A public health approach to cervical cancer screening in Africa through community-based self-administered HPV testing and mobile treatment provision

Implementation science research to understand the readiness of a mobile clinic intervention to screen for high-risk HPV infections and associated morbidity in Mali and Nigeria

Access to and community acceptance of point-of-care testing for high-risk human papillomavirus (hrHPV) are vital to cervical cancer (CC) prevention. The World Health Organization (WHO) reports high rates of HPV-16/18 (oncogenic hrHPV strains) in Sub-Saharan Africa (SSA). In rural Mali and peri-urban Nigeria, prevention efforts are limited by cognitive, socio-cultural, logistical, and resource-related barriers, leading to ongoing transmission, late diagnoses, limited treatment options, and preventable deaths. To address these barriers, we prepared a mobile clinic intervention providing self-sample collection and rapid hrHPV testing. Pre-implementation research assessed factors influencing success in both countries. Using implementation science methods, focus groups per target community were conducted with political/administrative, religious, business, community leaders, and women of screening age. Participants also completed a short survey on HPV knowledge. Data were analysed using descriptive statistics and thematic analysis. From January 2024 to January 2025, planning occurred alongside the mobile clinic's manufacturing and shipping. Eighteen focus groups were held between January and March 2025 - ten in Mali (with additional sessions for marketplace leaders) and eight in Nigeria. Results will inform site-specific adaptations. A follow-up study will document real-time implementation adjustments to support scale-up. Culturally tailored, context-specific strategies are key to addressing disparities in HPV-related cancer prevention. Implementation science can assess community readiness and guide effective intervention delivery.

The socioeconomic burden of cervical cancer and its implications for strategies required to achieve the WHO elimination targets

INTRODUCTION

Cervical cancer is almost entirely preventable by vaccination and screening. Population-based vaccination and screening programs are effective and cost effective, but millions of people do not have access to these programs, causing immense suffering. The WHO Global Strategy for the elimination of cervical cancer as a public health problem calls for countries to meet ambitious vaccination, screening, and treatment targets.

AREAS COVERED

Epidemiological evidence indicates marked socioeconomic gradients in the burden of cervical cancer and vaccination, screening, and treatment coverage. The unacceptable socioeconomic burden of cervical cancer is largely a function of inequitable access to these programs. We discuss these inequities, and highlight strategies enabled by new evidence and technology. Single dose HPV vaccination, HPV-based screening, and the rapidly moving technology landscape have enabled task-shifting, innovation in service delivery and the possibility of scale. Equitable access to optimal care for the treatment of invasive cancers remains a challenge.

EXPERT OPINION

Cervical cancer can be eliminated equitably. It will require global political will, sustained public and private investment, and community leadership to safely and sustainably embed proven tools, technology and infrastructure in local health and knowledge systems.

Investigating the healthcare-seeking behaviors of mobile phone users to improve cervical cancer screening in rural Uganda

OBJECTIVE

Cervical cancer is the leading cause of cancer in low- and middle-income countries, despite being preventable. Uganda, which lacks an effective screening program, has one of the highest global cervical cancer incidence rates. Mobile health (mHealth) technology has the potential to improve healthcare-seeking behaviors and access. The present study describes the connection between mobile phone access and healthcare-seeking behaviors in rural Uganda.

METHODS

Women were eligible for this cross-sectional study if they had no prior screening or treatment for cervical cancer in the past 5 years, were aged 30 to 49 years old, and were residents of the South Busoga Forest reserve. Survey data was analyzed using descriptive statistics and chi-square tests.

RESULTS

Of the 1434 participants included in the analysis, 91.4% reported having access to a mobile phone. Most respondents were aged 30-40 years, had a partner, had ≤primary education, and were farmers. Participants with mobile phone access were significantly more likely to report attending a healthcare outreach visit (access = 87.3%, no access = 72.6%, P < 0.001) or visiting a health center (access = 96.9%, no access = 93.5%, P < 0.001). Participants in both groups had largely positive attitudes around and good knowledge of cervical cancer screening.

