Elimination Of Cervical Cancer Research Articles

Economic consequences of the implementation of primary DNA-HPV genotype testing in Bulgaria

There is a global call for action for cervical cancer elimination as a public health problem—WHO Strategy 90-70-90. One of the strategic pillars, alongside vaccination, is cervical cancer screening. This aims to assess the economic consequences and cost-effectiveness of primary DNA-HPV testing for cervical cancer screening in Bulgaria. Combined cost-effectiveness (CEA) and cost-benefit (CBA) analysis was performed to evaluate the net benefit of the HPV genotype testing program among women aged 30–54 in Bulgaria and to compare its cost-effectiveness with the current practice. ICER was presented separately for only direct costs and direct + indirect costs. The CBA analysis for the age group 30-54 shows that the benefit/cost ratio of DNA-HPV primary screening is 1.03 and the net present benefit accounts for 373,023 euro thus making the program beneficial for the healthcare system. CEA shows that HPV screening is cost-effective over the current practice of PAP testing with ICER 1634 euro/LYG when considering only direct costs and—8020 euro/LYG for direct and indirect costs. The ICER in terms of the sensitivity rate of the testing methods is 1316 euros. The LYG earned with the HPV testing account for 4989 for the observed women. Primary hrHPVDNA-based screening is an important scientific and clinical advance since it offers better reassurance of low cancer risk compared to cytology-only screening conducted at the same interval. Primary hrHPV screening can be considered as a dominant alternative to current cytology-based cervical cancer screening approaches including cytology alone and contesting and providing better benefit.

Expert recommendation for real-world study on the application of human papillomavirus vaccine in the Yangtze River Delta region

Cervical cancer has become a global public health problem that poses a serious threat to women's health. Human papillomavirus (HPV) vaccination is an important primary preventive measure for cervical cancer. With the accelerated application of the HPV vaccine in China, conducting real-world studies (RWS) on the application of HPV vaccines can guide the rational use of the vaccine, which is of great significance for the strategy and practice of accelerating the elimination of cervical cancer in China. The Yangtze River Delta Cervical Cancer and Female Lower Genital Tract Infection Prevention and Control Alliance and Yangtze River Delta Immunization Integration Working Group organized an expert group to develop the "Expert recommendation for real-world study on the application of HPV vaccine in the Yangtze River Delta region". Based on the current situation of medical informatization and HPV vaccination administration in China, as well as literature and cases from domestic and international studies, this study describes the data chain of HPV vaccination and evaluation, introduces the study design, study direction, database construction, data governance and statistical analysis of RWS, and provides expert recommendation on the problems in carrying out the practice of HPV vaccine RWS, aiming to guide the RWS of HPV vaccine application and promote the generation of real-world evidence (RWE) in China.

Concomitant human papillomavirus (HPV) vaccination and screening for elimination of HPV and cervical cancer.

HPV vaccination with concomitant HPV-based screening of young women has been proposed for faster cervical cancer elimination. We describe the baseline results of a population-based trial of this strategy to reduce the incidence of HPV. All 89,547 women born 1994-1999 and resident in the capital region of Sweden were personally invited to concomitant HPV vaccination and HPV screening with 26,125 women (29.2%) enrolled between 2021-05-03 and 2022-12-31. Baseline HPV genotyping of cervical samples from the study participants finds, compared to pre-vaccination prevalences, a strong decline of HPV16 and 18 in birth cohorts previously offered vaccination, some decline for cross-protected HPV types but no decline for HPV types not targeted by vaccines. Our dynamic transmission modelling predicts that the trial could reduce the incidence of high-risk HPV infections among the 1994-1998 cohorts by 62-64% in 3 years. Baseline results are prevalences of HPV infection, validated transmission model projections, and power estimates for evaluating HPV incidence reductions at follow-up (+/-0.1% with 99.9% confidence). In conclusion, concomitant HPV vaccination and HPV screening appears to be a realistic option for faster cervical cancer elimination. Clinicaltrials.gov identifier: NCT04910802; EudraCT number: 2020-001169-34.

Impact of interventions to improve HPV vaccination acceptance and uptake in school-based programs: Findings of a pilot project in Quebec

ContextVaccination coverage against human papillomavirus (HPV) in school-based programs in Quebec, Canada, is suboptimal despite more than a decade of introduction. Three interventions to improve HPV vaccine acceptability and coverage in school-based programs were developed, implemented as part of a multicomponent strategy and evaluated. MethodSixty-four (64) schools were recruited, of which 32 received the interventions (pilot schools), and 32 received usual vaccination activities (control schools). Two approaches were used to assess the impact of the interventions. Pre-post questionnaires were completed by parents in both pilot and control schools. Quantitative analyses of vaccination coverage using the Quebec immunization registry were conducted. ResultsParticipating parents (n = 989 in the pre-intervention survey and n = 772 in the post-intervention one) were generally aware of HPV and HPV vaccination. Most parents were confident about vaccination, had little or no hesitation and had decided to have their child vaccinated. Parents in the pilot schools were less concerned about vaccine safety than those in the control schools after the interventions. Parents in the pilot schools were also more likely to have decided to have their child vaccinated. A statistically significant difference of 7.4 % in HPV vaccine coverage between pilot and control schools was observed (82.9 % vs 75.5 %, p <0.0001). ConclusionAlthough school-based programs offer equitable access to vaccination and minimize access barriers, it remains crucial to identify effective interventions to improve vaccine uptake further and reach the WHO cervical cancer elimination goal. Our multicomponent strategy appears to have positively impacted HPV vaccine acceptability and coverage and could be adapted to other contexts where vaccination is delivered in school-based programs.

