BMJ Global Health

Worldwide burden of cervical human papillomavirus (HPV) in women over 50 years with abnormal cytology: a systematic review and meta-analysis

Introduction More than half of global cervical cancer cases occur among women older than 50. However, global estimates regarding the human papillomavirus (HPV) prevalence among this population are lacking, especially for women with abnormal cytology. Therefore, we conducted a systematic review and meta-analysis to estimate the worldwide HPV prevalence in women aged 50 and older with abnormal cytology. Methods We searched PubMed, Scopus and Web of Science for quantitative studies reporting any or high-risk (HR)-HPV prevalence for women 50 years and older with abnormal cytology (atypical squamous cells of undetermined significance and higher). We extracted data on world region, subregion, cervical lesion type, recruitment setting, HPV test, year of study conduct and HPV prevalence from the included studies. We assessed the risk of bias of the included studies using a modified Newcastle-Ottawa scale. We estimated the pooled prevalence and 95% CIs of any-HPV and HR-HPV using random-effects models, considering the world regions. Additionally, we estimated the prevalence by HPV type, lesion type and age groups. Results Overall, 113 studies met the inclusion criteria, of which 104 were included in the meta-analysis. Among women aged 50 and older with abnormal cytology, the estimated global pooled prevalence of any-HPV from 53 studies, including 14 585 women, was 54.5% (95%CI, 46.0 to 62.8%), and the HR-HPV prevalence from 85 studies, covering 33 672 women, was 43.0% (95%CI, 36.6 to 49.5%). There was a higher HR-HPV prevalence among women with high-grade lesions and women living in the African continent. No major differences in HR-HPV prevalence between the age groups of women over 50 years were found. The most common single HPV types worldwide were 16 and 52, with pooled prevalence estimates of 12.0% (95%CI, 8.0% to 17.7%) and 8.4% (95%CI, 4.4% to 15.4%), respectively. Conclusion Our findings highlight the relevance of targeted screening interventions among women 50 years and older. To achieve the elimination of cervical cancer, age-inclusive screening strategies should be considered. PROSPERO registration number CRD42021241365.

Time to diagnosis for breast, cervical and colorectal cancer in Zimbabwe and South Africa: a cross-sectional study

Introduction Shorter time to diagnosis may lead to better cancer outcomes in Southern Africa. This study measured the time from symptoms to first healthcare visit (patient interval; PI) and diagnosis (diagnostic interval; DI) and associated factors for breast, cervical and colorectal cancer in Zimbabwe and South Africa (SA). Methods A cross-sectional survey collected data on socio-demographics, cancer awareness, barriers to seeking care, symptoms, healthcare visits and diagnosis after recent cancer diagnosis. Cox regression was used to determine factors associated with PI and DI. Results This study included 1021 participants (Zimbabwe 396, SA 625). Symptom and risk factor recall was low. Median PIs were shorter than DIs across cancers and regions. For breast cancer, those reporting more health-seeking barriers had longer PIs (Zimbabwe HR 0.801, 95% CI 0.703 to 0.913; SA HR 0.885, 95% CI 0.817 to 0.958), while greater emotional response to symptoms was associated with a shorter PI (Zimbabwe HR 1.194, 95% CI 1.101 to 1.295; SA HR 1.145, 95% CI 1.079 to 1.216). Interpreting a cervical symptom as serious (Zimbabwe) was associated with a shorter PI. DIs were longer in less-resourced regions and increased with number of healthcare visits before diagnosis. Significantly shorter DIs occurred when the first provider was a clinic doctor or specialist compared with a clinic nurse. Conclusions Efforts to improve timely cancer diagnosis in Zimbabwe and SA should focus on supporting primary healthcare providers in managing and referring symptomatic patients, enhancing cancer symptom awareness and interpretation, and addressing barriers to care.

