies have indicated that human papillomavirus (HPV) testing as a triage for managing equivocal cytology is cost-effective. The aim of this study was to assess the costs of alternative roll-out options.

Methods:

Detailed cost estimates were collected from six laboratories where HPV triage had been implemented. Costs were assessed for the two different service delivery models that were implemented; a ‘hub and spoke model’ of central HPV testing in a microbiology laboratory with separate cytology laboratories, and an ‘integrated model’ where HPV testing was conducted within the cytology laboratory.

Results:

Comparison of alternative delivery models indicated that setting up HPV processing within existing cytology laboratory, i.e., an ‘integrated cytology/HPV laboratory’ generated savings in staff time amounting to between £2.54 and 4.86 per sample processed. Running full HPV testing batches was also an important consideration. For full batches to be run on a twice weekly basis requires having no more than two laboratories per Strategic Health Authority.

Conclusions:

To be cost-efficient, and to meet turn-around times, HPV testing needs to be conducted at integrated cytology/HPV testing centres with sufficient throughput to run full batches of HPV tests.

Cost-effectiveness of cervical cancer screening: cytology versus human papillomavirus DNA testing

OBJECTIVE

To determine the most cost-effective screening programme for cervical cancer.

DESIGN

Cost-effectiveness analysis from a societal perspective.

SETTING

The Netherlands.

POPULATION

Dutch women who have not been invited for human papillomavirus (HPV) vaccination.

METHODS

We calibrated the microsimulation screening analysis (MISCAN) model to Dutch epidemiological data. We used this model to consider nine screening strategies that use: (i) cytological testing with cytology triage for borderline/mildly abnormal smears; (ii) HPV testing with cytology triage for HPV-positive smears; or (iii) cytological testing with HPV triage for borderline/mildly abnormal smears. For each strategy, we varied the number of screening rounds, the time interval, the age of the first screening, and the type of cytological testing (conventional or liquid-based cytology).

MAIN OUTCOME MEASURES

Quality-adjusted life years (QALYs) gained and costs from a societal perspective.

RESULTS

Under the base-case assumptions, primary HPV testing with cytology triage is the most cost-effective strategy. Using cost-effectiveness thresholds of € 20,000 and € 50,000 per QALY gained yields optimal screening programmes with three and seven screening rounds, respectively. The results are sensitive to several uncertain model inputs, most importantly the costs of the HPV test. For women aged 32 years or younger, primary cytology screening is more cost-effective than primary HPV testing.

CONCLUSIONS

Increasing the interval between screening rounds and changing the primary test from cytology to HPV testing can improve the effectiveness and decrease the costs of cervical cancer screening in the Netherlands.

Human papillomavirus deoxyribonucleic acid testing in developed countries

Cervical cancer has been largely eliminated in developed countries with the implementation of cytology-based screening programmes that depend on a call-recall system, followed by colposcopy and biopsy, treatment of precancerous lesions and follow up. With the discovery that persistent infection with high-risk human papillomavirus types is necessary for the development of cervical cancer, several tests for human papillomavirus deoxyribonucleic acid have been developed that can identify women at risk. Human papillomavirus deoxyribonucleic acid testing is more sensitive and only slightly less specific than cytology for detecting cervical intraepithelial neoplasia. It is also more reproducible, with the potential for self-sampling. Human papillomavirus genotyping, messenger RNA analysis and other biomarkers can help to further stratify this group and diminish referrals to colposcopy. Initially, human papillomavirus testing was used as an adjunct to cytology for triage of borderline cases, but evidence has shown its superiority as a screening method and in the follow up of women treated for cervical intraepithelial neoplasia.

Cost-effectiveness analysis for Pap smear screening and human papillomavirus DNA testing and vaccination

INTRODUCTION

As the effectiveness of cytology-based screening programme for cervical cancer in mortality reduction has reached a plateau, various preventive strategies have been considered, including intensive Pap smear screening and the supplemental use of human papillomavirus (HPV) DNA test or HPV vaccination. Cost and effectiveness of these various preventive strategies are therefore of great concern for health policy makers.

OBJECTIVE

We intended to assess whether the combination of HPV DNA testing or HPV vaccination with Pap smear screening programme or the sole annual Pap smear screening is more effective and cost-effective in prevention of cervical cancer than the existing triennial Pap smear screening programme.

