Maine and Hurlburt Respond

While Tsu and LaMontagne claim that our article contains inaccuracies, the authors present little evidence to back up this statement. They cite experience in “demonstration projects.” Such experience—in carefully implemented and monitored, and (presumably) well-financed projects—cannot be taken as an indication of performance in large, routine programs. It is not surprising that demonstration projects have lower rates of loss-to-follow-up than do the estimates (15% per visit) that we drew from the work of Goldie et al.1 Tsu and LaMontagne's statements that “immunization has much less socioeconomic variation than screening” and “vaccination and its promotion are creating a demand for screening” are apparently drawn from the same body of experience, and the only reference given is to an article in press by the same authors. We accept, however, their criticism of our statement about the cost of injections. The fact that “[s]everal countries are already implementing both screening for older women and vaccinating young adolescent girls” does not allay our concerns about low rates of screening among women in many countries.2 Given that there is so little programmatic overlap between these two interventions in terms of personnel, training, supplies, clients, it seems far from automatic that promoting vaccination for girls will improve screening among women older than 30 years. In summary, we do not think that Tsu and LaMontagne's critique weakens the two central arguments of our study: That while vaccines are effective against the strains of HPV responsible for 70% of cervical cancer, their effectiveness in the field may actually be lower than screening women with vinegar and water and treating the lesions detected during the same visit; That vaccine programs, no matter how well implemented, are unlikely to provide benefits to the millions of women already infected with HPV who will die over the 20 or so years it will take for the girls currently being vaccinated to reap the benefits. Finally, it was heartening to read the article in the current issue of the Bulletin of the World Health Organization, entitled “Screening is Still the ‘Best Buy’ for Tackling Cervical Cancer.”3