Participation in cervical cancer screening among migrants and non-migrants in primary healthcare in Lisbon: a register-based study

Introduction Cervical cancer screening is a critical preventive measure to reduce the burden of cervical cancer. Yet, disparities persist worldwide, particularly among migrant populations. This study examined cervical cancer screening participation among migrant and non-migrant women enrolled in the primary healthcare centres in the Lisbon district. Methods This cross-sectional study analysed healthcare records from 88 278 women aged 25–60 years. Participation was assessed based on documented screening within nationally recommended timeframes. Migrants were classified by nationality into Portuguese-speaking and non-Portuguese-speaking groups. Screening participation was compared between groups, adjusting for age, family doctor assignment, primary healthcare unit type and provider gender. Logistic regression identified factors influencing participation. Results Migrants showed lower uptake of cervical cancer screening: 19.6% for non-Portuguese-speaking and 31.9% for Portuguese-speaking migrants, compared with 43.7% in non-migrants. After adjusting for confounders, non-Portuguese-speaking migrants had significantly lower odds of participation (OR 0.46, 95% CI 0.43 to 0.50, p<0.01), while Portuguese-speaking migrants had participation rates similar to non-migrants (p=0.29). Key healthcare factors that were associated with higher participation include enrolment in Family Health Units (FHUs) (OR=3.55, 95% CI 3.41 to 3.70, p<0.01) and having an assigned female family doctor (OR 1.43, 95% CI 1.37 to 1.50, p<0.01). Conclusions Migrant women face unique barriers to cervical cancer screening, particularly language and cultural differences. These findings highlight the need for tailored screening programmes incorporating multilingual support, cultural mediation and self-sampling for human papillomavirus testing as an alternative screening method. Enhancing healthcare delivery through training, improved access to family doctors and more incentive-driven FHUs could significantly improve screening uptake. Addressing these disparities is crucial for advancing health equity and enhancing cervical cancer prevention.

Comparative efficacy, feasibility and acceptability of HPV DNA testing on first-void urine versus self-collected vaginal samples: a real-world study in a resource-limited setting

Introduction Self-sampling for cervical cancer screening is a promising strategy to improve coverage and reduce strain on health systems. First-void urine (FVU) has emerged as a non-invasive alternative to self-collected vaginal samples for detecting high-risk human papillomavirus (HPV). However, most supporting evidence is from colposcopy clinic settings and not from screening settings. This community-based study in Eastern India aimed to (1) assess agreement between HPV testing on FVU and vaginal samples, (2) compare their accuracy in detecting cervical intraepithelial neoplasia grade 2 (CIN2+) lesions and (3) evaluate feasibility and acceptability in a resource-limited setting. Methods At multiple rural clinics, 2500 women aged 30–60 years provided both FVU and self-collected vaginal samples. All samples were tested centrally using the Cobas4800 assay; discordant results were retested with the Allplex HR-HPV assay. HPV-positive women were referred for colposcopy and biopsy. Acceptability and preference were assessed through structured surveys with 1500 women and focus group discussions with health workers. These health workers counselled women at the clinics to provide both self-collected samples. Results All participants provided satisfactory samples, except for two FVU samples, which did not yield satisfactory test results on repeated analysis. Agreement between FVU and vaginal samples for HPV detection was 99.0% (κ=0.90), with high concordance for HPV 16/18 (κ=0.90). CIN2+ detection rates were 6.0 and 7.2 per 1000 women screened with FVU and vaginal samples, respectively (p=0.6), with no statistically significant difference in sensitivity. Among surveyed women, 98.1% preferred urine sampling. Health workers favoured both self-sampling methods over speculum-based clinician collection. Conclusion HPV testing using FVU demonstrates high agreement with vaginal self-sampling, comparable accuracy in detecting CIN2+ lesions and greater acceptability among women. This method is feasible and well-suited for cervical cancer screening in resource-limited settings.