METHODS

A Markov decision model was constructed to compare total costs and effectiveness between different preventive strategies (including annual Pap smear, HPV DNA testing or HPV vaccination together with Pap smear screening programme) as opposed to the triennial Pap smear screening alone (the comparator). Probabilistic cost-effectiveness (C-E) analysis was adopted to plot a series of simulated incremental C-E ratios scattered over C-E plane and also to yield the acceptability curve for different comparisons of strategies. The threshold of vaccine cost and the influence of attendance rate were also investigated.

RESULTS

Compared with triennial Pap smear screening programme, most of preventive strategies cost more but gain additional life years (quadrant I of C-E plane) except HPV DNA testing with Pap smear every 5 years dominated by triennial Pap smear screening programme. The most cost-effective strategy was annual Pap smear (incremental C-E ratio = $31 698), followed by HPV DNA testing with Pap smear every 3 years ($36 627), and vaccination programme with triennial Pap smear screening ($44 688) with the corresponding cost-effective probabilities by the acceptability curve being 65.52%, 52.08% and 35.84% given the threshold of $40 000 of willingness to pay. Vaccination combined with triennial Pap smear would be as cost-effective as annual Pap smear provided the cost of vaccination was lowered to $250 per full course of injection.

CONCLUSIONS

Among various preventive strategies annual Pap smear screening programme is still the most cost-effective and additional HPV DNA testing is a cost-effective choice under a reasonable threshold of willingness to pay. Vaccination programme in combination with triennial screening would be cost-effective if vaccine cost can be greatly reduced in a large economic scale.

Cervical cancer screening among HIV-infected women: an economic evaluation in a middle-income country

Due to the recent widespread availability of highly active antiretroviral therapy (HAART) in middle-income countries, there has been an increase in life expectancy for women on HAART, but no corresponding decrease in cervical cancer incidence. This study evaluates the optimal cervical cancer screening strategy for HIV-infected women in a middle-income country. We developed a mathematical model, which simulates the natural history of the HPV infection, as well as the HIV-mediated immunosupression among women in Brazil. Our model was calibrated using data from the IPEC/FIOCRUZ Women's HIV-infected cohort. The model compares the lifetime effects, costs and cost-effectiveness of strategies combining cytology, HPV DNA test and colposcopy at different screening intervals for different CD4 count strata (27 strategies in total). We found that the strategy with the best cost-effectiveness profile (cost-effectiveness ratio-U$4,911/year of life saved [YLS] and probability of being cost-effective-86%) was HPV testing followed by cytology triage every year for all HIV infected women, considering a very cost-effective threshold given by Brazil's GDP per capita (US$8,625/YLS). The results were robust to changes in the input parameters as demonstrated in one-way, scenario, threshold and probabilistic sensitivity analysis. Our study indicates that annual HPV testing followed by cytology triage for all HIV-infected women is likely to be very cost-effective in a middle-income country like Brazil. The results reflect the synergic effect of using a highly sensitive screening test (HPV DNA test) in sequence with a highly specific test (cytology).

HPV testing as a triage for borderline or mild dyskaryosis on cervical cytology: results from the Sentinel Sites study

BACKGROUND

Earlier pilot studies of human papillomavirus (HPV) triage concluded that HPV triage was feasible and cost-effective. The aim of the present study was to study the impact of wider rollout of HPV triage for women with low-grade cytology on colposcopy referral and outcomes.

METHODS

Human papillomavirus testing of liquid-based cytology (LBC) samples showing low-grade abnormalities was used to select women for colposcopy referral at six sites in England. Samples from 10,051 women aged 25-64 years with routine call or recall cytology reported as borderline or mild dyskaryosis were included.

RESULTS

Human papillomavirus-positive rates were 53.7% in women with borderline cytology and 83.9% in those with mild dyskaryosis. The range between sites was 34.8-73.3% for borderline cytology, and 73.4-91.6% for mild dyskaryosis. In the single site using both LBC technologies there was no difference in rates between the two technologies. The positive predictive value of an HPV test was 16.3% for CIN2 or worse and 6.1% for CIN3 or worse, although there was considerable variation between sites.

CONCLUSION

Triaging women with borderline cytological abnormalities and mild dyskaryosis with HPV testing would allow approximately a third of these women to be returned immediately to routine recall, and for a substantial proportion to be referred for colposcopy without repeat cytology. Variation in HPV-positive rates results in differing colposcopy workload.