From primary HPV infection to carcinoma in situ: A mathematical approach to cervical intraepithelial neoplasia

AbstractCervical intraepithelial neoplasia (CIN) is the development of abnormal cells on the surface of the cervix, caused by a human papillomavirus (HPV) infection. Although in most of the cases it is resolved by the immune system, a small percentage of people might develop a more serious CIN which, if left untreated, can develop into cervical cancer. Cervical cancer is the fourth most common cancer in women globally, for which the World Health Organization (WHO) recently adopted the Global Strategy for cervical cancer elimination by 2030. With this research topic being more imperative than ever, in this paper, we develop a nonlinear mathematical model describing the CIN progression. The model consists of partial differential equations describing the dynamics of epithelial, dysplastic, and immune cells, as well as the dynamics of viral particles. We use our model to explore numerically three important factors of dysplasia progression, namely, the geometry of the cervix, the strength of the immune response, and the frequency of viral exposure.

Addressing cervical cancer prevention in Bhutan: A study on the use of loop electrosurgical excision procedures at the primary health care level

AbstractBackgroundCervical cancer is the top and fourth leading cause of death among women in Bhutan and worldwide, respectively. The cervical cancer elimination flagship program initiated by the Ministry of Health aims to achieve the 90–70–90 goals by 2030. To achieve this, detection and treatment of pre‐cancerous lesions of the cervix through colposcopy and loop electrosurgical excision procedure (LEEP) are being carried out through the outreach health camps.MethodsThis descriptive study aimed to assess the safety and tolerability of LEEP under local anesthesia and assess the margin status of high‐grade lesion (HGL). We analyzed 193 records of clients who underwent LEEP at Wangdue Phodrang Hospital from 26 September to 5 October 2022. The sociodemographic profile, intraoperative pain, complications, and histopathological reports were described using structured pro forma.ResultsThe mean age of clients was 40.9 ± 8.5 years (range 25–66 years). There were 3.1% who had intraoperative and 2.6% who had postoperative bleeding. There were 18.6% who had foul‐smelling vaginal discharge, and 8.3% had moderate‐to‐severe intraoperative pain. Histopathological assessment revealed 29.5% with chronic cervicitis, 34.2% with HGL, and 1.6% with microinvasive cervical carcinoma. The margin positivity for HGL was 36.4%.ConclusionGiven the safety profile of LEEP under local anesthesia in our setting, the scope of providing a complete cervical cancer screening and treatment package at the primary health care level looks promising. Based on the higher rate of overtreatment and margin positivity, we recommend the practical implementation of standard colposcopy guidelines.

Vaccination and screening strategies to accelerate cervical cancer elimination in Norway: a model-based analysis.

Experts have proposed an 'EVEN FASTER' concept targeting age-groups maintaining circulation of human papillomavirus (HPV). We explored effects of the vaccination component of these proposals compared with cervical cancer (CC) screening-based interventions on age-standardized incidence rate (ASR) and CC elimination (<4 cases/100,000) timing in Norway. We used a model-based approach to evaluate HPV vaccination and CC screening scenarios compared with a status-quo scenario reflecting previous vaccination and screening. For cohorts ages 25-30 years, we examined 6 vaccination scenarios that incrementally increased vaccination coverage from current cohort-specific rates. Each vaccination scenario was coupled with three screening strategies that varied screening frequency. Additionally, we included 4 scenarios that alternatively increased screening adherence. Population- and cohort-level outcomes included ASR, lifetime risk of CC, and colposcopy referrals. Several vaccination strategies coupled with de-intensified screening frequencies lowered ASR, but did not accelerate CC elimination. Alternative strategies that increased screening adherence could both accelerate elimination and improve ASR. The vaccination component of an 'EVEN FASTER' campaign is unlikely to accelerate CC elimination in Norway but may reduce population-level ASR. Alternatively, targeting under- and never-screeners may both eliminate CC faster and lead to greater health benefits compared with vaccination-based interventions we considered.

Projected Time for the Elimination of Cervical Cancer Under Various Intervention Scenarios: Age-Period-Cohort Macrosimulation Study.

