Aquarius Population Health

In the study, we performed a cost-consequence analysis to evaluate the financial implications and potential benefits of two different screening protocols: 1) HPV (human papillomavirus) primary screening, and 2) co-testing. The analysis, informed with input from experts in Belgium, indicated that compared to HPV primary, implementing co-testing would increase cervical precancer detection rates and could reduce screening costs if the cost of the HPV test and LBC were cost-neutral compared to the current cost of LBC screening. These findings provide insights for decision-makers in designing an optimal cervical screening programme for women aged 25-64 in Belgium.

Cervical cancer, primarily driven by persistent HPV infections, continues to pose a significant health concern. Timely detection through cervical screening plays a key role in preventing its progression. Many countries have adopted HPV primary screening, where samples are first tested for the presence of high-risk HPV and only positive samples are then assessed using liquid-based cytology (LBC). Whilst others, such as the US and Germany, have adopted a co-testing approach, where all samples are assessed using both LBC and HPV testing.

As the Belgium government considers developing a national HPV primary screening programme, assessing the costs and potential benefits of different screening strategies is paramount.

Our analysis sought to provide a comprehensive comparison of HPV primary screening versus co-testing within the Belgian healthcare landscape where the prevalence of HR-HPV is 13% in screen eligible women. A decision tree model was developed, adapting the HRV primary algorithm used in the Netherlands and the co-testing algorithm used in Germany and Luxembourg. Data from Danish Horizon studies was used to inform the underlying probabilities. Given the uncertainty surrounding test reimbursement, in collaboration with experts, we devised a cost-neutral pricing strategy for co-testing, offering it as a potential pricing approach tailored for Belgium.

The model outputs indicate that co-testing would be more effective at detecting precancerous lesions and result in the detection of 27% more cases of CIN2+ (a grade of cervical intraepithelial neoplasia which requires treatment) whilst potentially save costs – depending on the pricing strategy used for the HPV test and LBC.

Dombrowski C, Bourgain C, Ma Y, et al. An economic evaluation of two cervical screening algorithms in Belgium: HR-HPV primary compared to HR-HPV and liquid-based cytology (LBC) co-testing (preprint). Health Economics. 2023 Sep 08; doi:10.1101/2023.09.07.23295193.

The article is published in the European Journal of Cancer Prevention:

This is one of many HPV and screening related projects that we have been involved in and which will inform national screening policy. To learn more about our other work at Aquarius, please visit our website or get in touch at