The costs, clinical benefits, and cost-effectiveness of screening for cervical cancer in HIV-infected women.

BACKGROUND Women with HIV infection have a higher risk for cervical squamous intraepithelial lesions than do women without HIV infection, and the optimal regimen for cervical cancer screening in these women is uncertain. OBJECTIVE To assess the net health consequences, costs, and cost-effectiveness of various screening strategies for cervical neoplasia and cancer in HIV-infected women. DESIGN A cost-effectiveness analysis from a societal perspective done by using a state-transition Markov model. Values for incidence, progression, and regression of cervical neoplasia; efficacy of screening and treatment; progression of HIV disease; mortality from HIV infection and cancer; quality of life; and costs were obtained from the literature. SETTING Simulated clinical practice in the United States. PATIENTS HIV-infected women representative of the U.S. population. INTERVENTION Six main screening strategies--no screening, annual Papanicolaou smears, annual Papanicolaou smears after two negative smears obtained 6 months apart (recommended by the Centers for Disease Control and Prevention), semiannual Papanicolaou smears, annual colposcopy, and semiannual colposcopy--were considered. MEASUREMENTS Quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness. RESULTS Annual Papanicolaou smear screening resulted in a 2.1-month gain in quality-adjusted life expectancy for an incremental cost of $12,800 per QALY saved. Annual Papanicolaou smear screening after two negative smears obtained 6 months apart provided an additional 0.04 QALYs at a cost of $14,800 per QALY saved. Semiannual Papanicolaou smear screening provided a further 0.17 QALYs at a cost of $27,600 per QALY saved. Annual colposcopy cost more but provided no additional benefit compared with that given by semiannual Papanicolaou smear screening, and semiannual colposcopy exceeded $375,000 per QALY saved. Results were most sensitive to the rate of progression of neoplasia to invasive cancer. CONCLUSIONS In HIV-infected women, cervical cancer screening with annual Papanicolaou smears after two negative smears obtained 6 months apart offers quality-adjusted life expectancy benefits at a cost comparable to that of other clinical preventive interventions.