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Optimising HPV Vaccination for Cervical Cancer Prevention in Women Living with HIV: A Cost-Effectiveness Analysis Across 13 African Countries

Year: 2026

Type: preprint

Abstract: **Background:** Women living with HIV face a substantially higher risk of persistent HPV infection and cervical cancer, yet HPV vaccination strategies targeting this high-risk population remain limited in many low- and middle-income countries. We evaluated the lifetime health impact and cost-effectiveness of HIV-targeted HPV vaccination strategies across 13 sub-Saharan African countries. **Methods:** We developed an age-structured Markov model of HPV infection and cervical cancer in a closed cohort of 100,000 females, stratified by HIV status, and calibrated it separately for each country to age-specific cervical cancer incidence, cervical cancer mortality, and female HIV prevalence. Six HIV-targeted strategies were compared with routine two-dose vaccination at age 14 years. The strategies either provided a booster dose to previously vaccinated WLHIV or combined a booster for previously vaccinated WLHIV with a three-dose primary catch-up course for previously unvaccinated WLHIV. Interventions were delivered at ages 18 or 24 years under standard- and high-coverage assumptions. Outcomes included cervical cancer cases averted, cervical cancer deaths averted among WLHIV, discounted disability-adjusted life-years (DALYs) averted, additional physical vaccine doses, and incremental costs from the health-system and vaccination-programme perspectives. **Results:** All HIV-targeted vaccination strategies reduced cervical cancer burden relative to routine vaccination across the 13 countries. Higher-coverage strategies generally produced greater health gains, with mean DALYs averted ranging from 9.05 for booster vaccination at age 24 years to 88.42 for high-coverage combined booster and catch-up vaccination at age 24 years. However, the relative performance of vaccination at ages 18 and 24 varied across strategies and countries. Booster-only strategies achieved the greatest health gains per additional vaccine dose, while combined strategies at higher coverage produced larger overall benefits. From the health-system perspective, 68 of 78 country-strategy comparisons were more effective and less costly than routine vaccination after accounting for avoided cervical cancer treatment costs. From the vaccination-programme perspective, all strategies required additional expenditure. **Conclusions:** Targeted HPV vaccination among women living with HIV can reduce cervical cancer burden and may be cost-saving when avoided treatment costs are considered. Higher-coverage combined strategies produced the greatest overall health gains, while booster-only strategies were more dose-efficient, supporting context-specific vaccination decisions.

Source: medRxiv

DOI: 10.64898/2026.10.05.26364501

Authors: Sahar Trabelsi, Kaja Abbas, Taylor A. Holryod, Caroline L. Trotter, Amira Kebir, Slimane Ben Miled