Gabriel Conzuelo-Rodriguez

Outcomes for Step-Wise Implementation of a Human Papillomavirus Testing–Based Cervical Screen-and-Treat Program in El Salvador

PURPOSE The Cervical Cancer Prevention in El Salvador (CAPE) project is a public-sector intervention introducing lower-cost human papillomavirus (HPV) testing in all four departments of the Paracentral region that screened a total of 28,015 women. After demonstrating success of an HPV screen-and-treat (S&T) algorithm over colposcopy management in the first two phases, the third phase scaled up the S&T strategy. We present results from phase III and evaluate S&T components across the entire project. METHODS During phase III, 17,965 women age 30-59 years underwent HPV testing. HPV-positive women were asked to return and, if eligible, received gas-based cryotherapy. We compare loss to follow-up and time intervals between S&T steps across the three phases. RESULTS There were no differences in HPV positivity across phases (phase I, 11.9%; phase II, 11.4%; phase III, 12.3%; P = .173). Although most HPV-positive women completed indicated follow-up procedures within 6 months in phases I (93.3%, 111 of 119) and II (92.3%, 429 of 465), this proportion declined to 74.9% (1,659 of 2,214; P < .001) in phase III. Mean days between testing and delivery of results to patients increased over program phases (phase I, 23.2 days; phase II, 46.7 days; phase III, 99.8 days; P < .001). CONCLUSION A public-sector implementation of an HPV-based S&T algorithm was successfully scaled up in El Salvador, albeit with losses in efficiency. After CAPE, the Ministry of Health changed its screening guidelines and procured additional tests to expand the program.

Long-term impact of cervical ablation in visual assessment of the squamocolumnar junction: implications for subsequent screening and follow-up

Cervical cancer screen-and-treat programs, which combine human papillomavirus (HPV)-based screening with immediate ablation of lesions, are a key strategy for reducing cervical cancer burden in low-resource settings. Although ablation is known to impair squamocolumnar junction (SCJ) visibility in the short-term, its long-term effects remain unclear, with potential implications for subsequent screening and follow-up. This study evaluated whether prior ablation is associated with incomplete SCJ visualization approximately 5 years post-treatment. We analyzed data from the Cervical Cancer Prevention in El Salvador program. Women aged 34 to 55 years who previously participated in Cervical Cancer Prevention in El Salvador were invited for HPV testing approximately 5 years after their initial screening. Those with positive results were further evaluated through visual inspection with acetic acid and colposcopy. We used generalized linear models to assess the association between prior ablation and incomplete SCJ visualization, adjusting for age, parity, and time since the initial HPV screen. Incomplete SCJ visualization was more frequent among women with prior ablation compared to those without previous treatment, both during colposcopy (47% vs 28%; OR 2.34, 95% CI 1.20 to 4.56) and visual inspection with acid (40% vs 25%; OR 2.06, 95% CI 1.05 to 4.01). Older age was also associated with impaired visualization, but the association between prior ablation and incomplete SCJ visibility remained significant after adjustment. Ablative treatment has a sustained impact on SCJ visualization that persists for years after the procedure, limiting the effectiveness of visualization-based surveillance. These findings underscore the need for efficient and affordable triage strategies to minimize unnecessary ablation in screen-and-treat programs and improve long-term follow-up care in low-resource settings.