Heather N. Pedersen

Uptake of community-based, self-collected HPV testing vs. visual inspection with acetic acid for cervical cancer screening in Kampala, Uganda: preliminary results of a randomised controlled trial

To compare two cervical cancer screening methods: community‐based self‐collection of high‐risk human papillomavirus (HR‐HPV) testing and visual inspection with acetic acid (VIA).

Cost-effectiveness of cervical cancer screening methods in low- and middle-income countries: A systematic review

The incidence of cervical cancer in low‐ and middle‐income countries (LMICs) is five times higher than that observed in high‐income countries (HICs). This discrepancy is largely attributed to the implementation of cytology‐based screening programmes in HICs. However, due to reduced health system infrastructure requirements, HPV testing (self‐ and provider‐collected) and visual inspection with acetic acid (VIA) have been proposed as alternatives that may be better suited to LMICs. Knowing the relative value of different screening options can inform policy and the development of sustainable prevention programs. We searched MEDLINE and EMBASE for English language publications detailing model‐based cost‐effectiveness analyses of cervical cancer screening methods in LMICs from 2000 to 2016. The main outcome of interest was the incremental cost‐effectiveness ratio (ICER). Quantitative data were extracted to compare commonly evaluated screening methods and a descriptive review was conducted for each included study. Of the initial 152 articles reviewed, 19 met inclusion criteria. Generally, cytology‐based screening was shown to be the least effective and most costly screening method. Whether provider‐collected HPV testing or VIA was the more efficient alternative depended on the cost of the HPV test, loss to follow‐up and VIA test performance. Self‐collected HPV testing was cost‐effective when it yielded population coverage gains over other screening methods. We conclude that HPV testing and VIA are more cost‐effective screening methods than cytology in LMICs. Policy makers should consider HPV testing with self‐collection of samples if it yields gains in population coverage.

Strategies for community education prior to clinical trial recruitment for a cervical cancer screening intervention in Uganda

Introduction Community engagement and education can improve acceptability and participation in clinical trials conducted in Kisenyi, Uganda. In preparation for a randomized controlled trial exploring different methods for cervical cancer screening, we explored optimal engagement strategies from the perspective of community members and health professionals. Methods We conducted key informant interviews followed by serial community forums with purposeful sampling and compared the perspectives of women in Kisenyi (N = 26) to health-care workers (HCW) at the local and tertiary care center levels (N = 61) in a participatory, iterative process. Results Key themes identified included format, content, language, message delivery, and target population. Women in Kisenyi see demonstration as a key part of an educational intervention and not solely a didactic session, whereas health professionals emphasized the biomedical content and natural history of cervical cancer. Using local language and lay leaders with locally accessible terminology was more of a priority for women in Kisenyi than clinicians. Simple language with a clear message was essential for both groups. Localization of language and reciprocal communication using demonstration between community members and HCW was a key theme. Conclusion Although perceptions of the format are similar between women and HCW, the content, language, and messaging that should be incorporated in a health education strategy differ markedly. The call for lay leaders to participate in health promotion is a clear step toward transforming this cervical cancer screening project to be a fully participatory process. This is important in scaling up cervical cancer screening programs in Kisenyi and will be central in developing health education interventions for this purpose.

Understanding Men’s Perceptions of Human Papillomavirus and Cervical Cancer Screening in Kampala, Uganda

Purpose This preliminary study explores Ugandan men’s knowledge and attitudes about human papillomavirus (HPV), cervical cancer, and screening. Methods A local physician led an education session about cervical cancer for 62 men in Kisenyi, Kampala in Uganda. Trained nurse midwives administered surveys to assess knowledge and attitudes before and after the education session. Results From the pre-education survey, only 24.6% of men had heard of HPV previously, and 59% of men had heard of cervical cancer. Posteducation, 54.5% of men believed only women could be infected with HPV and 32.7% of men believed antibiotics could cure HPV. Despite their limited knowledge, 98.2% of men stated they would support their partners to receive screening for cervical cancer, and 100% of men surveyed stated they would encourage their daughter to get the HPV vaccine if available. Conclusions Knowledge of HPV and cervical cancer among Ugandan men is low. Even after targeted education, confusion remained about disease transmission and treatment. Ongoing education programs geared toward men and interventions to encourage spousal communication about reproductive health and shared decision making may improve awareness of cervical cancer prevention strategies.

