Benefits and harms of cervical screening, triage and treatment strategies in women living with HIV
Michaela Hall, Kate T. Simms, John M. Murray, Adam Keane, Diep Nguyen, Michael Caruana, Gigi Lui, Helen Kelly, Linda O. Eckert, Nancy Santesso, Sílvia de Sanjosé, Edwin Swai, Ajay Rangaraj, Morkor Newman Owiredu, Cindy L. Gauvreau, Owen Demke, Partha Basu, Marc Arbyn, Shona Dalal, Nathalie Broutet, Karen Canfell
Abstract
To support a strategy to eliminate cervical cancer as a public health problem, the World Health Organisation (WHO) reviewed its guidelines for screening and treatment of cervical pre-cancerous lesions in 2021. Women living with HIV have 6-times the risk of cervical cancer compared to women in the general population, and we harnessed a model platform ('Policy1-Cervix-HIV') to evaluate the benefits and harms of a range of screening strategies for women living with HIV in Tanzania, a country with endemic HIV. Assuming 70% coverage, we found that 3-yearly primary HPV screening without triage would reduce age-standardised cervical cancer mortality rates by 72%, with a number needed to treat (NNT) of 38.7, to prevent a cervical cancer death. Triaging HPV positive women before treatment resulted in minimal loss of effectiveness and had more favorable NNTs (19.7-33.0). Screening using visual inspection with acetic acid (VIA) or cytology was less effective than primary HPV and, in the case of VIA, generated a far higher NNT of 107.5. These findings support the WHO 2021 recommendation that women living with HIV are screened with primary HPV testing in a screen-triage-and-treat approach starting at 25 years, with regular screening every 3-5 years.