CONCLUSION

While attendance to healthcare services was high amongst participants, those with mobile phone access were more likely to seek healthcare services. Further inquiry into this association between mobile phone access and healthcare-seeking behavior is needed to optimize the improvements to cervical cancer screening when implementing interventions such as mHealth technology.

Early evaluation of a screen-and-treat strategy using high-risk HPV testing for Uganda: Implications for screening coverage and treatment

Background

Uganda has a high burden of cervical cancer and its current coverage of screening based on visual inspection with acetic acid (VIA) is low. High-risk HPV (hrHPV) testing is recommended by the World Health Organization as part of the global elimination strategy for cervical cancer. In this context, country-specific health economic evaluations can inform national-level decisions regarding implementation. We evaluated the recommended hrHPV screen-and-treat strategy to determine the minimum required levels of coverage and treatment adherence, as well as the maximum price level per test, for the strategy to be cost-effective in Uganda.

Methods

We conducted a headroom analysis to estimate potential room for spending on implementing the hrHPV screen-and-treat strategy at different levels of coverage and treatment adherence (from 10% to 100%) at each screening round, and at different price levels of the hrHPV test. We compared the strategy with the existing VIA-based screen-and-treat policy in Uganda. We calculated headroom as the product of number of life years gained by the strategy and the willingness-to-pay threshold, minus the incremental costs incurred by the strategy. Positive headroom was interpreted as an indication of cost-effectiveness.

Results

Compared with VIA-based screening with low 5% coverage, the hrHPV screen-and-treat strategy required at least 30% coverage and adherence for positive mean headroom, and compared with 30% VIA-based screening coverage, the minimum levels were 60%. At 60% coverage and adherence, the maximum acceptable price per hrHPV test was found to be between 15 and 30 international dollars.

Conclusions

The hrHPV-based screen-and-treat strategy could be cost-effective in Uganda if the screening coverage and treatment adherence are at least 30% in each screening round, and if the price per test is set below 30 international dollars. The minimum required levels of screening coverage and adherence to treatment provide potential starting points for decision-makers in planning the rollout of hrHPV testing. The headroom estimates can guide the planning costs of screening infrastructure and campaigns to achieve the required coverage and treatment adherence in Uganda.

Association between metabolic syndrome and cervical cancer among women in Southwestern Uganda: A case-control study

Objective

To determine the association between MetS and its components with cervical cancer among women in South-western Uganda.

Methods

We conducted an unmatched case-control study on 470 participants in a 1:2 case-to-control ratio among women in southwestern Uganda. We recruited 157 women with cervical cancer as cases and 313 women without cervical cancer as controls at the Mbarara Regional Referral Hospital Cervical Cancer Clinic. We assessed for MetS using the National Cholesterol Education Programme Adult Treatment Panel III (NCEP ATP III) criteria. We used a multivariable binary logistic regression analysis to determine the association between MetS and its components with cervical cancer adjusted for potential confounders. We reported the adjusted odds ratios (aOR) and 95% confidence intervals (CI).

Results

Cases were significantly older than controls: 52.4 ± 13.15 versus 41.9 ± 11.9 respectively, p < 0.001. We found MetS was independently associated with cervical cancer (aOR 1.66; 95 % CI 1.07-2.57). Age ≥ 50 years (aOR-2.20; 95 % CI 1.35-3.56), HIV infection (aOR 2.51, 95 % CI 1.56-4.05), increasing parity (aOR 1.16, 95 % CI 1.06-1.26), and a lack of formal education (aOR 6.41, 95 % CI, 1.33-30.86) were also associated with cervical cancer. However, none of the components of MetS was associated with cervical cancer.

Conclusion

In Ugandan women, MetS was associated with a higher likelihood of cervical cancer. We, therefore recommend combined screening for MetS and cervical cancer in order to reduce morbidity and mortality from both Mets and cervical cancer.