Intersectional stigma and resilience in the uptake of cervical cancer prevention services in Nigeria: a qualitative study

Background Cervical cancer is one of the leading causes of death among women in Africa, but stigma often delays cervical cancer prevention. We explore the perceptions, enablers and nurturers through the lens of intersectional stigma in the uptake of cervical cancer prevention services in Nigeria. Method Indepth interviews and focus group discussions were conducted among women aged 30–65 years and girls aged 9–26 years in Lagos, Nigeria. Data were analysed thematically. Using the relationships and expectation domain of the PEN-3 cultural model, we identified perceptions, enablers and nurturers related to the uptake of primary and secondary cervical cancer prevention services in Nigeria. We also explored how social identities may intersect with health-related stigmas and affect the uptake of these services. Result We interviewed 31 women and 31 girls. 61% of the participants were Christians and 39% were Muslims and were from the three major ethnic groups in Nigeria: Igbo (34%), Hausa (38%) and Yoruba (28%). Themes emerging from the data: (1) positive perceptions (self-efficacy): many women understood the importance of protecting themselves and their daughters from cervical cancer and strongly believed that they could educate their partners/husbands and would not let other people’s experiences with the vaccine influence them negatively. (2) Negative perceptions (anticipated stigma): some women expressed that because the human papillomavirus that causes cervical cancer is mainly sexually transmitted, they were concerned that they may be perceived as being promiscuous if they decide to commence routine cervical cancer screening. (3) Enablers (social support): nearly all women wanted the support of their spouses before receiving cervical cancer screening. (4) Nurturers (resilience): many clearly understood the complex social and economic realities faced by Nigerians that negatively affect their access to healthcare. Conclusion These findings offer intersectional insights into advancing public health and culturally anchored interventions to preventing cervical cancer-related stigma in Nigeria.

Long-term outcomes after cervical cancer screening in El Salvador: primary human papillomavirus screen-and-treat compared with cytology

Introduction From 2012 to 2017, the Cervical Cancer Prevention in El Salvador (CAPE) piloted and scaled up a human papillomavirus (HPV) screen-and-treat intervention. Findings resulted in El Salvador’s adoption of the strategy as part of the national programme, but long-term clinical outcomes are unknown. Here, we compare the detection of high-grade cervical intraepithelial neoplasia grade 2 or higher (CIN2+) and HPV infection after recommended screening intervals between two groups: women who participated in CAPE and a comparable group screened via cytology. Methods CAPE participants who had undergone screening at least 5 years previously (screen-and-treat group) and women in the same age range with conventional cytology screening 2 to 3 years previously (cytology group) were recruited for repeat screening with primary HPV testing. Women with positive HPV results were referred for colposcopy and cervical biopsy to determine further management. Women with negative HPV results received recommendations for routine future screening according to national guidelines. Results A total of 6631 women were enrolled (screen-and-treat = 4087; cytology=2544). Significantly less CIN2+ was detected in the screen-and-treat group at 0.7% (29/4087) than in the cytology group at 2.1% (54/2544) (p<0.001) with a risk ratio of 0.41 (95% CI 0.26 to 0.61). HPV positivity was also lower in the screen-and-treat group at 9.5% (388/4077) compared with the cytology group at 11.5% (293/2445) (p=0.008). Conclusion At the first round of repeat screening after the implementation of CAPE, women who underwent HPV testing in a screen-and-treat strategy had significantly less CIN2+ and HPV positivity compared with those who underwent cytology. These outcomes occurred despite a longer screening interval for HPV testing than cytology. Findings provide reassurance for women and health systems that primary HPV screen-and-treat programmes with extended screening intervals, like the one in El Salvador, are achievable and effective in low- and middle-income settings.

Early experience scaling up a breast cancer early detection initiative integrated with cervical cancer screening in Rwanda

