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

Abstract

Background: Sub-Saharan Africa bears the world's highest incidence of cervical cancer. To address the lack of widespread screening and treatment that contributes to this burden, the World Health Organization (WHO) recommends that low-resource countries adopt simplified protocols for screening directly coupled with treatment. The WHO recommendations present an opportunity -- akin to what has been done for HIV care in Africa -- for a true public health approach to cervical cancer control in resource-poor settings. We evaluated the feasibility of such a public health approach to cervical cancer that features community-based self-administered HPV screening and mobile treatment provision. Methods: In two rural districts of western Uganda, we first trained Village Health Team members (VHTs, also known as Community Health Workers) in a one-day session in the fundamental aspects of cervical cancer and its prevention. We then provided guidance to the VHTs to mobilize adult women from different communities within the district to attend a one-day HPV screening fair at a central location in their respective community. On the day of the fair, the study team and VHTs provided educational talks and instructions for self-collection of a vaginal sample. The samples were subsequently tested for high risk HPV (hrHPV) E6/E7 mRNA using the APTIMA® platform. Women who tested positive for hrHPV were re-contacted and referred for treatment with cryotherapy at a mobile treatment unit in their community. Visual assessment with acetic acid was used to guide suitability for cryotherapy in the mobile treatment unit versus further referral to a larger facility for a loop electrosurgical excision procedure (LEEP). Results: Between March and November 2016, 2,142 women attended a health fair in one of 24 communities in rural Western Uganda and expressed interest in being screened for cervical cancer; 1902 were eligible for cervical cancer screening of which 1,892 (99.5%) provided a self-collected vaginal sample. The median age of those screened was 34 years (IQR: 28-40), HIV prevalence was 11%, and most (95%) had not been previously screened. Almost all women stated that they would perform the self-collection again and recommend it to a friend. Prevalence of any hrHPV mRNA was 21% (HPV-16, 6%; HPV-18/45, 1.9%). Among the 393 women with detectable hrHPV mRNA, 89% had their results transmitted to them, of whom 86% returned to the mobile treatment unit. At the mobile treatment, 85% of women underwent ablative therapy, with the remainder deferred either because of pregnancy (9.0%), need for LEEP (2.6%) or other reasons (3.3%). Conclusion: A public health approach to cervical cancer screening, featuring community-based self-administered HPV testing and mobile treatment, was feasible and readily accepted by community women. The process is termed a "public health approach" because -- as is the case for HIV care in the region -- it explicitly concedes perfection at the individual level in deference to reaching a larger fraction of the population. The findings support further optimization and evaluation of this approach as a means of scaling up cervical cancer control in low resource settings. If resources for cancer control remain limited in sub-Saharan Africa, this public approach may offer one of the most efficient solutions for stemming the incessant tide of cervical cancer in the region.

Cervical cancer prevention: Human papillomavirus testing as primary screening

“…Strategies to implement HPV testing as primary screening include community‐based interventions to increase coverage of screening, especially in rural areas where access to health facilities may be limited. Community health campaigns and home visits by community health workers in particular have been shown to increase screening uptake, especially when women are given the option to self‐collect samples for HPV testing 18‐24 . A study in Uganda found over 99% compliance among women who were offered HPV tests by self‐collection, whereas VIA at a health clinic reached only approximately 48% compliance, given that self‐collection allowed women to provide samples immediately upon recruitment by health workers at home or work visits 23 .…”

“…Offering self‐sampling options for HPV testing can be advantageous, because it allows task shifting to the women themselves, especially in light of frequent provider shortages in low‐resource settings 27 . The quality of self‐collected samples is comparable to clinician‐collected samples, 28‐33 and women also consider self‐collection to be acceptable, adequately private, and preferable over clinician‐collected sampling 20,30,34,35 . However, despite the general acceptance of self‐collection among women, lack of confidence in and awareness of HPV testing and self‐collection have also been reported in some contexts as barriers to screening uptake 16,27,36‐38 .…”

“…Among common HPV DNA test types (eg, careHPV, Hybrid Capture 2, Aptima, and Xpert DNA), processing usually occurs in batches and can take several hours after being transferred from the community screening site to the laboratory 39 . Treatment acquisition among HPV‐positive women thus remains inadequate; the proportion of screen‐positive women accessing care ranges from 32% to 60% among several community‐based cervical cancer screening interventions 18‐23 . In 1 study, implementing mobile treatment sites resulted in treatment rates as high as 86% among women notified, which involved stationing convenient treatment units within the community and moving from community to community to provide treatment for intervals of several days 20 .…”

“…Treatment acquisition among HPV‐positive women thus remains inadequate; the proportion of screen‐positive women accessing care ranges from 32% to 60% among several community‐based cervical cancer screening interventions 18‐23 . In 1 study, implementing mobile treatment sites resulted in treatment rates as high as 86% among women notified, which involved stationing convenient treatment units within the community and moving from community to community to provide treatment for intervals of several days 20 . Such strategies may aid in improving accessibility of treatment and linking HPV‐positive women to treatment, but follow‐up will continue to pose issues unless single‐visit HPV‐based strategies can be offered to women.…”