Experiences and perspectives regarding human papillomavirus self-sampling in sub-Saharan Africa: A systematic review of qualitative evidence

Introduction

Cervical cancer screening coverage remains low in sub-Saharan Africa (SSA) due to limited access and low uptake of available services by women. The use of HPV-based self-sampling intervention for cervical cancer screening has the potential to increase screening coverage in the region. This study aimed to analyse qualitative evidence on the experiences and perspectives of women, healthcare workers, and policymakers regarding HPV self-sampling.

Methods

We reviewed qualitative studies from January 2011 to March 2023 in PubMed, Scopus, Medline Ovid, Cochrane, and WEB of Science databases for articles with qualitative data on HPV self-sampling from different countries in SSA. The socio-ecological model was used to guide data analysis and the study findings.

Results

Thirteen qualitative studies were included for analysis, and they revealed themes under the intrapersonal, interpersonal, community, and health systems constructs of the Socio-ecological model. Intrapersonal themes included the acceptability of self-sampling, self-efficacy, and the perceived value of self-sampling. The interpersonal construct had themes such as women's spousal relationships, peer support, and the health worker's relationship with the women. The community construct had two themes: social stigma and misinformation, and the influence of cultural norms and religion. Finally, the health systems construct had themes such as the setting for self-sampling, follow-up availability of treatment services and education and awareness.

Conclusion

This study highlights the factors influencing the acceptability and uptake of an HPV-based self-sampling intervention for cervical cancer screening in SSA. Considering these findings when designing interventions in SSA is crucial to ensure acceptance and demand among end-users. Self-sampling interventions offer the potential to reach many unscreened women and increase cervical cancer screening coverage in SSA, which is an essential strategy towards achieving the World Health Organisation's cervical cancer elimination targets by the close of the century.

Understanding of cervical cancer, acceptability of HPV self-collection, and prevalence of HPV in a semi-urban setting in Bangladesh

Human Papillomavirus (HPV) self-sampling has been implemented successfully as an alternative to traditional forms of cervical cancer screening in low-resource settings. Through Bangladesh's current national cervical cancer screening program, only about 10% of the at-risk population is reached. Thus, Bangladesh is an ideal setting to consider HPV self-sampling to improve cervical cancer prevention efforts. However, the feasibility and acceptability of HPV self-sampling has not been evaluated in Bangladesh. We aimed to understand levels of HPV and cervical cancer knowledge and to evaluate the feasibility and acceptability of HPV self-sampling for cervical cancer screening in a semi-urban Bangladeshi community. Participants were recruited from a local clinic; 164 women completed a cross-sectional questionnaire about attitudes towards screening, and cervical cancer and HPV risk factor knowledge, and provided self-collected cervical samples for high-risk HPV testing. Of the participants, 4.3% tested positive for high-risk HPV and were referred for appropriate follow-up care. Nearly all participants had heard of cervical cancer, though specific knowledge was quite low. Self-sampling for high-risk HPV testing had high rates of acceptability, high rates of convenience, and very little discomfort and embarrassment reported in this study population, making implementing HPV self-sampling as a form of cervical cancer screening in Bangladesh appear feasible.

Point-of-care testing with Xpert HPV for single-visit, screen-and-treat for cervical cancer prevention: a demonstration study in South Africa

Human papillomavirus (HPV)-based screen-and-treat (SAT) is recommended but implementation presents operational challenges. We implemented HPV-SAT at a research site in Khayelitsha, South Africa, screening 3062 women aged 30-65 years (44% women living with HIV [WHIV]). All were screened using point-of-care Xpert HPV and almost all received their HPV results on the same day. HPV-positivity occurred in 41.5% of WHIV and 17.4% of women without HIV (WNoH) reducing to 26.2% in WHIV and 10.4% in WNoH applying treatment eligibility criteria based on high viral load in the channels detecting HPV16, 18, 45, 16, 18, 31, 33, 35, 52, 58. Among those eligible for treatment, 91.3% were considered suitable for ablative therapy, and 94.6% underwent thermal ablation on the same day, with no serious adverse events. Twelve months later, 39.0% of WHIV and 65.2% of WNoH treated with ablative therapy were clear of HPV. In women who were HPV-positive but ineligible for treatment, 19.1% and 12.9% had histologically-confirmed cervical intraepithelial neoplasia grade 2 or worse (CIN2+) at 12 months. SAT programs need to weigh trade-offs between overtreatment versus delayed or no treatment for women who test positive for HPV. Treatment modalities for precancerous lesions need to be improved.