Background Late-stage breast cancer contributes to a growing number of deaths in sub-Saharan Africa (SSA) but few studies examine scalable early detection strategies. Following small-scale pilots, in 2020 Rwanda launched an adapted Women’s Cancer Early Detection Programme (WCEDP), integrating clinical breast exam (CBE) for symptomatic patients with cervical cancer screening. A WCEDP-specific electronic health record (EHR) was developed to facilitate patient tracking. Methods We used the RE-AIM implementation science framework to retrospectively evaluate implementation of breast cancer early detection within the WCEDP over 12 months in the first three scale-up districts (population: 2 009 888), using routinely-collected electronic and paper data from 15 health centres and 3 hospitals. We examined the WCEDP’s Reach in the target population, Effectiveness linking patients to care, Adoption by facilities and fidelity to the Implementation protocol. Results Regarding Reach, average weekly health centre visits for CBE increased from 18 to 33 post-WCEDP launch; of 1688 women receiving CBE through the WCEDP, 12.0% were ≥50 years. Regarding effectiveness, among 383 women referred to district or referral hospitals, 157 (40.9%) had no documented referral facility visit. Of those seen at a referral facility, median days from health centre to district hospital visit and from district to referral hospital visit were 6 (IQR 1.8–14.8) and 8 (IQR 5.0–40.5) respectively. Among the 36 patients receiving biopsy, 72.2% were biopsied within 60 days of initial presentation. In terms of adoption, 79 clinicians were trained in cancer early detection, with 69.6% remaining at WCEDP facilities after 3 years. Regarding implementation fidelity, WCEDP clinics were held 52.6% of weeks. EHR data quality was inconsistent, with half of patients seen at district hospitals for breast care lacking EHR documentation. Interpretation Breast cancer early detection services can be implemented in resource-constrained SSA health facilities. Integration with cervical cancer screening may be a promising strategy. However, investing in data systems is critical to support programme evaluation and high-quality care.

The role of non-medical providers in increasing access to cervical screening: a scoping review

Introduction Involving non-medical providers (NMPs) in cervical screening interventions could be a promising strategy to increase cervical screening participation among never or underscreened populations. We undertook a scoping review of published literature to explore the potential role of NMPs in increasing cervical screening participation. Methods We searched three databases (MEDLINE, EMBASE and CINAHL) to identify relevant scientific research articles published between 2016 and 2024 and extracted data using a standardised extraction tool. Results Our review identified 35 studies (randomised controlled trials (RCTs): n=12, non-RCTs: n=23) from a breadth of geographical and country-level income settings including Australia and New Zealand (n=3), Africa (n=7), Asia (n=4), Europe (n=3) and North (n=15) and South (n=3) America. NMPs in the included studies were community health workers, nurses and midwives; and their key roles involved identifying and recruiting target populations, delivering health education and raising awareness of cervical screening, facilitating self-sampling and providing navigation and follow-up assistance. Most studies included screening participants aged ≥30 years, who were underscreened, not pregnant, from ethnic minority populations, and living in rural or remote communities. NMP-facilitated cervical screening interventions were largely feasible and acceptable among target populations. Compared with the standard of care, which did not involve NMPs, NMP-facilitated interventions generally demonstrated an increased uptake of cervical screening in RCTs (n=11 out of 12) with relative increases ranging from 1.11 to 42.73. In four RCTs, where NMPs facilitated self-sampling, cervical screening uptake rates ranged from 32.0% to 81.0%. Most non-RCTs (n=18) involved NMPs in facilitating self-sampling, with screening uptake rates ranging from 9.0% to 100.0%. Key strategies identified were capacity-building of NMPs through training, and employing outreach strategies to reach underscreened women. Conclusion NMPs could play a wider and an important role in cervical screening, particularly in the context of self-sampling and have the potential to increase access and equity in cervical screening.

The relationship between rural residence and cervical cancer screening in three sub-Saharan countries with different national screening policies

Purpose To compare cervical cancer screening prevalence between urban and rural women aged 30–49 years in three sub-Saharan African countries chosen by their country-specific screening strategy (Burkina Faso, which has a systematic population-based cervical cancer screening programme in place; Tanzania, where opportunistic screening options only are implemented; and Ghana, which has implemented neither one). Methods We used the most recent Demographic and Health Surveys data from Burkina Faso, Ghana and Tanzania. We restricted our analysis to women aged 30–49 eligible for cervical cancer screening and categorised them by their place of residence as urban or rural. We calculated screening proportions using country-specific survey weights to estimate the absolute prevalence difference in cervical cancer screening between urban/rural residents. Results Rural participants represented 69.5% in Burkina Faso, 64.6% in Tanzania and 42.8% in Ghana. Burkina Faso women reported higher cervical cancer screening prevalence at 19.9%, and Ghana participants reported the lowest at 7.4%. Compared with urban participants, rural women screened less across countries, with an absolute prevalence difference in screening wider in Tanzania at 13.1% (95% CI 10.6% to 15.7%), followed by Burkina Faso at 11.1% (95% CI 7.7% to 14.6%) and narrower in Ghana at 5.9% (95% CI 4.1% to 7.7%). Conclusion We found a consistently low screening uptake and a screening prevalence gap disfavouring rural women from these three sub-Saharan African countries, with the narrowest urban/rural gap in Ghana and the widest in Tanzania, which has a large opportunistic cervical cancer screening programme. Our findings offer no indication of a potential benefit of having a systematic screening programme as a tool that can mitigate the screening gap between urban and rural populations. Further screening uptake studies, including more countries, are needed on this topic, which should account for the existing country-specific non-screening related factors in the healthcare system that may influence cervical cancer screening uptake.

