Why the Cost of Purchasing the careHPV Test in Myanmar Was Many Times Greater Than That Reported in the International Literature
Authors: Tin-Oo C. , Hlaing H.N. Tin , Nandar C.S. , Aung T. , Fishbein D. 
Published: September 2018

Background: Human papillomavirus (HPV) testing is recommended for primary or coprimary screening for cervical cancer (CC screening) in countries of all income levels. Inclusion of low-income countries (LICs) in these recommendations was in part due to development and evaluation of the careHPV test kit (QIAGEN, supported by PATH), a simple, accurate, affordable HPV screening test. In numerous published economic analyses, cost of equipment and supplies (E&S) and conducting a careHPV test in LICs was estimated to be $US5/test. When we sought to purchase the E&S for 1000 careHPV tests in Myanmar to begin a pilot test of HPV-based CC screening in a Ministry of Health and Sports (MOHS) women's hospital, we were quoted a price of US$42/test. Aim: Determine why the price for the careHPV test in Myanmar was so much greater than that reported in the literature. Methods: We reviewed published economic analyses and conducted a cost analysis of E&S purchased for careHPV testing in Myanmar. We obtained assistance from QIAGEN and PATH to negotiate the lowest possible price for proprietary E&S, and nonproprietary E&S was purchased at the lowest domestic or international price. Standard methods of economic evaluation were used, classifying E&S as capital (C) or recurrent (R). We converted costs to United States dollars ($), calculated $/test and obtained the charge to patients for other CC screening tests in Myanmar. Results: QIAGEN only sold the careHPV test through a local distributor, who added a larger profit than permitted. We negotiated a purchase price of $36/test for proprietary E&S, including test system hardware ($25,555 [C]), training panel ($1540 [C]), cervical brushes ($788 [R]), transport medium ($788 [R]), and microtiter plates ($6982 [R]). R included a 38% markup for transportation, duties, and profits. Required nonproprietary E&S purchased included: refrigerator ($1081 [C]), two pipetters ($1100 [C]), power source ($150 [C]), pipette tips ($156 [R]), and plate sealers ($38 [R]). The final cost was $38,294 ($38/test; C: $29,426 [$29/test]; R: $8,868 [$9/test]). If no additional C was required, the E&S for 20,000 tests would cost $10/test. Although the charge for careHPV has not been set, the MOHS charge for a conventional Pap is $1.50. In the private sector, the charge for Pap is $8 (conventional) to $20 (automated), and between $50 and $125 for HPV tests. Conclusion: Our $38 cost/test is conservative since it was negotiated and did not include patient time, MOHS labor or other program implementation costs. The reported $5/test did not include some required E&S and assumed purchase and scale-up to 20,000 tests in the first year, further reducing cost/test. In contrast, in Myanmar and other LICs, scale-up of CC screening programs has been slow, costly, and problematic. Advocates for careHPV based CC screening should be aware that initial costs may be high. Cost-effectiveness models should be adjusted to include a wider possible range of costs.