Malawi has the highest rates of cervical cancer incidence and mortality in the world. This project aims to (1) identify the most effective and cost-effective approach to cervical cancer prevention for women in Malawi via screening and treatment of precancerous lesions; and (2) calculate the likely budgetary impact of implementing this strategy at-scale. A computerized decision model will be used to compare the relative impact (health outcomes, costs, and cost- effectiveness) of different cervical cancer prevention strategies among women in Malawi. This analysis will be the first to include thermocoagulation, a reemerging technology for lesion removal; and will be unique in its risk stratification by HIV status. It will also innovate around how budget impact analyses can be used to inform more nuanced strategies for implementation and scale-up in resource-limited settings. The project will leverage a long-standing partnership between UCLA and Partners in Hope, a Malawian medical organization. New information, including about thermocoagulation in the Malawian context, will be included in this analysis. Malawi recently recommended biannual screening and treatment to prevent cervical cancer, for all women in HIV care. It is essential to consider the implications of this policy, particularly given resource constraints within the Malawian health system, and the potential costs (in dollars and health outcomes) of biannual lesion screening and removal. Economic evaluation studies as proposed here are essential for informing evidence-based policymaking, particularly when real-world evaluation studies are not practical -- and have shaped cancer screening guidelines here in the United States. As cervical cancer is a major challenge in many low-income countries, this study may also inform practice and policy in other settings. It will also provide insights about opportunities to leverage other health services (i.e., for HIV care) to address cancer, which is an area of emerging interest for researchers and policymakers in resource-poor settings worldwide even in high-income countries.
Cervical cancer is a major cause of death and disability for women in many countries; in Malawi, women typically present with advanced disease, and the country's cervical cancer incidence and mortality rates are the highest worldwide. Despite the far greater cervical cancer burden in low-income countries, relatively little is known about optimal prevention strategies in these contexts, particularly in HIV-endemic settings: the underlying infections are associated, and women with HIV are living longer due to highly effective treatment so are increasingly exposed to cancer-attributable mortality risk. Identifying an optimal strategy for primary, secondary and/or tertiary prevention requires targeted, locally context-specific comparative effectiveness and cost-effectiveness research.