EVALUATING HPV TESTING for CERVICAL CANCER SCREENING in FOUR COUNTRY'S HIV PROGRAMS

ABSTRACT

Background: Cervical cancer disproportionately affects women in resource-limited settings, as access to secondary prevention is currently limited. Women living with HIV (WLHIV) are at increased risk of human papillomavirus (HPV) infection and once infected are at greater risk of progression to cancer;therefore, timely screening and treatment is of utmost concern. The goal of the pilots was to introduce integrated HPV testing using existing NAT platforms in public health HIV programs in sub-Saharan Africa and describe the cascade of care. Methods: Observational, prospective pilot studies were conducted across 32 facilities in Malawi, Nigeria, Uganda, and Zimbabwe between September 2019 and April 2021. All countries except Zimbabwe utilized near-point-of-care (POC) devices for HPV testing. Zimbabwe conducted testing on platforms at a centralized laboratory;Uganda conducted HPV testing on both near-POC and centralized platforms. Self-collected sampling was offered as an alternative to clinician-sampling in Malawi, Nigeria, and Uganda. The target population was WLHIV;age-inclusion criteria followed country guidelines, ranging from 25-49 years. All women identified as HPV-positive were to receive visual inspection with acetic acid (VIA), and if pre-cancerous or cancerous lesions were evident, receive treatment or referral. Results: Across the four countries, 14155 tests were conducted, with 4% of tests invalid and 5% missing results, leaving 12962 valid results (Table). HPV prevalence was 35%. 66% of HPV-positive women received their result (median time to result: 34 days, interquartile range 7-64). Among women who received VIA, 584 (22%) were VIA-positive and among those 86% received treatment (70% on same-day as VIA). 30 (1%) were suspected of cancer and of those 80% had a documented referral for tertiary care. In Uganda, 53% of HPV-positive women tested at centralized laboratory received VIA versus 73% of women tested on near-POC devices (p=0.07). Conclusion: HPV testing was found to be feasible across the four pilot countries in a public health setting. While many women did not receive their HPV results, these pilots were conducted during COVID-19, where lockdowns and other disruptions to health-seeking behavior were major barriers. Once women did receive VIA, most who required treatment received it, the majority on the same day. With proper systems in place, use of HPV testing for cervical cancer screening program as recommended by WHO is a promising model in low-and middle-income countries.