Introducing a High-Risk HPV DNA Test Into a Public Sector Screening Program in El Salvador.

OBJECTIVE: In a primary human papillomavirus (HPV) screening program, we compared the 6-month follow-up among colposcopy and noncolposcopy-based management strategies for screen-positive women. MATERIALS AND METHODS: Women aged 30 to 49 years were screened with HPV DNA tests using both self-collection and provider collection of samples. Women testing positive received either (1) colposcopy management (CM) consisting of colposcopy and management per local guidelines or (2) screen-and-treat (ST) management using visual inspection with acetic acid to determine cryotherapy eligibility, with eligible women undergoing immediate cryotherapy. One thousand women were recruited in each cohort. Of these, 368 (18.4%) of 2000 women were recruited using a more intensive outreach strategy. Demographics, HPV positivity, and treatment compliance were compared across recruitment and management strategies. RESULTS: More women in the ST cohort received treatment within 6 months compared with those in the CM cohort (117/119 [98.3%] vs 64/93 [68.8%]; p < .001). Women recruited through more intensive outreach were more likely to be HPV positive, lived in urban areas, were more educated, and had higher numbers of lifetime sexual partners and fewer children. CONCLUSIONS: Women in the CM arm were less likely to complete care than women in the ST arm. Targeted outreach to underscreened women successfully identified women with higher prevalence of HPV and possibly higher disease burden.

Factors affecting attendance to cervical cancer screening among women in the Paracentral Region of El Salvador: a nested study within the CAPE HPV screening program.

BACKGROUND: Cervical cancer is the third most commonly occurring cancer among women and the fourth leading cause of cancer-related deaths in women worldwide, with more than 85 % of these cases occurring in developing countries. These global disparities reflect the differences in cervical cancer screening rates between high-income and medium- and low-income countries. At 19 %, El Salvador has the lowest reported screening coverage of all Latin American countries. The purpose of this study is to identify factors affecting public sector HPV DNA-based cervical cancer screening participation in El Salvador. METHODS: This study was nested within a public sector screening program where health promoters used door-to-door outreach to recruit women aged 30-49 years to attend educational sessions about HPV screening. A subgroup of these participants was chosen randomly and questioned about demographic factors, healthcare utilization, previous cervical cancer screening, and HPV knowledge. Women then scheduled screening appointments at their public health clinics. Screening participants were adherent if they attended their scheduled appointment or rescheduled and were screened within 6 months. The association between non-adherence and demographic variables, medical history, history of cancer, sexual history, birth control methods, and screening barriers was assessed using Chi-square tests of significance and logistic regression. RESULTS: All women (n = 409) enrolled in the study scheduled HPV screening appointments, and 88 % attended. Non-adherence was associated with a higher number of lifetime partners and being under-screened-defined as not having participated in cervical cancer screening within the previous 3 years (p = 0.03 and p = 0.04, respectively); 22.8 % of participants in this study were under-screened. CONCLUSIONS: Adherence to cervical cancer screening after educational sessions was higher than expected, in part due to interactions with the community-based health promoters as well as the educational session itself. More effective recruitment methods targeted toward under-screened women are required.

Comparison of depth of necrosis using cryotherapy by gas and number of freeze cycles.

OBJECTIVE: This study aimed to establish the noninferiority of a single-freeze application with CO2 or N2O compared with the standard double freeze with N2O for cryotherapy treatment. MATERIALS AND METHODS: Sixty women undergoing hysterectomy for reasons other than cervical cancer or precancer were randomized to 1 of 3 techniques as follows: (1) double freeze with N2O, (2) single freeze with N2O, or (3) single freeze with CO2. The cervix was separated and cut into anterior and posterior segments, and the deepest area of necrosis was recorded. Comparisons were made using regression analysis. The margin of noninferiority was defined as 0.8 mm. RESULTS: On the anterior lip, a single freeze with N2O was noninferior to a double freeze of the same gas, but on the posterior lip, the single freeze was not. The single freeze of CO2 did not provide sufficient depth of necrosis in either lip to infer noninferiority versus the double freeze with N2O. CONCLUSIONS: A single freeze with N2O is noninferior to a double-freeze technique in the anterior but not the posterior lip. However, the result for posterior lips was close to reaching statistical significance. In addition, CO2 had approximately 1 mm shallower depth of necrosis compared with N2O techniques; however, the clinical implications are unknown. Given the extensive use of CO2 globally, further clinical evaluation is needed.