Harnessing primary healthcare to reduce the burden of cervical cancer in the Eastern Mediterranean Region

Cervical cancer remains a significant public health challenge in the WHO Eastern Mediterranean Region (EMR), with significant implications for women’s health and sustainable development. Despite being largely preventable, the EMR reported high prevalence of new cases and deaths in 2022. The burden is expected to increase by 2050. Primary healthcare (PHC) offers a cost-effective platform for delivering essential health services, such as human papilloma virus vaccination and early detection and referral programmes, which are crucial for reducing cervical cancer incidence and mortality. The paper discusses the role of PHC in cervical cancer interventions, showcasing successful examples from EMR countries and examining barriers like resource constraints, sociocultural factors and systemic inefficiencies. It also proposes solutions, such as enhancing infrastructure and human resources, fostering public–private partnerships and adopting innovative screening methods. By addressing these gaps and leveraging PHC’s potential, EMR countries can improve cervical cancer outcomes and promote health equity for girls and women across the region.

Applying the Information–Motivation–Behavioral Skills model to a video-assisted HPV intervention to promote self-screening uptake: a qualitative study in Western Kenya

Introduction Human papillomavirus (HPV) is the leading source of cervical cancer in Kenya. HPV, like other sexually transmitted infections, is stigmatised, which hinders efforts to address the disease. Education and empowerment are crucial in combating HPV stigma and increasing screening uptake. We conducted qualitative analyses of a video-assisted HPV educational intervention in Kisumu, Kenya to determine its impact on women’s knowledge, motivation and behaviour for HPV and cervical cancer prevention. The stigma-responsive video featured a group discussion with an individual describing her experience with HPV, self-testing and preventive treatment. Methods Three focus group discussions (FGDs) were conducted with 10 women, respectively, ages 30–64, from three intervention clinics, to explore their experience with the video-assisted education, perspectives on HPV and self-sampling, and the feasibility of peer-led education to increase screening and follow-up. The initial codebook was developed prior to the FGDs using an Information–Motivation–Behavioral (IMB) Skills model framework, followed by a rapid analysis to identify missing themes. We conducted qualitative coding using NVivo V.12. The IMB Skills model was used to analyse the codes and findings from the FGDs to assess the impact of the education. Result Women in FGDs identified the lack of community-level knowledge on HPV and the stigma and fear of physical pain from pelvic examination as barriers to HPV screening. Many participants mentioned that the knowledge gained through the video reduced their stigma and fear, and it motivated them to screen. Participants demonstrated behavioural change through self-sampling uptake, community empowerment and referral to watch the video. Conclusion From the FGDs, we found the direct mechanism linking information, motivation and screening behaviour in our video-assisted HPV educational intervention. The intervention improved women’s self-reported HPV-related knowledge and increased their motivation for self-sampling and engagement in preventive behaviours. We recommend scaling up the intervention by bringing the video-assisted education to more clinics in Kisumu.

