Human papillomavirus vaccination for adults aged 30 to 45 years in the United States: A cost-effectiveness analysis

Background A nonavalent human papillomavirus (HPV) vaccine has been licensed for use in women and men up to age 45 years in the United States. The cost-effectiveness of HPV vaccination for women and men aged 30 to 45 years in the context of cervical cancer screening practice was evaluated to inform national guidelines. Methods and findings We utilized 2 independent HPV microsimulation models to evaluate the cost-effectiveness of extending the upper age limit of HPV vaccination in women (from age 26 years) and men (from age 21 years) up to age 30, 35, 40, or 45 years. The models were empirically calibrated to reflect the burden of HPV and related cancers in the US population and used standardized inputs regarding historical and future vaccination uptake, vaccine efficacy, cervical cancer screening, and costs. Disease outcomes included cervical, anal, oropharyngeal, vulvar, vaginal, and penile cancers, as well as genital warts. Both models projected higher costs and greater health benefits as the upper age limit of HPV vaccination increased. Strategies of vaccinating females and males up to ages 30, 35, and 40 years were found to be less cost-effective than vaccinating up to age 45 years, which had an incremental cost-effectiveness ratio (ICER) greater than a commonly accepted upper threshold of $200,000 per quality-adjusted life year (QALY) gained. When including all HPV-related outcomes, the ICER for vaccinating up to age 45 years ranged from $315,700 to $440,600 per QALY gained. Assumptions regarding cervical screening compliance, vaccine costs, and the natural history of noncervical HPV-related cancers had major impacts on the cost-effectiveness of the vaccination strategies. Key limitations of the study were related to uncertainties in the data used to inform the models, including the timing of vaccine impact on noncervical cancers and vaccine efficacy at older ages. Conclusions Our results from 2 independent models suggest that HPV vaccination for adult women and men aged 30 to 45 years is unlikely to represent good value for money in the US. Author summary Why was this study done? Policies for increasing the upper age limit for human papillomavirus (HPV) vaccination to women and men up to age 45 years are being considered in several countries, but the public health value of such policies is uncertain. An important background consideration is to understand the impact and costs of HPV vaccination in the context of existing cervical cancer screening. This study was conducted to directly inform the deliberations of the Advisory Committee on Immunization Practices (ACIP) to guide HPV vaccination policy for women and men in the United States. What did the researchers do and find? Two modeling groups that are part of the Cancer Intervention and Surveillance Modeling Network (CISNET) used independent mathematical models calibrated to the US population to evaluate the cost-effectiveness of extending HPV vaccination in females and males up to ages 30, 35, 40, or 45 years. We conducted the analysis in the context of HPV transmission dynamics, historical HPV vaccination uptake, and detailed cervical cancer screening practice patterns in the US population. We evaluated cost and health outcomes of HPV vaccination up to age 45 years for cervical disease, as well as 6 other disease outcomes (5 noncervical HPV-related cancers and genital warts) in both women and men. Findings from both models suggest that at current prices, HPV vaccination beyond age 26 years is not cost-effective, even under a range of sensitivity analyses and favorable assumptions regarding HPV vaccination effectiveness and costs. What do these findings mean? HPV vaccination of women and men aged 30 to 45 years provides limited health benefit at the population level, at a substantial cost (at current HPV vaccine prices). Public health decision-makers considering the option to extend HPV vaccination to adults up to age 45 years should consider this evaluation of the value-and the opportunity costs-of adopting such a policy.