Impact of the COVID-19 Pandemic on Cancer Screening Delays

PURPOSE

To examine delays in cancer screenings during the COVID-19 pandemic.

METHODS

Participants from previous studies (N = 32,989) with permissions to be recontacted were invited to complete a survey between June and November 2020. Participants (n = 7,115) who met the age range for cancer screenings were included. Participants were asked if they planned to have and then if they postponed a scheduled mammogram, Pap test, stool blood test, colonoscopy, or human papillomavirus (HPV) test. Logistic regression was used to determine the factors associated with cancer screening delays for each planned test.

RESULTS

The average age was 57.3 years, 75% were female, 89% were non-Hispanic White, 14% had public insurance, and 34% lived in rural counties. Those who planned cancer screenings (n = 4,266, 60%) were younger, more likely to be female, with higher education, had private insurance, and lived in rural counties. Specifically, 24% delayed a mammogram (n = 732/2,986), 27% delayed a Pap test (n = 448/1,651), 27% delayed an HPV test (n = 59/220), 11% delayed a stool blood test (n = 44/388), and 36% delayed a colonoscopy (n = 304/840). Age, race/ethnicity, education, and health insurance were associated with delays in cancer screenings (all P < .05). Compared with non-Hispanic White women, non-Hispanic Black women had lower odds of delaying a mammogram (odds ratio [OR], 0.60; 95% CI, 0.39 to 0.94), Hispanic women had higher odds of delaying Pap test (OR, 2.46; 95% CI, 1.34 to 4.55), and women with other race/ethnicity had higher odds of delaying both Pap test (OR, 2.38; 95% CI, 1.41 to 4.02) and HPV test (OR, 5.37; 95% CI, 1.44 to 19.97).

CONCLUSION

Our findings highlighted the urgency for health care providers to address the significant delays in cancer screenings in those most likely to delay. Strategies and resources are needed to help those with barriers to receiving guideline-appropriate cancer screening.

[Faible niveau de dépistage du cancer du col de l'utérus, disparités géographiques et déterminants sociodémographiques du dépistage chez les femmes adultes au Burkina Faso : résultats de la première enquête nationale en population générale]

OBJECTIVE

To explore the level, geographical disparities and sociodemographic determinants of cervical cancer screening uptake among adult women in Burkina Faso by using data from the first national population-based survey.

METHODS

This was a cross-sectional secondary analysis of primary data obtained by the 2013 World Health Organization (WHO) Stepwise Approach to Surveillance survey conducted in Burkina Faso. All 13 Burkinabè regions, with their different rates of urbanization, were surveyed. Lifetime cervical cancer screening uptake was explored. We included 2293 adult women for analyses and performed Student's t, chi-square and Fisher's exact tests, and logistic regression.

RESULTS

Only 6.2% (95% CI: 5.3-7.3) of women had ever been screened for cervical cancer. For two regions ("Centre" and "Hauts-Bassins"), the pooled frequency was 16.6% (95% CI: 13.5-20.1) while in the other eleven regions it was significantly lower, 3.3% (95% CI: 2.5-4.2). In urban and rural areas, the respective frequencies for the screening uptake were 18.5% and 2.8% (p < 0.001), and in educated and un-educated women, frequencies were 27.7% and 3.3% (p < 0.001) respectively. The sociodemographic factors associated with screening uptake were being educated (adjusted odd-ratio [aOR] = 4.3; 95% CI: 2.8-6.7), urban residence (aOR = 3.8, 95% CI: 2.5-5.8) and having an occupation providing income (aOR = 3.1, 95% CI: 1.8-5.4).

