Purpose: India, a low-income country with a high-risk of cervical cancer, accounts for more than 25% of new cases worldwide. We estimated the cost-effectiveness of alternative cervical cancer prevention strategies in India, including screening three times per lifetime and adolescent prophylactic vaccination against two of the most common cancer-causing HPV types (types 16 and 18).

Methods: We used an empirically-calibrated simulation model of HPV infection and cervical cancer to estimate cancer reduction, lifetime costs (international $2005), and incremental cost-effectiveness ratios associated with different prevention strategies. Calibration was conducted using a likelihood-based approach that formally compared model outcomes with epidemiologic data from India (e.g., age-specific prevalence of HPV and precancerous lesions, HPV type-distribution in invasive cancer and precancerous lesions, and cervical cancer incidence). Analyses were conducted with a random sample of 50 good-fitting parameter sets. Strategies included screening at age 35, 40 and 45 with cytology (requiring three visits) or HPV testing (requiring two visits), vaccination at age 12 prior to sexual debut, and combined screening and vaccination. Coverage for screening and vaccination was 70% in the base case.

Results: The mean reduction in lifetime cancer risk for screening alone varied from 32% (range, 20%-44%) to 44% (range, 31%-55%) depending on whether cytology or HPV testing was used. Vaccination alone reduced cancer by 44% (range, 28%-57%), while vaccination plus screening with HPV testing reduced cancer by 69% (range, 60%-81%). At a cost of $10 (~$2 per dose) per vaccinated woman (inclusive of three doses, administration, wastage, and vaccine support activities), vaccination alone was cost-saving relative to no intervention. Provided the cost per vaccinated woman was less than $25 (~$5 per dose), screening alone was dominated by vaccination, and screening and vaccination was consistently less than the GDP per capita (I$3,460), a commonly cited threshold for cost-effectiveness. At vaccine costs approaching those in the U.S., vaccination exceeded $10,000 per YLS.

Conclusions: Adolescent HPV 16,18 vaccination plus screening adult women three times per lifetime would be considered an attractive public health investment for India provided vaccine price could be negotiated below $5 per dose and the cost per vaccinated woman is below $25.