A comparison of screening tests for detection of high-grade cervical abnormalities in women living with HIV from Cameroon

Abstract

Background: Women living with human immunodeficiency virus (WLWH), especially those living in low-and middle-income countries (LMIC), are at increased risk of cervical cancer. The optimal cervical-cancer screening strategy for WLWH has not been determined. We therefore conducted a pilot study of screening methods in WLWH living in Limbe, Cameroon. Methods: Five-hundred sixty-six WLWH, aged 25-59 years, were enrolled. After self-collecting a cervicovaginal specimen, they underwent a pelvic exam, during which a provider also collected a cervical specimen and visual inspection after acetic acid (VIA) was performed. Both self-and provider-collected specimens were tested for highrisk HPV by the Xpert HPV Test (Cepheid, Sunnyvale, CA, USA), with the residual of the latter used for liquid-based cytology. Women testing HPV positive on either specimen and/or VIA positive were referred to colposcopy and biopsies. However, because of poor attendence for follow-up colposcopy for the screen positives due to civil strife and technical issues with biopsies, high-grade cytology and/or clinical diagnosis of cancer was used as the primary high-grade cervical abnormality endpoint. Clinical performances for high-grade cervical abnormality of HPV testing and VIA for screening WLWH, and the most carcinogenic HPV genotypes and/or VIA to triage high-risk HPV-positive WLWH, were evaluated.

Comparison of human papillomavirus‐based cervical cancer screening strategies in Tanzania among women with and without HIV

“…Our finding of low sensitivity of VIA triage is in line with studies from Sub-Saharan Africa of women living with HIV 6,8,15 and the general population, 10 as well as studies from other LMICs. 7,9 VIA performs poorly in older women due to difficulties in visualizing the squamocolumnar junction, but even when we limited the analysis to women aged <49 years, the sensitivity of VIA triage was <40%.…”

“…An important limitation is that because the study was conducted in a real‐life screen‐and‐treat context, biopsies were not obtained and thus we did not have histologically verified endpoints of cervical high‐grade disease. Instead we used cytological diagnoses as the gold reference standard, as was previously done in Cameroon 8 . Although cytologic reading was performed by highly skilled cytotechnicians in Denmark, cytology has imperfect sensitivity for histological high‐grade disease 3 .…”

“…Self‐sampling has the potential to increase screening uptake and reduce workload for health professionals, and has shown high acceptability in Sub‐Saharan Africa 28 . Although absolute performance of screening tests may differ on self‐ vs clinician‐collected samples, relative patterns between screening strategies are likely similar for both specimen types 8 . Finally, our results were based on the HC2 and Inno‐LiPA tests, which are not suitable for rapid HPV testing at community health facilities in low‐resource settings, due to high costs and heavy laboratory infrastructure requirements.…”

“…2 The 2021 WHO guidelines also take the link between human immunodeficiency virus (HIV) and HPV into account, 4 and recommend either "screen-andtreat" or "screen-triage-and-treat" for the general population of women, whereas in women living with HIV, "screen-triage-and-treat" is recommended to reduce the risk of overtreatment. 2 Several triage methods for HPV positive women have been evaluated in LMICs, including visual inspection with acetic acid (VIA), [5][6][7][8][9][10] measuring HPV viral load 9,[11][12][13] and partial genotyping for HPV16/18 or HPV16/18/45. [5][6][7][8]11,12,14 However, few studies have directly compared several HPV-based screening strategies in Sub-Saharan Africa.…”

Modelling cervical cancer elimination using single‐visit screening and treatment strategies in the context of high HIV prevalence: estimates for KwaZulu‐Natal, South Africa

“…For HPV‐based strategies, we derived estimates of specificity from the simulations as the proportion of all screened women ⩽CIN1 who screen negative. With this approach, the specificity of HPV DNA testing (Table S22) is higher than published estimates [38–40]. A potential explanation for this discrepancy is that our model may simulate a lower prevalence of HPV‐infected states ⩽CIN1 than among sampled populations, leading it to underestimate overtreatment with HPV‐based strategies.…”