Longitudinal study on quality of life following cervical cancer treatment in Botswana

Purpose This study longitudinally assessed the quality of life (QoL) in patients who completed chemoradiation (CRT) for cervical cancer in Botswana and compared the QoL for those living with and without HIV infection. Methods Patients with cervical cancer recommended for curative CRT were enrolled from August 2016 to February 2020. The European Organisation for Research and Treatment of Cancer Core Quality-of-Life (QLQ-C30) and cervical cancer-specific (QLQ-Cx24) questionnaires, translated into Setswana, were used to assess the QoL of patients prior to treatment (baseline), at the end of treatment (EOT) and in 3 month intervals post-treatment for 2 years, and statistical analyses were performed. Results A total of 294 women (median age: 46 years) were enrolled and followed up for an average of 16.4 months. Of women with recorded staging, most had FIGO stage III/IV disease (64.4%). Women living with HIV (WLWH; 74.1%) presented at earlier ages than those without HIV (44.8 years vs 54.7 years, p<0.001). The QoL for all domains did not differ by HIV status at baseline, EOT or 24 month follow-up. Per QLQ-C30, the mean global health status score (72.21 vs 78.37; p<0.01) and the symptom (12.70 vs 7.63; p=0.04) and functional scales (88.34 vs 91.85; p<0.01) improved significantly from the EOT to the 24 month follow-up for all patients; however, using the QLQ-Cx24 survey, no significant differences in the symptom burden (12.53 vs 13.67; p=0.6) or functional status (91.23 vs 89.90; p=0.53) were found between these two time points. Conclusion The QoL increased significantly for all patients undergoing CRT, underscoring the value of pursuing curative CRT, regardless of the HIV status.

Health and economic effects of introducing single-dose or two-dose human papillomavirus vaccination in India

Background Cervical cancer is a major public health problem in India, where access to prevention programmes is low. The WHO-Strategic Advisory Group of Experts recently updated their recommendation for human papillomavirus (HPV) vaccination to include a single-dose option in addition to the two-dose option, which could make HPV vaccination programmes easier to implement and more affordable. Methods We combined projections from a type-specific HPV transmission model and a cancer progression model to assess the health and economic effects of HPV vaccination at national and state level in India. The models used national and state-specific Indian demographic, epidemiological and cost data, and single-dose vaccine efficacy and immunogenicity data from the International Agency for Research on Cancer India vaccine trial with 10-year follow-up. We compared single-dose and two-dose HPV vaccination for a range of plausible scenarios regarding single-dose vaccine protection, coverage and catch-up. We used a healthcare sector payer perspective with a time horizon of 100 years. Results Under the base-case scenario of lifelong protection of single-dose vaccination in 10-year-old girls with 90% coverage, the discounted incremental cost-effectiveness ratio (ICER) of nationwide vaccination relative to no vaccination was US$406 (₹INR30 000) per DALY (disability-adjusted life-years) averted. This lay below an opportunity-cost-based threshold of 30% Indian gross domestic product per capita in each Indian state (state-specific ICER range: US$67–US$593 per DALY averted). The ICER of two-dose vaccination versus no vaccination vaccination was US$1404 (₹INR104 000). The ICER of two-dose vaccination versus single-dose vaccination, assuming lower initial efficacy and waning of single-dose vaccination, was at least US$2282 (₹INR169 000) per DALY averted. Conclusions Nationwide introduction of single-dose HPV vaccination at age 10 in India is highly likely to be cost-effective whereas extending the number of doses from one to two would have a less favourable profile.

WHO should adjust its global strategy for cervical cancer prevention

Temporal trends in cervical cancer incidence and mortality in economically emerging countries, 1992–2021: an age-period-cohort analysis