Acceptability of self-collected versus provider-collected sampling for HPV DNA testing among women in rural El Salvador.

OBJECTIVE: To determine the acceptability of self-collected versus provider-collected sampling among women participating in public sector HPV-based cervical cancer screening in El Salvador. METHODS: Two thousand women aged 30-49 years underwent self-collected and provider-collected sampling with careHPV between October 2012 and March 2013 (Qiagen, Gaithersburg, MD, USA). After sample collection, a random sample of women (n=518) were asked about their experience. Participants were questioned regarding sampling method preference, previous cervical cancer screening, HPV and cervical cancer knowledge, HPV risk factors, and demographic information. RESULTS: All 518 women approached to participate in this questionnaire study agreed and were enrolled, 27.8% (142 of 511 responding) of whom had not received cervical cancer screening within the past 3 years and were considered under-screened. Overall, 38.8% (n=201) preferred self-collection and 31.9% (n=165) preferred provider collection. Self-collection preference was associated with prior tubal ligation, HPV knowledge, future self-sampling preference, and future home-screening preference (P<0.05). Reasons for self-collection preference included privacy/embarrassment, ease, and less pain; reasons cited for provider-collection preference were result accuracy and provider knowledge/experience. CONCLUSION: Self-sampling was found to be acceptable, therefore screening programs could consider offering this option either in the clinic or at home. Self-sampling at home may increase coverage in low-resource countries and reduce the burden that screening places upon clinical infrastructure.

Depot-medroxyprogesterone acetate contraception use among Salvadoran women: an in-depth analysis of attitudes and experiences.

OBJECTIVE: To survey a cross-section of reproductive-age Salvadoran women in order to assess the factors that influence their decision to use depot-medroxyprogesterone acetate (DMPA), an injectable form of contraception. METHODS: Reproductive-age women at three rural Salvadoran health clinics were asked to participate in a study to assess their current and past experiences using DMPA contraception. Verbal informed consent was obtained, and research coordinators administered a 23-question survey. RESULTS: Surveys were completed in 425 women with an average age of 27.36 years. Average duration of DMPA contraception use was 2.89 years. The majority (84%) of past and present users were very satisfied with DMPA contraception, most commonly because they did not have to remember to use it daily (44.9%). The side effects of DMPA appear to be a significant indicator of whether women heard about and wanted to use other forms of long-term reversible contraception, such as an intrauterine device (IUD) or implant. CONCLUSIONS: The main reason Salvadoran women chose to use DMPA is because they do not have to think about it on a daily basis. However, many women do not like the side effects and may be open to explore using other long-term reversible methods of contraception, such as IUDs or implants. It is possible that with increased access to educational information about IUD use, safety, and effectiveness, more women would use this form of long-term contraception as opposed to sterilization.

Cervical cancer screening and treatment training course in El Salvador: experience and lessons learned.

BACKGROUND: Visual inspection with acetic acid (VIA) is a simple, low-cost alternative to traditional Pap smears that could greatly benefit the amount of screening and treatment available in low-resource areas, such as rural El Salvador. The objective of this study was to train Salvadoran health providers in VIA and cryotherapy using a week-long competency course. METHODS: Health providers participated in the VIA training course, which consisted of 1 half-day of didactics, followed by 4 and 1 half days of clinical training. Pretests and posttests were administered. A 1-day didactic refresher course was administered to assess the quality of services being provided. RESULTS: Sixty-eight nurses and physicians completed the training course. Each trainee screened approximately 120 women and performed, on average, seven cryotherapy treatments. The average trainee improved his or her score by 15% on the theoretical test and 16.7% on the image test. At the completion of the 1-day refresher, average test scores were the highest among all the courses. The final assessment was based on 41 providers. CONCLUSIONS: The course proved a successful tool for training healthcare providers in methods of cervical cancer screening and treatment. The course is replicable in other low-resource settings in different countries. It also provided trainees with the opportunity to adapt their clinical skills in their realistic work setting.

Cervical cancer screening in low- and middle-income countries.

Cervical cancer is a leading cause of death among women in the developing world. Conventional cytology-based cervical cancer screening programs have been largely ineffectual at reducing the cervical cancer burden in low-resource settings. In response, alternative strategies have been tested, such as visual inspection with acetic acid (VIA) screening and human papillomavirus (HPV) DNA-based testing. This manuscript reviews literature addressing the programmatic approaches to implementing cervical cancer screening programs in low-resource settings, highlighting the challenges, barriers, and successes related to the use of cytology, VIA, and HPV-DNA based screening programs.