Understanding integrated HPV testing and treatment of pre-cancerous cervical cancer in Burkina Faso, Cote d'Ivoire, Guatemala and Philippines: study protocol.

BACKGROUND: Many low- and-middle-income countries are disproportionately burdened by cervical cancer, resulting in high morbidity and mortality. HPV-DNA testing coupled with treatment with thermal ablation is a recommended screening and precancer treatment strategy, but not enough is known about how this can be effectively implemented in the context of integrated services. The (Scale Up Cervical Cancer Elimination by Secondary prevention Strategy, (SUCCESS) project is conducting a study to understand this approach, integrated into existing women's health services in Burkina Faso, Cote d'Ivoire, Guatemala, and the Philippines (2020-2024). METHODS: A hybrid effectiveness-implementation type III mixed-methods observational study design is used to assess feasibility, acceptability, and costs of integrated service delivery in 10 sites per country, selected considering urban/rural location, facility level, onsite/offsite laboratories, and health services type. In each country, a sample size of 2227 women aged 25-49 years will be enrolled with about 20% being women living with HIV. The primary outcome is proportion of HPV positive women completing precancer treatment, if eligible, within three months of screening. Data collection and analysis includes; facility and client exit surveys, key informant and client interviews, registries and project records extractions, and costing data analysis. Analysis includes descriptive statistics, context description, thematic analysis, and document analysis. Quantitative analyses will be stratified by participant's HIV status. DISCUSSION: Recruitment of study participants started in April 2022 (Burkina Faso and Côte d'Ivoire) and August 2022 (Guatemala and the Philippines). Enrolment targets for women screened, client exit, in-depth and key informant interviews conducted were reached in Burkina Faso and Cote d'Ivoire in November 2022. Guatemala and Philippines are expected to complete enrolment by June 2023. Follow-up of study Participants 12-months post-treatment is ongoing and is expected to be completed for all countries by August 2024. In LMICs, integrating cervical cancer secondary prevention services into other health services will likely require specific rather than incidental recruitment of women for screening. Reconfiguration of laboratory infrastructure and planning for sample management must be made well in advance to meet induced demand for screening. Trail Registration ClinicalTrials.Gov ID: NCT05133661 (24/11/2021).

Mentoring approaches in a safe surgery program in Tanzania: Lessons learned during COVID-19 and recommendations for the future.

Background: COVID-19 has dramatically affected the delivery of health care and technical assistance. This is true in Tanzania, where maternal mortality and surgical infection rates are significantly higher than in high-income countries. This paper describes lessons learned about the optimal application of in-person and virtual mentorship in the Safe Surgery 2020 program to improve the quality of surgical services in Tanzania before and after the COVID-19 pandemic. Methods: From January 2018 through December 2020, Safe Surgery 2020 supported 40 health facilities in Tanzania's Lake Zone to improve the quality of surgical care. A blended surgical mentorship model, employing both onsite and virtual mentorship, was central to the program's capacity development approach. With COVID-19, the program pivoted to full virtual mentorship. Through continuous learning and adaptation processes, including a human-centered design workshop, surveys assessing mentors' confidence with different competencies, and focus group discussions with mentors, mentees and safe surgery program staff, the program distilled the optimal use of mentorship models. Results: Developing complex surgical skills, addressing contextual considerations, problem-solving, and building trusting relationships were best suited to in-person mentorship, whereas virtual mentorship was most effective in supporting mentees' quality improvement projects, data use, case discussions, and reinforcing clinical practices. Leading successful virtual learning required enhanced facilitation skills and active engagement of health facility leadership. Conclusions: In-person and virtual mentorship offer distinct benefits and complement each other when combined. Investing more in-person mentorship at the beginning of programs allows for the establishment of trust that is foundational to effective mentorship.

Reducing surgical site infections and mortality among obstetric surgical patients in Tanzania: a pre-evaluation and postevaluation of a multicomponent safe surgery intervention.