Introduction The economically emerging countries contributed to over half of the global cervical cancer (CC) burden and are good examples showing how rapid economic growth and health policy change affect the trends of CC burden. This study aimed to analyse the time trends of CC burden across Brazil, Russia, India, China and South Africa (BRICS) and associations with age, period and birth cohort from 1992 to 2021. Methods Data on CC incident cases, deaths, age-standardised incidence rates (ASIRs) and age-standardised mortality rates (ASMRs) were sourced from the Global Burden of Disease Study 2021 to demonstrate the temporal trends of CC burden for BRICS countries from 1992 to 2021. An age-period-cohort model was used to determine the net drift, local drift, longitudinal age curves, as well as period and cohort relative risks regarding CC incidence and mortality. Results Between 1992 and 2021, the ASIR of CC decreased from 16.5 to 15.6 per 100 000 women (−5.5%) and the ASMR declined from 10.1 to 6.7 per 100 000 women (−33.7%) in BRICS. Brazil reported continuous decreases in both CC incidence (net drift: −1.1%, 95% CI −1.1% to −1.0%) and mortality (net drift: −1.7%, 95% CI −1.80% to −1.6%). India also had reduced CC incidence and mortality but experienced worsening period effects from 2012 onwards. Russia and China experienced decreasing trends in mortality yet increasing trends in incidence, and there were apparent unfavourable trends among young and middle-aged women in Russia. South Africa maintained the highest CC incidence (40.0 per 100 000 women, 95% CI 35.0 to 45.6) and mortality (21.3 per 100 000 women, 95% CI 18.8 to 24.1) across the BRICS and had the steepest growth of CC incidence and mortality rates with increasing age. Conclusion Despite an overall decreasing trend of CC burden in BRICS, substantial heterogeneity exists across nations. Identifying country-specific priority groups and tailoring interventions is essential, and the patterns observed have implications for public health strategies applicable not just to BRICS nations but also to many other emerging economies facing substantial CC burden.

The impact of scaling up cervical cancer screening and treatment services among women living with HIV in Kenya: a modelling study

Introduction We aimed to quantify health outcomes and programmatic implications of scaling up cervical cancer (CC) screening and treatment options for women living with HIV in care aged 18–65 in Kenya. Methods Mathematical model comparing from 2020 to 2040: (1) visual inspection with acetic acid (VIA) and cryotherapy (Cryo); (2) VIA and Cryo or loop excision electrical procedure (LEEP), as indicated; (3) human papillomavirus (HPV)-DNA testing and Cryo or LEEP; and (4) enhanced screening technologies (either same-day HPV-DNA testing or digitally enhanced VIA) and Cryo or LEEP. Outcomes measured were annual number of CC cases, deaths, screening and treatment interventions, and engaged in care (numbers screened, treated and cured) and five yearly age-standardised incidence. Results All options will reduce CC cases and deaths compared with no scale-up. Options 1–3 will perform similarly, averting approximately 28 000 (33%) CC cases and 7700 (27%) deaths. That is, VIA screening would yield minimal losses to follow-up (LTFU). Conversely, LTFU associated with HPV-DNA testing will yield a lower care engagement, despite better diagnostic performance. In contrast, option 4 would maximise health outcomes, averting 43 200 (50%) CC cases and 11 800 (40%) deaths, given greater care engagement. Yearly rescreening with either option will impose a substantial burden on the health system, which could be reduced by spacing out frequency to three yearly without undermining health gains. Conclusions Beyond the specific choice of technologies to scale up, efficiently using available options will drive programmatic success. Addressing practical constraints around diagnostics’ performance and LTFU will be key to effectively avert CC cases and deaths.

HPV self-sampling for cervical cancer screening: a systematic review of values and preferences

Introduction The WHO recommends human papillomavirus (HPV) cervical self-sampling as an additional screening method and HPV DNA testing as an effective approach for the early detection of cervical cancer for women aged ≥30 years. This systematic review assesses end user’s values and preferences related to HPV self-sampling. Methods We searched four electronic databases (PubMed, Cumulative Index to Nursing and Allied Health Literature, Latin American and Caribbean Health Sciences Literature and Embase) using search terms for HPV and self-sampling to identify articles meeting inclusion criteria. A standardised data extraction form was used to capture study setting, population, sample size and results related to values and preferences. Results Of 1858 records retrieved, 72 studies among 52 114 participants published between 2002 and 2018 were included in this review. Almost all studies were cross-sectional surveys. Study populations included end users who were mainly adolescent girls and adult women. Ages ranged from 14 to 80 years. Most studies (57%) were conducted in high-income countries. Women generally found HPV self-sampling highly acceptable regardless of age, income or country of residence. Lack of self-confidence with collecting a reliable sample was the most commonly cited reason for preferring clinician-collected samples. Most women preferred home-based self-sampling to self-sampling at a clinic. The cervical swab was the most common and most accepted HPV DNA sampling device. Conclusions HPV self-sampling is generally a highly accepted method of cervical cancer screening for end users globally. End user preferences for self-sampling device, method and setting can inform the development of new and expanded interventions to increase HPV screening.