Economic evaluation of strategies for managing women with equivocal cytological results in Brazil

In Brazil, current management of women with screening results of atypical squamous cells of undetermined significance (ASC-US) is to offer repeat testing at 6-month intervals. Alternative management strategies that have been adopted in many high-income settings are to offer immediate colposcopy referral or to utilise human papillomavirus (HPV) DNA testing as a triage for colposcopy referral, and to consider different strategies according to women's age. The objective of our study was to evaluate the lifetime cost effectiveness in terms of cost per years of life saved (YLS) of these alternative strategies for a middle income setting. A Markov model was developed using data from the Ludwig-McGill cohort and calibrated to independent observational datasets and local cost estimates obtained. In the base-case analysis, repeat cytology was the least costly strategy but also the least effective. Based on the WHO threshold for very cost-effective interventions, HPV triage for women above 30 years-old was the strategy with the highest probability of being cost effective. HPV triage including younger women with ASCUS results would also be a cost-effective option. Whilst there was a slight further gain in effectiveness with immediate colposcopy referral, it was also more expensive and did not appear to be cost effective. Threshold analysis indicated that an HPV test would have to be more than twice as expensive as a cytology test for HPV triage to no longer be cost effective. In conclusion, our results indicate that in middle income settings HPV triage is likely to be the optimal strategy for managing women presenting with ASC-US results.

The role of human papillomavirus testing in the management of women with low-grade abnormalities: multicentre randomised controlled trial

OBJECTIVE

To assess the value of a single human papillomavirus (HPV) test in making decisions on management of women with cervical cytology showing borderline nuclear abnormality (BNA) or mild dyskaryosis. In particular, to determine whether information on high-risk (hr) HPV status would be valuable in the choice between (1) cytological surveillance versus immediate referral to colposcopy, and (2) at colposcopy, between biopsy and recall versus immediate large loop excision of the transformation zone (LLETZ).

DESIGN

Multicentre individually randomised controlled trial, nested within the NHS Cervical Screening Programmes, investigating the value of HPV testing by testing for interactions between HPV status and (1) cytological surveillance versus colposcopy, and (2) biopsy and recall versus immediate LLETZ. Setting Grampian, Tayside and Nottingham. Population Women (n = 4439), aged 20-59 years, with a cytology test showing borderline nuclear abnormalities or mild dyskaryosis during October 1999 to October 2002.

METHODS

High-risk HPV status was determined at recruitment using the polymerase chain reaction assay with the GP5+/6+ general primer system. The results of this HPV testing were not disclosed to either the participating women or to those involved in their management. Women were randomised to either (1) 6-monthly cytological screening in primary care or (2) referral for colposcopy. Human papillomavirus status was used to stratify both randomisations. All women were followed for 3 years, concluding with an invitation to an exit appointment at which colposcopic examination was undertaken. In addition, in women who were randomised to initial colposcopy and underwent colposcopy, the association between hrHPV status and presence of cervical intraepithelial neoplasia (CIN) grade 2 or more severe disease (henceforth CIN2 or worse) was examined.

MAIN OUTCOME MEASURES

Sensitivity, specificity, positive and negative predictive values of the HPV test for predicting CIN2 or worse and the implications for the choice of management between cytological surveillance and immediate referral for colposcopy.

RESULTS

There were no significant interactions between management and HPV status. Hence, in women with mild dyskaryosis or BNA who are HPV positive, there is no advantage of (1) immediate colposcopy over cytological surveillance (P = 0.76) or (2) immediate LLETZ over biopsy and recall (P = 0.27). The sensitivity of HPV testing for detection of CIN2 or worse was 75.2% (95% CI 68.8-81.0%) among women with mild dyskaryosis and 69.9% (95% CI 61.7-77.3%) among those with BNA. Specificity was higher in those with BNA (71.3%; 95% CI 68.5-74.1%) than in those with mild dyskaryosis (46.9%; 95% CI 42.2-51.6%). Sensitivity decreased with increasing age whereas specificity increased. The negative predictive value was high, particularly among women with BNA (94.5%; 95% CI 92.9-96.0%). Across all ages, 22% of women who had CIN2 or worse were HPV negative. Conversely, 40% of those who were HPV positive did not have CIN. HPV was a much more reliable predictor in women aged over 40 years.

CONCLUSIONS

We conclude that in younger women with low-grade cytological abnormalities, a single HPV test would not be useful in determining who should be referred for colposcopy or the most effective management at colposcopy. In women over 40, a negative HPV test could be used to rule out further investigation.