CONCLUSION

There was a significantly wide range in screening uptake between Burkina Faso regions, and the overall national as well as the region-specific levels were far below the WHO's target for cervical cancer elimination. Cervical cancer interventions should be tailored specifically for Burkinabè women with different educational levels, and prevention strategies based on community engagement integrating psychosocial considerations could be helpful.

Human papillomavirus testing on self-collected samples to detect high-grade cervical lesions in rural Bhutan: The REACH-Bhutan study

BACKGROUND

"REACH-Bhutan" aimed to evaluate the feasibility and clinical performance of a community-based screening program for cervical cancer in rural Bhutan using self-collected samples for high-risk human papillomavirus (HR-HPV) testing.

METHODS

In April/May 2016, 2590 women aged 30-60 years were screened across rural Bhutan by providing a self-collected sample for careHPV testing. All careHPV-positive women, plus a random sample of careHPV-negative women, were recalled for colposcopy and biopsy. Self-samples also underwent GP5+/6+ polymerase chain reaction (PCR)-based HR-HPV DNA detection and genotyping. Cross-sectional screening indices were estimated against histological high-grade squamous intraepithelial lesions or worse (hHSIL+), including imputation of hHSIL+ in women without colposcopy.

RESULTS

HR-HPV positivity was 10.2% by careHPV and 14.8% by GP5+/6+ PCR. Twenty-two cases of hHSIL+ were histologically diagnosed, including one invasive cancer; an additional 7 hHSIL+ were imputed in women without colposcopy. HR-HPV testing by GP5+/6+ showed higher sensitivity for hHSIL+ (89.7%, 95% CI 72.6-97.8) than careHPV (75.9%, 95% CI 56.5-89.7). Negative predictive value was also slightly higher for GP5+/6+ (99.9%, 95% CI 99.6-100) than careHPV (99.7%, 95% CI 99.4-99.9). Specificity, however, was lower for GP5+/6+ (86.1%, 95% CI 84.6-87.4) than careHPV (90.6%, 95% CI 89.4-91.7), as was positive predictive value (6.9%, 95% CI 4.5-9.9 vs. 8.5%, 95% CI 5.4-12.6). Of 377 HR-HPV-positive women by GP5+/6+, 173 (45.9%) were careHPV-positive, including 54.7% HPV16-positive and 30.2% HPV18-positive women.

CONCLUSIONS

The final REACH-Bhutan results show that screening for cervical cancer with self-collection of samples and HR-HPV testing, in addition to our previous report of achieving high participation, can also perform well to detect women with hHSIL+.

Mapping evidence on the acceptability of human papillomavirus self-sampling for cervical cancer screening among women in sub-Saharan Africa: a scoping review

OBJECTIVES

The objective of this scoping review was to map evidence on the acceptability of self-sampling for human papillomavirus testing (HPVSS) for cervical cancer screening among women in the sub-Saharan Africa region.

DESIGN

Scoping review.

METHODS

Using Arksey and O'Malley's framework, we searched Scopus, PubMed, Medline Ovid, Cochrane and Web of Science databases for evidence on the acceptability of HPVSS among women aged 25 years and older published between January 2011 and July 2021. We included studies that reported evidence on the acceptability of HPVSS for cervical cancer screening. Review articles and protocols were excluded. We also searched for evidence from grey literature sources such as dissertations/theses, conference proceedings, websites of international organisations such as WHO and relevant government reports. Two reviewers independently performed the extraction using a pre-designed Excel spreadsheet and emerging themes were narratively summarised.