Self-collection based HPV testing for cervical cancer screening among women living with HIV in Uganda: a descriptive analysis of knowledge, intentions to screen and factors associated with HPV positivity

BackgroundWomen living with HIV (WHIV) are disproportionately impacted by cervical dysplasia and cancer. The burden is greatest in low-income countries where limited or no access to screening exists. The goal of this study was to describe knowledge and intentions of WHIV towards HPV self-collection for cervical cancer screening, and to report on factors related to HPV positivity among women who participated in testing.MethodsA validated survey was administered to 87 HIV positive women attending the Kisenyi Health Unit aged 30–69 years old, and data was abstracted from chart review. At a later date, self-collection based HPV testing was offered to all women. Specimens were tested for high risk HPV genotypes, and women were contacted with results and referred for care. Descriptive statistics, Chi Square and Fischer-exact statistical tests were performed.ResultsThe vast majority of WHIV (98.9%) women did not think it necessary to be screened for cervical cancer and the majority of women had never heard of HPV (96.4%). However, almost all WHIV found self-collection for cervical cancer screening to be acceptable. Of the 87 WHIV offered self-collection, 40 women agreed to provide a sample at the HIV clinic. Among women tested, 45% were oncogenic HPV positive, where HPV 16 or 18 positivity was 15% overall.ConclusionsIn this group of WHIV engaged in HIV care, there was a high prevalence of oncogenic HPV, a large proportion of which were HPV genotypes 16 or 18, in addition to low knowledge of HPV and cervical cancer screening. Improved education and cervical cancer screening for WHIV are sorely needed; self-collection based screening has the potential to be integrated with routine HIV care in this setting.

Implementation considerations using HPV self-collection to reach women under-screened for cervical cancer in high-income settings

The success of cytology (Pap screening) programs is undeniable and has drastically reduced cervical cancer rates in high-income settings where it has been implemented1. However, cytology for primary cervical cancer screening has a number of limitations including poor sensitivity, a taxing demand on human and operational infrastructure, high health system costs, and limited uptake rates, leading researchers and policy-makers to question whether further gains in public health are possible using this approach2. Persistent infection with high-risk genotypes of human papillomavirus (hpv) is well established as the necessary cause for development of cervical cancer3. Research has shown a 30% improvement in sensitivity in detecting high-grade lesions, cervical squamous intraepithelial neoplasia (cin) grade 2 or greater (cin2+), can be achieved with high-risk hpv dna testing compared with cytology4. A negative hpv test confers two-fold greater reassurance against the development of cervical cancer over three years compared with a negative cytology test2,5. The Netherlands has recently transitioned from cytology to hpv testing for primary cervical cancer screening in their National program. Many organized screening programs intend to implement primary hpv screening6-9, including Australia, which will begin implementation in December 2017. A consistent barrier to cytology-based cervical cancer screening is non-attendance, which can be addressed through hpv testing using self-collected samples. Primary cervical cancer screening with hpv dna testing allows for the opportunity of self-collected samples, which is not possible with cytology. In hpv self-collection the sample is obtained vaginally by the woman herself, using a device such as a swab or brush. The swab is subsequently tested for high-risk strains of hpv in a laboratory. With this approach to screening, programs can mail self-collection kits directly to women who are overdue for screening as an alternative to a clinic-based visit. Self-collected cervical samples receiving hpv testing show comparable cin2+ sensitivity compared with clinician-collected samples tested with cytology and with hpv10-12. Self-collection has proven to be highly acceptable among women13. Human papil lomav irus self-col lect ion has the potential to overcome many of the personal and systemlevel barriers to screening that exist for cytology or other clinic-based screening methods. Some women, particularly those who have experienced abuse14 or are otherwise marginalized, may find self-sampling preferable because of such things as cultural/religious embarrassment or discomfort associated with a pelvic exam13,15-17. Time, transportation, inconvenient clinic hours, or not having a regular practitioner are also relevant factors associated with under-screening that can be mitigated through hpv self-collection using mailed samples13,16,17. However, there are psychosocial barriers to hpv screening, including women’s lack of awareness and fears around hpv and cervical cancer screening, which cannot be addressed through self-collection-based screening alone17,18.

