Abstract
ObjectiveTo assess triage compliance and the effect of the time from screening to triage on follow-up among HPV-positive women.MethodsWe recruited 1232 women in a screening campaign in Madagascar from February to October 2015. In the first period (February–May), HPV tests were performed remotely using the cobas test. In the second period (May–October), testing was performed on-site using the Xpert HPV assay. HPV-positive women were invited for triage with visual inspection with acetic acid (VIA) and Lugol’s iodine (VILI). Systematic biopsy and endocervical brushing were performed on all HPV-positive women for quality control. Three groups were defined according to time from HPV testing to triage invitation for HPV-positive women—Group I: delayed (> 3 months), Group II: prompt (24–48 hours), and Group III: immediate (< 24 hours).ResultsA total 1232 self-sampled HPV tests were performed in the study period (496 in Group I, 512 in Group II, and 224 in Group III). Participants’ mean age was 43.2 ± 9.3 years. Mean time from screening to VIA/VILI testing was 103.5 ± 43.6 days. Overall HPV prevalence was 28.0%. HPV prevalence was 27.2% in Group I (cobas test), 29.2% in Group 2 (Xpert test), and 26,7% in Group III (Xpert test). The VIA/VILI compliance rate was 77.8% for Group I, 82.7% for Group II, and 95.0% for Group III. Of women undergoing VIA/VILI, 56.3% in Group I and 43.5% in Groups II/III had positive results. Prevalence of cervical intraepithelial neoplasia grade 2 or worse among HPV-positive women was 9.8% for Group I and 6.8% for Groups II/III. Non-adherence was higher among rural women, uneducated women, and women in Group I.ConclusionHPV-positive women with immediate VIA/VILI triage invitation had the best triage compliance. A single-day test and triage strategy is preferred for low-resource settings.
Highlights
Cervical cancer (CC) is the third most common cause of cancer mortality in lower-middleincome countries (LMIC) [1]
A total 1232 self-sampled Human papillomavirus (HPV) tests were performed in the study period (496 in Group I, 512 in Group II, and 224 in Group III)
A 2015 meta-analysis of 29 studies on visual inspection with acetic acid (VIA) and 19 studies on VILI reported the sensitivity for detecting cervical intraepithelial neoplasia grade 2 or worse (CIN2+) to be 73.2% for VIA and 88.1% for VILI [7]
Summary
Cervical cancer (CC) is the third most common cause of cancer mortality in lower-middleincome countries (LMIC) [1]. Approximately 311,000 women died from CC in 2018, with deaths in LMIC accounting for 85% of this Fig 2. In sub-Saharan Africa, in particular, CC is the most common cancer among women, mainly because of difficulties in implementing screening and treatment services [4,5]. CC ranks as the most frequent cancer among women in Madagascar. Visual inspection of the cervix with acetic acid (VIA) and Lugol’s iodine (VILI) is the nationally recommended approach for CC screening in Madagascar, as is the case in most LMIC. VIA/VILI has the advantages of being low-cost and providing immediate results, allowing screening and treatment during the same visit [6]. Quality indicators should focus on screening rate, positivity rate, treatment rate, and coverage rate [9]
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