Tracking progress towards universal health coverage for essential health services in China, 2008–2018

Introduction We comprehensively evaluate whether the Chinese Government’s goal of ensuring Universal Health Coverage for essential health services has been achieved. Methods We used data from the 2008, 2013 and 2018 National Health Services Survey to report on the coverage of a range of Sustainable Development Goals (SDG) indicator 3.8.1. We created per capita household income deciles for urban and rural samples separately. We report time trends in coverage and the slope index (SII) and relative index (RII). Results Despite much lower levels of income and education, rural populations made as much progress as their urban counterparts for most interventions. Coverage of maternal and child health interventions increased substantially in urban and rural areas, with decreasing rich-poor inequalities except for antenatal care. In rural China, one-fifth women could not access 5 or more antenatal visits. Coverage of 8 or more visits were 34% and 68%, respectively in decile D1 (the poorest) and decile D10 (the richest) (SII 35% (95% CI 22% to 48%)). More than 90% households had access to clean water, but basic sanitation was poor for rural households and the urban poorest, presenting bottom inequality. Effective coverage for non-communicable diseases was low. Medication for hypertension and diabetes were relatively high (>70%). But adequate management, counting in preventive interventions, were much lower and decreased overtime, although inequalities were small in size. Screening of cervical and breast cancer was low in both urban and rural areas, seeing no progress overtime. Cervical cancer screening was only 29% (urban) and 24% (rural) in 2018, presenting persisted top inequalities (SII 25% urban, 14% rural). Conclusion China has made commendable progress in protecting the poorest for basic care. However, the ‘leaving no one behind’ agenda needs a strategy targeting the entire population rather than only the poorest. Blunt investing in primary healthcare facilities seems neither effective nor efficient.

Towards the elimination of cervical cancer in low-income and lower-middle-income countries: modelled evaluation of the effectiveness and cost-effectiveness of point-of-care HPV self-collected screening and treatment in Papua New Guinea

Introduction WHO has launched updated cervical screening guidelines, including provisions for primary HPV screen-and-treat. Papua New Guinea (PNG) has a high burden of cervical cancer, but no national cervical screening programme. We recently completed the first field trials of a screen-and-treat algorithm using point-of-care self-collected HPV and same-day treatment (hereafter self-collected HPV S&T) and showed this had superior clinical performance and acceptability to visual inspection of the cervix with acetic acid (VIA). We, therefore, evaluated the effectiveness, cost-effectiveness and resource implications of a national cervical screening programme using self-collected HPV S&T compared with VIA in PNG. Methods An extensively validated platform (‘Policy1-Cervix’) was calibrated to PNG. A total of 38 strategies were selected for investigation, and these incorporated variations in age ranges and screening frequencies and allowed for the identification of the optimal strategy across a wide range of possibilities. A selection of strategies that were identified as being the most effective and cost-effective were then selected for further investigation for longer-term outcomes and budget impact estimation. In the base case, we assumed primary HPV testing has a sensitivity to cervical intraepithelial neoplasia 2 (CIN2+) + of 91.8% and primary VIA of 51.5% based on our earlier field evaluation combined with evidence from the literature. We conservatively assumed HPV sampling and testing would cost US$18. Costs were estimated from a service provider perspective based on data from local field trials and local consultation. Results Self-collected HPV S&T was more effective and more cost-effective than VIA. Either twice or thrice lifetime self-collected HPV S&T would be cost-effective at 0.5× gross domestic product (GDP) per capita (incremental cost-effectiveness ratio: US$460–US$656/life-years saved; 1GDPper-capita: US$2829 or PGK9446 (year 2019)) and could prevent 33 000–42 000 cases and 23 000–29 000 deaths in PNG over the next 50 years, if scale-up reached 70% coverage from 2023. Conclusion Self-collected HPV S&T was effective and cost-effective in the high-burden, low-resource setting of PNG, and, if scaled-up rapidly, could prevent over 20 000 deaths over the next 50 years. VIA screening was not effective or cost-effective. These findings support, at a country level, WHO updated cervical screening guidelines and indicate that similar approaches could be appropriate for other low-resource settings.