The use of p16(INK4A) immunocytochemistry in "Atypical squamous cells which cannot exclude HSIL" compared with "Atypical squamous cells of undetermined significance" in liquid-based cervical smears

Even though p16(INK4a) (p16) immunocytochemistry has proven a useful accessory tool verifying the identification of atypical squamous cells of undetermined significance (ASC-US) categorized smears, the procedure still has limitations. To date few studies examining the usefulness of p16 immunocytochemistry in atypical squamous cells which cannot exclude HSIL (ASC-H), compared with ASC-US in liquid-based cervical smears. Therefore, we examined the correlation of p16 immunocytochemical staining with follow-up biopsy results on ASC-H categorized smears and compared the data with those classified as ASC-US on 105 liquid-based cytology samples. We found no statistical significance in the p16 expression of ASC-US smears and the presence of squamous intraepithelial lesions (SIL) in follow-up biopsies (p = 0.546). However, p16 expression did significantly correlate with the presence of SIL (p = 0.002) in ASC-H smears. There was a statistically significant relationship between p16 expression and presence of high grade squamous intraepithelial lesions (HSIL) or more on the follow-up biopsies in both ASC-US (p = 0.012) and ASC-H (p < 0.001) categorized smears. In ASC-US categorized smears, there was no statistical significance between p16 expression and the HR-HPV viral load (p = 0.091). But there was a statistical significance between p16 expression and the HR-HPV viral load (p < 0.001) in ASC-H categorized smears. Our results indicate that p16 immunostaining is a much better useful marker for HR-HPV infection and detection of SIL in ASC-H categorized smears compared to those defined as ASC-US.

Cost-effectiveness of 21 alternative cervical cancer screening strategies

OBJECTIVES

The aim of this study is to assess the cost-effectiveness of 21 alternative cervical cancer screening (CCS) strategies.

METHODS

A cohort simulation model was developed to determine from a health systems perspective the cost-effectiveness of the 21 alternative CCS strategies that incorporated combinations of Papanicolaou's smear test (PAP), liquid-based cytology (LBC) or human papillomavirus deoxyribonucleic acid (HPV-DNA) testing. The model was calibrated to categorize total costs into four budgetary authorities: testing, physician, inpatient, and outpatient services. Within each category, alternative screening strategies were contrasted in terms of their cost impacts and the percent change calculated within each category. Epidemiologic data and costs were derived from administrative health databases. Estimates of test characteristics and quality-adjusted life years (QALYs) were derived from available literature.

RESULTS

Three-year screening with PAP and HPV-DNA triage testing for women older than 30 years of age (3-year PAP+HPV+PAP-age) is less costly and more effective saving $16,078 per additional QALY gained. Although there was an associated net cost decrease of 4.2% driven by a reduction in testing and physician costs of 22.1% and 18.6%, respectively, there is a cost increase of 0.8% and 27.7% in inpatient and outpatient services, respectively.

CONCLUSION

There is economic evidence to support adopting 3-year PAP+HPV+PAP-age. Budgetary resources can potentially be shifted from testing and physician services to fund the additional resource requirements for inpatient and outpatient services.

Options for managing low grade cervical abnormalities detected at screening: cost effectiveness study

OBJECTIVE

To estimate the cost effectiveness of alternative methods of managing low grade cervical cytological abnormalities detected at routine screening. Design Cost analysis within multicentre individually randomised controlled trial.

SETTING

Grampian, Tayside, and Nottingham.

PARTICIPANTS

4201 women with low grade abnormalities.

INTERVENTIONS

Cytological surveillance or referral to colposcopy for biopsy and recall if necessary or referral to colposcopy with immediate treatment based on colposcopic appearance.

MAIN OUTCOME MEASURES

Data on resource use collected from participants throughout the duration of the trial (36 months), enabling the estimation of both the direct (health care) and indirect (time and travel) costs of management. Quality of life assessed at recruitment and at 12, 18, 24, and 30 months, using the EQ-5D instrument. Economic outcomes expressed as costs per case of cervical intraepithelial neoplasia (grade II or worse) detected, by trial arm, as confirmed at exit, and cost utility ratios (cost per quality adjusted life year (QALY) gained) for the three pairwise comparisons of trial arms.