RESULTS

The initial search retrieved 1018 articles. Of these, 19 articles were eligible and included in the review. The following themes emerged from the included articles: acceptability of HPVSS; lack of self-efficacy to perform HPVSS, complications when performing HPVSS, preferences for provider sampling or assistance; setting of HPVSS; HPVSS by vulnerable populations.

CONCLUSION

Evidence shows that HPVSS is highly acceptable for cervical cancer screening in sub-Saharan Africa. Further research exploring the acceptability of HPVSS among women residing in rural areas is required, as well as studies to determine women's preferences for HPVSS intervention including the preferred type of sampling devices. Knowledge on the acceptability and preferences for HPVSS is important in designing women-centred interventions that have the potential to increase screening coverage and participation in cervical cancer screening programmes.

Prevalence of Human Papillomavirus in Different Mucous Membranes in HIV Concordant Couples in Rwanda

BACKGROUND

The prevalence of human papillomavirus (HPV) infections in other anatomical sites besides the uterine cervix is unknown in East Africa. Here, we assessed the prevalence and concordance of HPVs in different anatomical sites in HIV concordant couples in Rwanda.

METHODS

Fifty HIV-positive concordant male-female couples at the HIV clinic at the University Teaching Hospital of Kigali in Rwanda were interviewed, swabbed from the oral cavity (OC), oropharynx (OP), anal canal (AC), vagina (V), uterine cervix (UC) and penis. A pap smear test and a self-collected vaginal swab (Vself) were taken. Twelve high-risk (HR)-HPVs were analyzed.

RESULTS

HR-HPVs occurred in 10%/12% in OC, 10%/0% in OP and 2%/24% in AC (p = 0.002) in men and women, respectively. HR-HPVs occurred in 24% of UC, 32% of Vself, 30% of V and 24% of P samples. Only 22.2% of all HR-HPV infections were shared by both partners (κ -0.34 ± 0.11; p = 0.004). The type-specific HR-HPV concordance was significant between male to female OC-OC (κ 0.56 ± 0.17), V-VSelf (κ 0.70 ± 0.10), UC-V (κ 0.54 ± 0.13), UC-Vself (κ 0.51 ± 0.13) and UC-female AC (κ 0.42 ± 0.15).

CONCLUSIONS

HPV infections are prevalent in HIV-positive couples in Rwanda but concordance within couples is low. Vaginal self-sampling for HPV is representative of cervical HPV status.

MINI: A high-throughput point-of-care device for performing hundreds of nucleic acid tests per day

There are a variety of infectious diseases with a high incidence and mortality in limited resource settings that could benefit from rapid point of care molecular diagnosis. Global health efforts have sought to implement mass-screening programs to provide earlier detection and subsequent treatment in an effort to control transmission and improve health outcomes. However, many of the current diagnostic technologies under development are limited to fewer than 10 samples per run, which inherently restricts the screening throughput of these devices. We have developed a high throughput device called "MINI" that is capable of testing hundreds of samples per day at the point-of-care. MINI can utilize multiple energy sources - electricity, flame, or solar - to perform loop-mediated isothermal amplification (LAMP) in a portable and robust device which is ideal for use in limited resource settings. The unique opto-electronic design of MINI minimizes the energy and space requirements of the device and maximizes the optical isolation and signal clarity, enabling point-of-care analysis of 96 unique samples at once. We show comparable performance to a commercial instrument using two different LAMP assays for Kaposi's sarcoma-associated herpesvirus and a common housekeeping gene, GAPDH. With a single device capable of running hundreds of samples per day, increased access to modern molecular diagnostics could improve health outcomes for a variety of diseases common in limited resource settings.

Implementation research on noncommunicable disease prevention and control interventions in low- and middle-income countries: A systematic review

BACKGROUND

While the evidence for the clinical effectiveness of most noncommunicable disease (NCD) prevention and treatment interventions is well established, care delivery models and means of scaling these up in a variety of resource-constrained health systems are not. The objective of this review was to synthesize evidence on the current state of implementation research on priority NCD prevention and control interventions provided by health systems in low- and middle-income countries (LMICs).

