The Capulana study: a prospective evaluation of cervical cancer screening using human papillomavirus testing in Mozambique

Abstract

BackgroundCervical cancer is the leading cause of cancer and related deaths among women in Mozambique. There is limited access to screening and few trained personnel to manage women with abnormal results. Our objective was to implement cervical cancer screening with human papillomavirus (HPV) testing, with navigation of women with abnormal results to appropriate diagnostic and treatment services.MethodsWe prospectively enrolled women aged 30–49 years living in Maputo, Mozambique, from April 2018 to September 2019. All participants underwent a pelvic examination by a nurse, and a cervical sample was collected and tested for HPV using the careHPV test (Qiagen, Gaithersburg, Maryland, USA). HPV positive women were referred for cryotherapy or, if ineligible for cryotherapy, a loop electrosurgical excision procedure. Women with findings concerning for cancer were referred to the gynecologic oncology service.ResultsParticipants (n=898) had a median age of 38 years and 20.3% were women living with the human immunodeficiency virus. HPV positivity was 23.7% (95% confidence interval 21.0% to 26.6%); women living with human immunodeficiency virus were twice as likely to test positive for HPV as human immunodeficiency virus negative women (39.2% vs 19.9%, p<0.001). Most HPV positive women (194 of 213, 91.1%) completed all steps of their diagnostic work-up and treatment. Treatment included cryotherapy (n=158, 77.5%), loop electrosurgical excision procedure (n=30, 14.7%), or referral to a gynecologist or gynecologic oncologist (n=5, 2.5%). Of eight invasive cervical cancers, 5 (2.8%) were diagnosed in women living with human immunodeficiency virus and 3 (0.4%) in human immunodeficiency virus negative women (p=0.01).ConclusionCervical cancer screening with HPV testing, including appropriate follow-up and treatment, was feasible in our study cohort in Mozambique. Women living with human immunodeficiency virus appear to be at a significantly higher risk for HPV infection and the development of invasive cervical cancer than human immunodeficiency virus negative women.

HPV testing for cervical cancer screening in Mozambique: challenges and recommendations

“…HPV testing is recommended where resources permit due to the increased sensitivity and high negative predictive value of HPV testing compared with cervical cytology and VIA. 3 Based on WHO recommendations, we conducted a pilot study in Mozambique intending to perform HPV testing for cervical cancer screening, using the careHPV test (QIAGEN, Germantown, MD, USA) 4 . The careHPV test is a user-friendly assay developed for limited-resource settings and shows a sensitivity greater than VIA and cervical cytology.…”

“…The University of Texas MD Anderson Cancer Center, USA (MD Anderson) and the Universidade Eduardo Mondlane (UEM), Mozambique, conducted a cervical cancer screening pilot demonstration project of 898 women at General Hospital of Mavalane in Maputo, Mozambique from April 2018 to September 2019. 4 Women aged 30 to 49 underwent pelvic exams; the cervical samples were collected by trained nurses. According to the manufacturer's instructions, the samples were tested for high-risk HPV using careHPV.…”

Human Papillomavirus Serotypes in Abnormal Cervical Smears in Calabar Cross River State a Cross Sectional Study

“…However, 23.7% in Mozambique [30], 31% was seen in Harare, Zimbambwe [31], 60.3% among Colombian women [32], 65.0% in Gauteng [33], and 68.2% in the Western Cape provinces [34].…”

“…The higher prevalence in PCR-based studies may be defined by the different sensitivity of the test [30] - [34].…”

Cervical cancer prevention and control in women living with human immunodeficiency virus

“…Those cervical abnormalities that cover >75% of the cervical transformation zone, that are suspicious of cancer, and/or that cannot be fully visualized are deemed ineligible for ablative treatment and are referred for excisional treatment or cancer treatment, as needed. 238 WLWH are more likely than HIV-negative women to have an ablation-ineligible cervical abnormality, 239,240 again suggesting that WLWH have larger, harder-to-treat cervical abnormalities than HIV-negative women. Low CD4 counts [241][242][243] and high HIV viral loads 222 in WLWH are associated with the recurrence of cervical abnormalities after treatment.…”