RESULTS

The mean three year discounted costs of surveillance, immediate treatment, and biopsy and recall were pound150.20 (euro177, $249), pound240.30 (euro283, $415), and pound241.10 (euro284, $4000), respectively, viewed from the health service perspective. From the social perspective, mean discounted costs were pound204.40 (euro241, $339), pound339.90 (euro440, $563), and pound327.50 (euro386, $543), respectively. Estimated at the means, the incremental cost effectiveness ratios indicated that immediate treatment was dominated by the other two management methods, although it did offer the lowest cost per case of cervical intraepithelial neoplasia detected and treated. The pronounced skews in the distributions indicated that probabilistic uncertainty analysis would offer more meaningful estimates of cost effectiveness. The observed differences in the cost effectiveness ratios between trial arms were not significant.

CONCLUSION

Judged within the time frame of the TOMBOLA evaluation, there is no compelling economic reason to favour any one follow-up method over either of the others.

TRIAL REGISTRATION

ISRCTN 34841617.

Triage of women with equivocal or low-grade cervical cytology results: a meta-analysis of the HPV test positivity rate

Consistent evidence underlines the utility of human papillomavirus (HPV) DNA testing in the management of women with equivocal cervical cytological abnormalities, but not in case of low-grade lesions. We performed a meta-analysis including studies where the high-risk probe of the Hybrid Capture-II is used to triage these two cytological categories. The triage test-positivity rate reflects the colposcopy referral workload.Data were pooled on the HPV test positivity rate in women with atypical squamous cells of undetermined significance (ASCUS/ASC-US) or low-grade squamous intraepithelial lesions (LSIL), derived from different cytological classification systems. The meta-analysis was restricted to studies, published between 1991 and 2007. A random-effect model was applied for meta-analytical pooling and the influence of covariates on the HPV positivity rate was analyzed by meta-regression. The variation by age was assessed within individual studies since age strata were not defined uniformly. On an average, 43% (95% CI: 40–46%) of women with ASCUS/ASC-US were high-risk HPV positive (range 23–74%). In women with LSIL, the pooled positivity rate was 76% (95% CI: 71–81%; range 55–89%). In spite of considerable inter-study heterogeneity, the difference in HPV positivity between the two triage groups was large and highly significant: 32% (95% CI: 27–38%). HPV rates dropped tremendously as age and cutoffs of test positivity increased. Other factors (cytological classification system, country, continent, collection method and year of publication) had no statistically significant impact, except in LSIL triage where HPV positivity was significantly lower in European compared to American studies. Women with LSIL, especially younger women, have high HPV positivity rates suggesting limited utility of reflex HPV triaging these cases. Research is needed to identify more specific methods to triage women with low-grade squamous cervical lesions.

Optimal cost-effectiveness decisions: the role of the cost-effectiveness acceptability curve (CEAC), the cost-effectiveness acceptability frontier (CEAF), and the expected value of perfection information (EVPI)

OBJECTIVE

To demonstrate how the optimal decision and level of uncertainty associated with that decision, can be presented when assessing the cost-effectiveness of multiple options. To explore and explain potentially counterintuitive results that can arise when analyzing multiple options.

METHODS

A template was created, based on the assumption of multivariate normality, in order to replicate a previous analysis that compared the cost-effectiveness of multiple options. We used this template to explain some of the different shapes that the cost-effectiveness acceptability curve (CEAC), cost-effectiveness acceptability frontier (CEAF), and expected value of perfection information (EVPI) may take, with changing correlation structure and variance between the multiple options.

RESULTS

We show that it is possible for 1) an option that is subject to extended dominance to have the highest probability of being cost-effective for some values of the cost-effectiveness threshold; 2) the most cost-effective (optimal) option to never have the highest probability of being cost-effective; and 3) the EVPI to increase when the probability of making the wrong decision decreases. Changing the correlation structure between multiple options did not change the presentation of results on the cost-effectiveness plane.

CONCLUSION

The cost-effectiveness plane has limited use in representing the uncertainty surrounding multiple options as it cannot represent correlation between the options. CEACs can represent decision uncertainty, but should not be used to determine the optimal decision. Instead, the CEAF shows the decision uncertainty surrounding the optimal choice and this can be augmented by the EVPI to show the potential gains to further research.