METHODS AND FINDINGS

On January 20, 2021, we searched MEDLINE and EMBASE databases from 1990 through 2020 to identify implementation research studies that focused on the World Health Organization (WHO) priority NCD prevention and control interventions targeting cardiovascular disease, cancer, diabetes, and chronic respiratory disease and provided within health systems in LMICs. Any empirical and peer-reviewed studies that focused on these interventions and reported implementation outcomes were eligible for inclusion. Given the focus on this review and the heterogeneity in aims and methodologies of included studies, risk of bias assessment to understand how effect size may have been compromised by bias is not applicable. We instead commented on the distribution of research designs and discussed about stronger/weaker designs. We synthesized extracted data using descriptive statistics and following the review protocol registered in PROSPERO (CRD42021252969). Of 9,683 potential studies and 7,419 unique records screened for inclusion, 222 eligible studies evaluated 265 priority NCD prevention and control interventions implemented in 62 countries (6% in low-income countries and 90% in middle-income countries). The number of studies published has been increasing over time. Nearly 40% of all the studies were on cervical cancer. With regards to intervention type, screening accounted for 49%, treatment for 39%, while prevention for 12% (with 80% of the latter focusing on prevention of the NCD behavior risk factors). Feasibility (38%) was the most studied implementation outcome followed by adoption (23%); few studies addressed sustainability. The implementation strategies were not specified well enough. Most studies used quantitative methods (86%). The weakest study design, preexperimental, and the strongest study design, experimental, were respectively employed in 25% and 24% of included studies. Approximately 72% of studies reported funding, with international funding being the predominant source. The majority of studies were proof of concept or pilot (88%) and targeted the micro level of health system (79%). Less than 5% of studies report using implementation research framework.

CONCLUSIONS

Despite growth in implementation research on NCDs in LMICs, we found major gaps in the science. Future studies should prioritize implementation at scale, target higher levels health systems (meso and macro levels), and test sustainability of NCD programs. They should employ designs with stronger internal validity, be more conceptually driven, and use mixed methods to understand mechanisms. To maximize impact of the research under limited resources, adding implementation science outcomes to effectiveness research and regional collaborations are promising.

Comparative assessment of test characteristics of cervical cancer screening methods for implementation in low-resource settings

Cervical cancer disproportionately affects low-resource settings. Papanicolaou, human papillomavirus (HPV), and visual inspection of cervix with acetic acid (VIA) testing, each with different characteristics, will reduce cervical cancer burden. We conducted a critical literature review using PubMed, Cochrane, WHO, and grey literature from 1994 to 2020. We examined efficacy, harms, and comparative effectiveness of screening methods by age, human immunodeficiency virus, provider characteristics, and assessed implementation challenges in low-resource settings. Comprehensive data on utility and efficacy of screening tests indicates that each screening has strengths and shortcomings but all confer acceptable performance. HPV and VIA appear more promising. Primary HPV test-and-treat, self-testing, and co-testing have been studied but data on triage plans, cost, support system, implementation and sustainability is unclear in low-resource settings. HPV testing could help target subgroups of older or higher risk women. VIA offers local capacity-building and scalability. Quality VIA technique after HPV testing is still required to guide post-screening treatments. VIA competencies decline gradually with current standard trainings. Stationary cervicography improves VIA quality but isn't scalable. Affordable smartphones eliminate this barrier, enhance training through mentorship, and advance continuing education and peer-to-peer training. Smartphone-based VIA facilitates cervical image storage for patient education, health promotion, record-keeping, follow-up care, remote expert support, and quality control to improve VIA reliability and reproducibility and reduce mis-diagnoses and burden to health systems. Rather than ranking screening methods using test characteristics alone in study or higher-resource settings, we advocate for scalable strategies that maximize reliability and access and reduce cost and human resources.

