Cost-effectiveness of HPV-based versus VIA-based cervical cancer screening among women living with HIV in Masaka District, Uganda.

Cervical cancer is a leading cause of cancer-related mortality among women in Uganda, with women living with HIV (WLHIV) at disproportionate risk due to immunosuppression-driven persistence of human papillomavirus (HPV). Despite national guidelines recommending HPV testing as the preferred screening modality, resource constraints drive continued reliance on visual inspection with acetic acid (VIA), and locally generated cost-effectiveness evidence for WLHIV is limited. This study evaluated the cost-effectiveness of HPV-based versus VIA-based cervical cancer screening among WLHIV in Masaka District, Uganda. A provider-perspective cost-effectiveness analysis was conducted using data from January to December 2024. Costs were estimated using an ingredient-based micro-costing approach capturing personnel, consumables, equipment, and overheads. A total of 1,732 WLHIV aged 25-65 years attended Uganda Cares Masaka: 1,404 screened by HPV-based testing and 326 by VIA. A decision-tree model simulated screening pathways, costs, and outcomes. The primary effectiveness measure was the number of positive cases detected and treated; the incremental cost-effectiveness ratio (ICER) was the primary economic outcome. Deterministic one-way and probabilistic (1,000 Monte Carlo iterations) sensitivity analyses were conducted. HPV-based screening detected 448 positives from 1,404 women screened (31.9%) versus 54 from 326 (16.6%) under VIA. The cost per woman screened was USD 2.58 (HPV) and USD 1.78 (VIA). The ICER was USD 2,895 per additional positive case detected, within the range of ICER estimates reported for cost-effective cervical cancer screening in comparable low- and middle-income settings. The ICER was most sensitive to HPV test kit costs and VIA overhead costs. All 1,000 probabilistic simulations remained in the northeast quadrant of the cost-effectiveness plane, confirming robustness. HPV-based screening is more effective and cost-effective than VIA for cervical cancer screening among WLHIV in Masaka District. These findings support national scale-up of HPV testing within integrated HIV care settings, contingent on procurement efficiencies and strengthened laboratory infrastructure.