Linear array genotyping and hybrid capture II assay in detecting human papillomavirus genotypes in women referred for colposcopy due to abnormal Papanicolaou smear

Summary:

The main objective of this study was to assess the feasibility of human papillomavirus (HPV) genotyping in women referred for colposcopy due to abnormal Papanicolaou (Pap) smear. A series of 248 women referred for colposcopy due to an abnormal Pap smear were analysed with the Roche Linear Array HPV genotyping test detecting 37 most frequent HPV types, and compared with hybrid capture II (HCII) assay for oncogenic (high-risk [HR] HPV) types as well as for p16INK4a expression using immunocytochemistry. All tests were performed in cervical samples collected in PreservCyt® liquid media for liquid-based cytology (ThinPrep), and colposcopic biopsy and/or loop electro excision procedure cone biopsy was used as the gold standard. HPV16 was the single most frequent genotype (29/258; 11.7%), followed by HPV51 (4.4%), HPV66 (3.6%), HPV42, 52 and 56 (3.2% for all). Linear array genotyping test significantly predicts both abnormal colposcopy (odds ratio [OR] = 9.0; 3.12-25.93), high-grade squamous intraepithelial lesions (OR = 9.6; 1.26-74.17) and cervical intraepithelial neoplasia (CIN) 3+ (OR = 29.3; 3.95-218.06). In detecting CIN3, linear array was equivalent (97.6%) to colposcopy in sensitivity (SE), both being superior to HCII (92.7%). Concordance between linear array and HCII was moderate (Cohen's kappa κ = 0.547; 95% confidence interval [CI]: 0.435-659). Specificity (SP) and positive predictive value (PPV) of linear array were significantly improved, if only HPV16 genotype was considered. Performance in the best balance is obtained, when linear array and colposcopy are combined, giving 82.9% SE, 93.9% SP, 73.9% PPV and 96.3% negative predictive value (NPV) as predictor of CIN3+ (OR 74.5; 95% CI: 27.36-202.72). In conclusion, linear array for HR-HPV is a highly sensitive test (97.6%) with high NPV (98.9%) in detecting CIN3+ lesions. HPV16 genotyping alone significantly improves SP and PPV of this test in management of women with abnormal cytology.

HPV triage testing or repeat Pap smear for the management of atypical squamous cells (ASCUS) on Pap smear: is there evidence of process utility?

A two-stage standard gamble was used to evaluate women's preferences for alternative managements of atypical squamous cells of undermined significance (ASCUS) on Pap smear (repeat Pap smear compared with immediate HPV test), and to test for the evidence of process utility. Women's utilities for the health state scenarios were clustered towards the upper end of the 0-1 scale with considerable variability in women's preferences. There was evidence of process utility, with immediate human papillomavirus (HPV) testing strategies having lower valuations than repeat Pap smear, where the clinical outcome was the same. Mean (95% CI) utilities for HPV testing (negative test) followed by resolution were 0.9967 (0.9957-0.9978) compared with repeat Pap smear followed by resolution: 0.9972 (0.9964-0.9980). Mean (95% CI) utilities for immediate HPV testing (positive test), followed by colposcopy, biopsy and treatment were 0.9354 (0.8544-1.0) compared with repeat Pap smear followed by colposcopy, biopsy and treatment: 0.9656 (0.9081-1.0). Our results add to the existing evidence that the impact of healthcare interventions on well-being is not limited to the effect of the intervention on the health outcomes expected from the intervention; process of care can have quality of life implications for the individual. A modelled application of trial-based data will allow characterisation of the true population costs, benefits, risks and harms of alternative triage strategies and subsequent policy implications thereof.

The impact of new technologies in cervical cancer screening: results of the recruitment phase of a large randomised controlled trial from a public health perspective

The decision to introduce liquid-based cytology (LBC) and HPV as screening tests involves criteria based on resource consumption. We used cross-sectional data at recruitment from the NTCC trial [ISRCTN81678807] on 28,000 women aged 35-60, randomised to receive a conventional Pap test or LBC plus HPV. We computed the resources employed to detect a CIN2+ with different screening strategies. In order to result in the same overall cost per CIN2+ detected as screening by conventional cytology, the unit cost of LBC used alone should be less than that of a conventional Pap while its unit cost may be up to 20% higher if HPV-triage for Atypical Squamous Cells of Undetermined Significance is applied together. With the same criterion the unit cost of HPV used alone may be about 20% higher than that of a Pap-test using a 1 pg/ml cut-off and over 40% higher using a 10 pg/ml cut-off. If HPV testing is applied with cytology-triage, a single HPV test may cost 20-30% more than a conventional Pap to result in the same overall cost per CIN2+ detected.