Implementing community-based human papillomavirus self-sampling with SMS text follow-up for cervical cancer screening in rural, southwestern Uganda

BACKGROUND

Self-collected HPV screening may improve cervical cancer screening coverage in low resource countries, yet data guiding implementation and follow-up of abnormal results are sparse.

METHODS

This is a prospective cohort implementation study of HPV self-testing program in Mbarara, Uganda with mobile phones to facilitate result notification and referral for treatment at a regional hospital. The effectiveness of the interventions was analyzed using Proctor's model of implementation. Women were interviewed following screening and at 6 months to assess acceptability and barriers to follow-up. Data were analyzed using descriptive statistics.

RESULTS

159 of 194 (82%) of eligible women underwent HPV self-sampling; of these, 27 (17%) returned positive for high-risk HPV subtypes. We sent SMS messages providing test results and follow-up instructions to all participants. Seventeen (63%) hrHPV-positive participants reported receiving SMS text instructions for follow-up, of whom 6 (35%) presented for follow-up. The most common reasons for not returning were: lack of transportation (n = 11), disbelief of results (n = 5), lack of childcare (n = 4), and lack of symptoms (n = 3). Confidence in test results was higher for self-screening compared to VIA (Likert score 4.8 vs 4.4, P = 0.001).

CONCLUSIONS

Despite the use of SMS text-based referrals, only one-third of women presented for clinical follow-up after abnormal HPV testing.

Cervical cancer prevention: Human papillomavirus testing as primary screening

Low- and middle-income countries carry a high burden of preventable cervical cancer cases and deaths. Because human papillomavirus DNA-based testing is increasingly becoming the preferred method of screening for cervical cancer prevention, this commentary discusses next steps and key considerations for its expansion.

Cervical Cancer Screening Postpandemic: Self-Sampling Opportunities to Accelerate the Elimination of Cervical Cancer

The persisting burden of cervical cancer in underserved populations and low-resource regions worldwide, worsened by the onset of the COVID-19 pandemic, requires proactive strategies and expanded screening options to maintain and improve screening coverage and its effects on incidence and mortality from cervical cancer. Self-sampling as a screening strategy has unique advantages from both a public health and individual patient perspective. Some of the barriers to screening can be mitigated by self-sampling, and resources can be better allocated to patients at the highest risk of developing cervical cancer. This review summarizes the implementation options for self-sampling and associated challenges, evidence in support of self-sampling, the available devices, and opportunities for expansion beyond human papillomavirus testing.

A public health approach to cervical cancer screening in Africa through community-based self-administered HPV testing and mobile treatment provision

The World Health Organization (WHO) refers to cervical cancer as a public health problem, and sub‐Saharan Africa bears the world's highest incidence. In the realm of screening, simplified WHO recommendations for low‐resource countries now present an opportunity for a public health approach to this public health problem. We evaluated the feasibility of such a public health approach to cervical cancer screening that features community‐based self‐administered HPV testing and mobile treatment provision. In two rural districts of western‐central Uganda, Village Health Team members led community mobilization for cervical cancer screening fairs in their communities, which offered self‐collection of vaginal samples for high‐risk human papillomavirus (hrHPV) testing. High‐risk human papillomavirus‐positive women were re‐contacted and referred for treatment with cryotherapy by a mobile treatment unit in their community. We also determined penetrance of the mobilization campaign message by interviewing a probability sample of adult women in study communities about the fair and their attendance. In 16 communities, 2142 women attended the health fairs; 1902 were eligible for cervical cancer screening of which 1892 (99.5%) provided a self‐collected vaginal sample. Among the 393 (21%) women with detectable hrHPV, 89% were successfully contacted about their results, of which 86% returned for treatment by a mobile treatment team. Most of the women in the community (93%) reported hearing about the fair, and among those who had heard of the fair, 68% attended. This public health approach to cervical cancer screening was feasible, effectively penetrated the communities, and was readily accepted by community women. The findings support further optimization and evaluation of this approach as a means of scaling up cervical cancer control in low‐resource settings.