Johnblack K Kabukye

Implementing Smartphone-Based Telemedicine for Cervical Cancer Screening in Uganda: Qualitative Study of Stakeholders’ Perceptions

Background In Uganda, cervical cancer (CaCx) is the commonest cancer, accounting for 35.7% of all cancer cases in women. The rates of human papillomavirus vaccination and CaCx screening remain low. Digital health tools and interventions have the potential to improve different aspects of CaCx screening and control in Uganda. Objective This study aimed to describe stakeholders’ perceptions of the telemedicine system we developed to improve CaCx screening in Uganda. Methods We developed and implemented a smartphone-based telemedicine system for capturing and sharing cervical images and other clinical data, as well as an artificial intelligence model for automatic analysis of images. We conducted focus group discussions with health workers at the screening clinics (n=27) and women undergoing screening (n=15) to explore their perceptions of the system. The focus group discussions were supplemented with field observations and an evaluation survey of the health workers on system usability and the overall project. Results In general, both patients and health workers had positive opinions about the system. Highlighted benefits included better cervical visualization, the ability to obtain a second opinion, improved communication between nurses and patients (to explain screening findings), improved clinical data management, performance monitoring and feedback, and modernization of screening service. However, there were also some negative perceptions. For example, some health workers felt the system is time-consuming, especially when it had just been introduced, while some patients were apprehensive about cervical image capture and sharing. Finally, commonplace challenges in digital health (eg, lack of interoperability and problems with sustainability) and challenges in cancer screening in general (eg, arduous referrals, inadequate monitoring and quality control) also resurfaced. Conclusions This study demonstrates the feasibility and value of digital health tools in CaCx screening in Uganda, particularly with regard to improving patient experience and the quality of screening services. It also provides examples of potential limitations that must be addressed for successful implementation.

High-risk human papillomavirus testing for underscreened populations: cost-effectiveness and affordability in three country settings

The high-risk human papillomavirus (hrHPV)-based screening recommended by the World Health Organization is expected to lead to worldwide reduction of the cervical cancer burden, but the countries burdened most by cervical cancer also struggle with the costs of transitioning to this approach. Country-specific evaluations are needed to inform policymakers on implementation of hrHPV-based screening for their setting. Following initial implementation in Uganda, Bangladesh and Slovakia focused on underscreened women in the PRESCRIP-TEC project, we investigated the potential cost-effectiveness and affordability of hrHPV-based screening strategies. Country-specific model-based cost-effectiveness and budget impact analyses were conducted for the three countries, comparing the PRESCRIP-TEC strategy with the existing screening strategy in each setting. Data from initial project implementation informed the relevant model parameters. The PRESCRIP-TEC strategy resulted in disability-adjusted life year (DALY) gains in all three countries. The cervical cancer incidence rate was reduced by a third for Uganda, 15% for Bangladesh and 11% for Slovakia. The incremental cost-effectiveness ratios were UGX 0.56 million per DALY for Uganda (I$ 475), BDT 76 thousand per DALY for Bangladesh (I$ 1698) and EUR 1782 (I$ 3637) per DALY for Slovakia. Substantial additional funding will be required to enable implementation, particularly in relation to the initial start-up costs. The provided estimates can serve to inform policymakers and researchers in the context of implementing hrHPV-based screening in diverse settings.

High-risk human papillomavirus testing for cervical cancer screening in Uganda: Considering potential harms and benefits in a low-resource setting

Objectives The World Health Organization supports both the screen-and-treat (ST) approach and the screen, triage and treat (STT) approach to cervical cancer screening using high-risk human papillomavirus (hrHPV) testing. For Uganda, the sequence of hrHPV-ST and hrHPV-STT could be similar, with visual inspection with acetic acid (VIA) after positive hrHPV tests in both. To consider potential tradeoffs (overtreatment in ST versus missed cancer cases in STT), we compared hrHPV-STT with VIA triage (STT-VIA), and STT with HPV 16/18 genotyping risk stratification, to hrHPV-ST for Uganda, in terms of overtreatment, cervical cancer incidence, and life years, for the general female population of Uganda. Methods A microsimulation model of cervical cancer was adapted. Incremental benefit-harm ratios of STT were calculated as ratios of prevented overtreatment to reduced life years, and to increased cancer cases. Additional scenarios with 20% difference in intra- and inter-screening follow-up between ST and STT were modeled. Results Both STT strategies resulted in life year losses on average compared to ST. STT-VIA prevented more overtreatment but led to increased cervical cancer incidence and life year losses. STT-G-VIA resulted in better harm-benefit ratios and additional costs. With better follow-up, STT prevented overtreatment and improved outcomes. Discussion For Uganda, the STT approach appears preferrable, if the screening sequences of hrHPV-based ST and STT are similar in practice. While VIA triage alone would reduce overtreatment the most, it could also result in more cancer cases. Risk stratification via genotyping could improve STT. Potential follow-up differences and resource availability should be considered by decision-makers when planning Uganda’s hrHPV-based screening strategy.