Limitations of acceptability curves for presenting uncertainty in cost-effectiveness analysis

Clinical journals increasingly illustrate uncertainty about the cost and effect of health care interventions using cost-effectiveness acceptability curves (CEACs). CEACs present the probability that each competing alternative is optimal for a range of values of the cost-effectiveness threshold. The objective of this article is to demonstrate the limitations of CEACs for presenting uncertainty in cost-effectiveness analyses. These limitations arise because the CEAC is unable to distinguish dramatically different joint distributions of incremental cost and effect. A CEAC is not sensitive to any change of the incremental joint distribution in the upper left and lower right quadrants of the cost-effectiveness plane; neither is it sensitive to radial shift of the incremental joint distribution in the upper right and lower left quadrants. As a result, CEACs are ambiguous to risk-averse policy makers, inhibit integration with risk attitude, hamper synthesis with other evidence or opinions, and are unhelpful to assess the need for more research. Moreover, CEACs may mislead policy makers and can incorrectly suggest medical importance. Both for guiding immediate decisions and for prioritizing future research, these considerable drawbacks of CEACs should make us rethink their use in communicating uncertainty. As opposed to CEACs, confidence and credible intervals do not conflate magnitude and precision of the net benefit of health care interventions. Therefore, they allow (in)formal synthesis of study results with risk attitude and other evidence or opinions. Presenting the value of information in addition to these intervals allows policy makers to evaluate the need for more empirical research.

The potential cost-effectiveness of prophylactic human papillomavirus vaccines in Canada

AIM

Clinical trials have shown prophylactic human papillomavirus (HPV) vaccines to be effective against infection and disease. We examined whether HPV vaccination has the potential to be cost-effective.

METHODS

A cohort model of the natural history of HPV was developed, which fits simultaneously Canadian age and type-specific data for infection, cervical intraepithelial neoplasia, cervical cancer (CC) and genital warts (GW). Quality-Adjusted Life-Years (QALYs) lost and costs were estimated using data from the literature.

RESULTS

Vaccinating 12-year-old girls (efficacy=95%, no waning, cost/course=CAN$ 400) against HPV-16/18 and HPV-6/11/16/18 is estimated to cost the health provider CAN$ 31,000 (80%CrI: 15,000-55,000) and CAN$ 21,000 (80%CrI: 11,000-33,000) per QALY-gained, respectively. Results were most sensitive to age at vaccination, duration of vaccine protection, vaccine cost and QALY-lost due to GW, and were least sensitive to the medical costs.

CONCLUSION

Vaccinating adolescent girls against HPV is likely to be cost-effective. The main benefit of vaccination will be in reducing CC mortality. However, unless screening is modified, the treatment costs saved through vaccination will be insignificant compared to the cost of HPV immunization.

Management of women with abnormal cervical cytology: treatment patterns and associated costs in England and Wales

OBJECTIVE

To evaluate the time from abnormal Papanicolaou smear detected during routine screening to the initiation of investigation and treatment of subjects and to evaluate its related costs.

DESIGN

Retrospective study of clinical records from women with abnormal cervical smears.

SETTING

Six specialist gynaecology/colposcopy clinics in England and Wales.

SAMPLE

Six hundred subsequent women (100 per clinic) with first abnormal cervical smear result at the specialist gynaecology/colposcopy clinic.

METHODS

Details of all clinic visits, tests and procedures during 24 months starting from the first abnormal cervical smear were collected from the year 2002.

MAIN OUTCOME MEASURES

Patterns of management after initial abnormal smear, time to start the investigation and/or treatment expressed in days/months and treatment costs by cytology and histology grades.

RESULTS

Significant age differences were observed between women with early grades of precancer lesions (32 years) and cancer (49 years) (P < 0.05). Subgroup analysis of women younger than 26 years indicates a representation of this age group in all the histology grades including cancer. Median time to initiate the investigation and/or treatment was 50 days. In contrast, for 5% of women, delay in management lasted for >1 year. Colposcopy and repeated cervical smears were the most frequent systematic investigations performed, while the large loop excision of the transformation zone procedure was the principal therapeutic procedure. Analysis of average treatment costs by referral cytology showed small differences between the three grades of cytological diagnoses (mild dyskaryosis, 408.96 British pound; moderate dyskaryosis, 442.55 British pound and severe dyskaryosis, 493.74 British pound). Analysis by histology grade showed that the cost for women with a negative result (263.34 British pound) differed markedly from that for women with cervical intraepithelial neoplasia (CIN) (CIN1, 419.39 British pound; CIN2, 572.29 British pound; and CIN3, 584.92 British pound).

