Background: High-risk human papillomavirus (hrHPV) testing has been recommended by the World Health Organization as the primary screening test in cervical screening programs. The option of self-sampling for this screening method can potentially increase women’s participation. Designing screening programs to implement this method among underscreened populations will require contextualized evidence. Methods: PREvention and SCReening Innovation Project Toward Elimination of Cervical Cancer (PRESCRIP-TEC) will use a multi-method approach to investigate the feasibility of implementing a cervical cancer screening strategy with hrHPV self-testing as the primary screening test in Bangladesh, India, Slovak Republic and Uganda. The primary outcomes of study include uptake and coverage of the screening program and adherence to follow-up. These outcomes will be evaluated through a pre-post quasi-experimental study design. Secondary objectives of the study include the analysis of client-related factors and health system factors related to cervical cancer screening, a validation study of an artificial intelligence decision support system and an economic evaluation of the screening strategy. Discussion: PRESCRIP-TEC aims to provide evidence regarding hrHPV self-testing and the World Health Organization’s recommendations for cervical cancer screening in a variety of settings, targeting vulnerable groups. The main quantitative findings of the project related to the impact on uptake and coverage of screening will be complemented by qualitative analyses of various determinants of successful implementation of screening. The study will also provide decision-makers with insights into economic aspects of implementing hrHPV self-testing, as well as evaluate the feasibility of using artificial intelligence for task-shifting in visual inspection with acetic acid. Trial registration: ClinicalTrials.gov, NCT05234112. Registered 10 February 2022

Objectives: The World Health Organization supports both the screen-and-treat (ST) approach and the screen, triage and treat (STT) approach to cervical cancer screening using high-risk human papillomavirus (hrHPV) testing. For Uganda, the sequence of hrHPV-ST and hrHPV-STT could be similar, with visual inspection with acetic acid (VIA) after positive hrHPV tests in both. To consider potential tradeoffs (overtreatment in ST versus missed cancer cases in STT), we compared hrHPV-STT with VIA triage (STT-VIA), and STT with HPV 16/18 genotyping risk stratification, to hrHPV-ST for Uganda, in terms of overtreatment, cervical cancer incidence, and life years, for the general female population of Uganda. Methods: A microsimulation model of cervical cancer was adapted. Incremental benefit-harm ratios of STT were calculated as ratios of prevented overtreatment to reduced life years, and to increased cancer cases. Additional scenarios with 20% difference in intra- and inter-screening follow-up between ST and STT were modeled. Results: Both STT strategies resulted in life year losses on average compared to ST. STT-VIA prevented more overtreatment but led to increased cervical cancer incidence and life year losses. STT-G-VIA resulted in better harm-benefit ratios and additional costs. With better follow-up, STT prevented overtreatment and improved outcomes. Discussion: For Uganda, the STT approach appears preferrable, if the screening sequences of hrHPV-based ST and STT are similar in practice. While VIA triage alone would reduce overtreatment the most, it could also result in more cancer cases. Risk stratification via genotyping could improve STT. Potential follow-up differences and resource availability should be considered by decision-makers when planning Uganda’s hrHPV-based screening strategy.

The high-risk human papillomavirus (hrHPV)-based screening recommended by the World Health Organization is expected to lead to worldwide reduction of the cervical cancer burden, but the countries burdened most by cervical cancer also struggle with the costs of transitioning to this approach. Country-specific evaluations are needed to inform policymakers on implementation of hrHPV-based screening for their setting. Following initial implementation in Uganda, Bangladesh and Slovakia focused on underscreened women in the PRESCRIP-TEC project, we investigated the potential cost-effectiveness and affordability of hrHPV-based screening strategies. Country-specific model-based cost-effectiveness and budget impact analyses were conducted for the three countries, comparing the PRESCRIP-TEC strategy with the existing screening strategy in each setting. Data from initial project implementation informed the relevant model parameters. The PRESCRIP-TEC strategy resulted in disability-adjusted life year (DALY) gains in all three countries. The cervical cancer incidence rate was reduced by a third for Uganda, 15% for Bangladesh and 11% for Slovakia. The incremental cost-effectiveness ratios were UGX 0.56 million per DALY for Uganda (I$ 475), BDT 76 thousand per DALY for Bangladesh (I$ 1698) and EUR 1782 (I$ 3637) per DALY for Slovakia. Substantial additional funding will be required to enable implementation, particularly in relation to the initial start-up costs. The provided estimates can serve to inform policymakers and researchers in the context of implementing hrHPV-based screening in diverse settings.

Cervical cancer is the fourth most common cancer in women globally, with an estimated 604 127 cases and 341 831 deaths in 2020 [1]. Low- and middle-income countries (LMICs) are disproportionately affected, accounting for more than 90% of cervical cancer mortality [2]. Compared to other cancers, the burden of cervical cancer has the largest inequity between high-income […]

Cervical cancer is a major public health challenge in low- and middle-income countries, where access to effective screening and treatment is limited. However, cost data to inform the implementation of cervical cancer screening are often unavailable. This study estimated the costs of cervical cancer screening and treatment pathway components in Uganda and Bangladesh of both existing visual inspection with acetic acid strategies and the World Health Organization-recommended high-risk human papillomavirus testing approaches. A mixed-methods costing study was conducted using data collected from multiple healthcare facilities to estimate cost of screening, including screening tests, triage, diagnosis, and the treatment of both precancerous lesions and cervical cancer. Depending on data availability, both micro and gross costing approaches were used from a top-down perspective. Costs are reported in 2022 international dollars (I$). Screening and treatment costs varied by procedure and country. In both countries, the cost per screening test was higher for high-risk human papillomavirus self-testing (Uganda, I$51.77; Bangladesh, I$66.24) than for visual inspection-with-acetic-acid-based screening (Uganda, to I$20.27; Bangladesh, I$18.41). Ablative treatment for precancerous lesions cost I$29.43 in Uganda and I$37.24 in Bangladesh, whereas cancer treatment costs were substantially higher, with gross estimates exceeding I$700 for chemotherapy and radiotherapy in Uganda. This study provides context-specific cost estimates for cervical cancer screening and treatment in 2 low- and middle-income countries that can support early-stage planning and policy decisions. The findings highlight the need for local data collection to strengthen future economic evaluations.