INTRODUCTION: Despite ongoing maternal health interventions, maternal deaths in Tanzania remain high. One of the main causes of maternal mortality includes postoperative infections. Surgical site infection (SSI) rates are higher in low/middle-income countries (LMICs), such as Tanzania, compared with high-income countries. We evaluated the impact of a multicomponent safe surgery intervention in Tanzania, hypothesising it would (1) increase adherence to safety practices, such as the WHO Surgical Safety Checklist (SSC), (2) reduce SSI rates following caesarean section (CS) and (3) reduce CS-related perioperative mortality rates (POMRs). METHODS: We conducted a pre-cross-sectional/post-cross-sectional study design to evaluate WHO SSC utilisation, SSI rates and CS-related POMR before and 18 months after implementation. Our interventions included training of inter-professional surgical teams, promoting use of the WHO SSC and introducing an infection prevention (IP) bundle for all CS patients. We assessed use of WHO SSC and SSI rates through random sampling of 279 individual CS patient files. We reviewed registers and ward round reports to obtain the number of CS performed and CS-related deaths. We compared proportions of individuals with a characteristic of interest during pre-implementation and post implementation using the two-proportion z-test at p≤0.05 using STATA V.15. RESULTS: The SSC utilisation rate for CS increased from 3.7% (5 out of 136) to 95.1% (136 out of 143) with p<0.001. Likewise, the proportion of women with SSI after CS reduced from 14% during baseline to 1% (p=0.002). The change in SSI rate after the implementation of the safe surgery interventions is statistically significant (p<0.001). The CS-related POMR decreased by 38.5% (p=0.6) after the implementation of safe surgery interventions. CONCLUSION: Our findings show that our intervention led to improved utilisation of the WHO SSC, reduced SSIs and a drop in CS-related POMR. We recommend replication of the interventions in other LMICs.

High-risk human papillomavirus prevalence in self-collected cervicovaginal specimens from human immunodeficiency virus (HIV)-negative women and women living with HIV living in Botswana.

BACKGROUND: The prevalence of high-risk human papillomavirus (hrHPV) is poorly described overall and in women living with HIV (WLWH) and HIV-negative women living in Botswana, a high HIV and cervical cancer-burden country. We conducted a pilot study of self-collection and high-risk HPV testing for cervical screening, from which data on HPV prevalence was available. METHODS: From five health facilities in the Kweneng East District, 1,022 women aged 30-49 years were enrolled to self-collect their cervicovaginal specimen for hrHPV testing by the Xpert HPV Test (Cepheid, Sunnyvale, CA, USA). Crude and age group-adjusted hrHPV prevalence by HIV status were calculated, and the relationship of hrHPV risk groups HPV16>HPV18/45>other hrHPV types) to the presence and severity of visible lesions. RESULTS: Of the 1,022 women enrolled, 1,019 (99.7%), 570 WLWH and 449 HIV-negative women, had hrHPV testing results. Crude hrHPV prevalences were 25.2% (95%CI = 21.2-29.4%) for HIV-negative women and 40.4% (95%CI = 36.3-44.5%) for WLWH. Age group-adjusted hrHPV prevalences were 23.7% (95%CI = 19.9-27.9%) for HIV-negative women and 41.3% (95%CI = 37.2-45.4%) for WLWH. Age group-adjusted prevalences of HPV16 (p<0.001), HPV18/45 (p<0.001), HPV31/33/35/52/58 (p<0.001), and HPV39/56/66/68 (p = 0.011) were greater among WLWH than HIV-negative women. Riskier hrHPV groups were more likely to have visible abnormalities (ptrend = 0.004) and visible abnormalities not eligible for cryotherapy (ptrend = 0.030). CONCLUSIONS: hrHPV infection was common among all women in the study living in Botswana, to a greater extent in WLWH than their HIV-negative counterparts. Strategies to triage hrHPV-positive women will be needed to avoid over-treating many women with benign hrHPV infections.