CONCLUSION

Time to investigation could be improved for a subgroup of women. Costs associated with investigation and treatment of women with abnormal cervical smears differ significantly between analyses by cytology and histology grade. This needs to be borne in mind when designing cost-effectiveness studies of cervical screening.

United Kingdom cervical cancer screening and the costs of time and travel

OBJECTIVES

The aim of this study was to estimate the time and travel costs generated by women when attending for Papanicolaou (Pap) smear tests or colposcopy appointments in the United Kingdom, both absolutely and relative to the health service cost of the national cervical cancer screening programs.

METHODS

Data were obtained from questionnaires completed by two samples of women participating in a three-center trial of management of low-grade abnormalities detected by screening (n = 1,106 for Pap smears and n = 1,203 for colposcopy appointments). Women were 20 to 59 years of age and resident in Grampian or Tayside, Scotland, or Nottingham, England. Questionnaire data were supplemented with sociodemographic information previously collected at the time of recruitment to the trial.

RESULTS

The mean total time and travel costs per attendance at a smear test and at a colposcopy appointment were estimated to be 9.2 pounds and 27.4 pounds, respectively, averaged across the three trial areas (valued at 2002 prices). Statistically significant intercenter disparities in time and travel costs were identified, particularly with respect to colposcopy appointments. For these, time and travel costs in Nottingham were substantially less than those in Grampian and Tayside (22.9 pounds, 30.2 pounds, and 32.1 pounds, respectively). Time and travel costs amount to 26 and 33 percent, approximately, over and above the direct health service costs of the English and Scottish screening programs, respectively.

CONCLUSIONS

The time and travel costs associated with participation in the UK cervical cancer screening programs are substantial and are not spatially uniform across the country.

Human Papillomavirus testing for the management of low-grade cervical abnormalities in the UK--Influence of age and testing strategy

BACKGROUND

The results of the UK pilot studies were encouraging with respect to the introduction of Human Papillomavirus (HPV) testing as a means to improve the management of low-grade cytological abnormalities. However, several important unresolved issues related to HPV triage remain, two of which are: what type of HPV test should be used and what age group should be targeted.

OBJECTIVES

To perform an evaluation of two commercial HPV detection tests and to correlate disease persistence and clearance with age and HPV status by the two tests.

STUDY DESIGN

We performed an evaluation of two commercial HPV tests in a cross-sectional analysis of 322 cervical cytology specimens with low-grade abnormalities. A subset of these specimens were then examined longitudinally, in order to correlate disease persistence and clearance with age and HPV status by the two detection tests.

RESULTS

The two tests performed similarly with respect to the longitudinal identification/prediction of high-grade cervical disease. Age did not appear to be a factor in determining which cases went on to manifest high-grade disease within 3 years of a low-grade result (p=0.678).

CONCLUSIONS

This study weakens the case for age-adjusted HPV triage of low-grade cervical abnormalities.

Chapter 19: Cost-effectiveness of cervical cancer screening

In the last two decades, computer-based models of cervical cancer screening have been used to evaluate the cost-effectiveness of different secondary prevention policies. Analyses in countries with existing screening programs have focused on identifying the optimal screening interval, ages for starting and stopping screening, and consideration of enhancements to conventional cytology, such as human papillomavirus (HPV)-DNA testing as a triage for equivocal results or as a primary screening test for women over the age of 30. Analyses in resource-poor settings with infrequent or no screening have focused on strategies that enhance the linkage between screening and treatment, consider noncytologic alternatives such as HPV-DNA testing, and target women between the ages of 35 and 45 for screening one, two, or three times per lifetime. Despite differences in methods and assumptions, this paper identifies the qualitative themes that are consistent among studies, and highlights important methodological challenges and high-priority areas for further work.

Human papillomavirus viral load: a possible marker for cervical disease in HIV-infected women

Laboratory markers of human papillomavirus infection have been recognized as relevant tools in programmes designed to reduce the burden of cervical cancer. The ongoing experience with these laboratory markers serves to confirm not only their negative predictive value (close to 100%) but also their positive association with developing or developed lesions. This aspect is particularly relevant in HIV-infected subjects who show an increased prevalence, incidence and severity of infections and lesions even in the era of efficacious control of their immunosuppression. Among the possible virus-related parameters proposed as relevant markers (viral persistence, load, expression, genomic integration capacity) we here analyse the informative value of human papillomavirus viral load measurement as a possible risk marker in this particular clinical setting.