Population-level sexual behaviours in adolescent girls before and after introduction of the human papillomavirus vaccine (2003–2013)

BACKGROUND: The human papillomavirus (HPV) vaccine is delivered widely through school-based immunization programs. Some groups have expressed concern that HPV vaccination programs will result in an increase in sexual risk-taking behaviours among adolescents. We aimed to evaluate population-level changes in sexual behaviours before and after implementation of the school-based HPV vaccination program in British Columbia. METHODS: In 2008, a school-based HPV vaccination program for girls was introduced in British Columbia. Using data from the BC Adolescent Health Survey — a longitudinal provincial survey administered in schools to capture adolescent physical and emotional health indicators, we conducted a linear trend analysis on sexual health behaviours and risk factors in adolescent girls before and after the implementation of vaccination for HPV (2003, 2008 and 2013). RESULTS: We analyzed data for 298 265 girls who self-identified as heterosexual. The proportion of girls reporting ever having sexual intercourse decreased from 21.3% (2003) to 18.3% (2013; adjusted odds ratio [OR] 0.79). Self-report of sexual intercourse before the age of 14 years decreased significantly from 2008 to 2013 (adjusted OR 0.76), as did reported substance use before intercourse (adjusted OR for 2003–2013 0.69). There was no significant change in the number of sexual partners reported (2003–2013). Between 2003 and 2013, girls’ reported use of contraception and condoms increased, while pregnancy rates decreased. INTERPRETATION: Since the implementation of school-based HPV vaccination program in BC, sexual risk behaviours reported by adolescent girls either reduced or stayed the same. These findings contribute evidence against any association between HPV vaccination and risky sexual behaviours.

Community-based HPV self-collection versus visual inspection with acetic acid in Uganda: a cost-effectiveness analysis of the ASPIRE trial

Background Cervical cancer is the leading cause of cancer death for women in Uganda, despite the potential for prevention through organised screening. Community-based self-collected human papillomavirus (HPV) testing has been proposed to reduce barriers to screening. Objective Our objective was to evaluate the cost-effectiveness of the Advances in Screening and Prevention of Reproductive Cancers (ASPIRE) trial, conducted in Kisenyi, Uganda in April 2014 (n=500). The trial compared screening uptake and compliance with follow-up in two arms: (1) community-based (ie, home or workplace) self-collected HPV testing (facilitated by community health workers) with clinic-based visual inspection with acetic acid (VIA) triage of HPV-positive women (‘HPV-VIA’) and (2) clinic-based VIA (‘VIA’). In both arms, VIA was performed at the local health unit by midwives with VIA-positive women receiving immediate treatment with cryotherapy. Design We informed a Monte Carlo simulation model of HPV infection and cervical cancer with screening uptake, compliance and retrospective cost data from the ASPIRE trial; additional cost, test performance and treatment effectiveness data were drawn from observational studies. The model was used to assess the cost-effectiveness of each arm of ASPIRE, as well as an HPV screen-and-treat strategy (‘HPV-ST’) involving community-based self-collected HPV testing followed by treatment for all HPV-positive women at the clinic. Outcome measures The primary outcomes were reductions in cervical cancer risk and incremental cost-effectiveness ratios (ICERs), expressed in dollars per year of life saved (YLS). Results HPV-ST was the most effective and cost-effective screening strategy, reducing the lifetime absolute risk of cervical cancer from 4.2% (range: 3.8%–4.7%) to 3.5% (range: 3.2%–4%), 2.8% (range: 2.4%–3.1%) and 2.4% (range: 2.1%–2.7%) with ICERs of US

The case for integrated human papillomavirus vaccine and HIV prevention with broader sexual and reproductive health and rights services for adolescent girls and young women

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Correlates of women’s intentions to be screened for human papillomavirus for cervical cancer screening with an extended interval

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