The World Health Organization aims for the global elimination of cervical cancer, necessitating modeling studies to forecast long-term outcomes. This paper introduces a macrosimulation framework using age-period-cohort modeling and population attributable fractions to predict the timeline for eliminating cervical cancer in Taiwan. Data for cervical cancer cases from 1997 to 2016 were obtained from the Taiwan Cancer Registry. Future incidence rates under the current approach and various intervention strategies, such as scaled-up screening (cytology based or human papillomavirus [HPV] based) and HPV vaccination, were projected. Our projections indicate that Taiwan could eliminate cervical cancer by 2050 with either 70% compliance in cytology-based or HPV-based screening or 90% HPV vaccination coverage. The years projected for elimination are 2047 and 2035 for cytology-based and HPV-based screening, respectively; 2050 for vaccination alone; and 2038 and 2033 for combined screening and vaccination approaches. The age-period-cohort macrosimulation framework offers a valuable policy analysis tool for cervical cancer control. Our findings can inform strategies in other high-incidence countries, serving as a benchmark for global efforts to eliminate the disease.

2024 Updates to Cervical Cancer Screening in Canada

The landscape of cervical cancer screening in Canada is about to undergo a major shift from cytology-based screening to testing directly for the presence of high-risk strains of the human papilloma virus (HPV), the persistence of which is known to be a prerequisite for the development of almost all cases of cervical cancer. In 2018, the World Health Organization declared a call to action for the worldwide elimination of cervical cancer by 2040. Subsequently the Canadian Partnership Against Cancer (CPAC) released an action plan outlining the necessary steps for Canada to reach this goal. One of the 3 major priorities identified in the action plan is the transition to primary HPV testing. This transition from screening to testing represents a major shift in infrastructure and also a shift in mindset for clinicians, policymakers, and the public. To help guide this transition, CPAC has collaborated with the Gynecologic Oncology Society of Canada (GOC) and the Society of Canadian Colposcopists (SCC) to release two open-access, evidence‑based guidelines in June 2023. These guidelines address how to manage a positive HPV screening test, and colposcopy in the context of primary HPV‑screening. This paper will outline the evolution of cervical cancer screening in Canada along with the rationale behind the transition to HPV testing. Also included is a discussion on the broad recommendations from the 2023 CPAC/GOC/SCC guidelines, as well as recommendations for age and interval of screening and special populations. Readers of this article in e-journal format can access the Canadian Guideline on the Management of a Positive Human Papillomavirus Test and Guidance for Specific Populations here. Readers may also access the 2023 Canadian Colposcopy Guideline: A Risk-Based Approach to Management and Surveillance of Cervical Dysplasia here.

Elimination of Cervical Cancer in Low-and Middle-Income Countries: Any Alternative to Pap Smear?

Elimination of Cervical Cancer in Low-and Middle-Income Countries: Any Alternative to Pap Smear?

Abstract 4805: Identifying neighborhood hot spots of HPV-associated cancers for targeted interventions of HPV vaccination uptake in underserved communities of South Florida

Abstract Background: Although the incidence of cervical cancer in the US has declined, the incidences of other HPV-associated cancers are on the rise. HPV vaccination is an important primary prevention strategy for reducing the burden of HPV-associated cancers. In South Florida (population over 6 million), the percentage of adolescents aged 13-15 years who completed the recommended HPV vaccine series is 54%, which lags significantly behind the Healthy People 2030 target of 80%. In addition, vaccination disparities exist in South Florida by races/ethnicities and sexes, with non-Hispanic black males having the lowest rate at 27%. To address HPV cancer disparities, we performed a geospatial analysis on the incidence of HPV-associated cancers by sex and races/ethnicity to identify communities in South Florida with high incidence of HPV-associated cancer to target interventions that may improve HPV-vaccine uptake via community outreach and engagement. Methods: The average annual (2010-2019) incidence of HPV-associated cancers in women (cervical, oropharyngeal, vulva, vaginal, and anal) and men (oropharyngeal, penile, and anal) were calculated for Hispanics, Non-Hispanic Whites (NHWs) and Non-Hispanic Blacks (NHB) at the census tract level across South Florida using data from the Florida Cancer Data System (FCDS), the state incident cancer registry. Geospatial hot spot analyses were used to identify clusters of census tracts with high HPV cancer incidence by sex and race/ethnicity. Socioeconomic and cervical screening data of the hot spots were analyzed to identify other neighborhood risk conditions that may be associated with high HPV cancer risk. Results: For Hispanics and NHBs in South Florida, census tract hot spots for male and female HPV cancers appear to overlap in low-income neighborhoods; however, hot spots for NHW males are mostly in medium to higher income areas and do not overlap with hot spots observed for NHW females, likely given that NHW females generally report higher cervical screening rates. Conclusion: There is a positive association between male and female HPV cancer incidence in Hispanic and NHB communities of South Florida, justifying the need for increased HPV vaccination and screening programs in these neighborhoods. While increasing cervical screening rate in the hot spot neighborhoods is urgent for cervical cancer control, increasing gender-neutral HPV vaccination uptake in these communities will not only reduce the incidences of male HPV cancers but also help to accelerate cervical cancer elimination by reducing HPV infection. Citation Format: Ming Lee, Sara Parrott, Rebecca Kaiser, Ridhi Vyas, Danielle Gabuzda, Arianna Vazquez, Daniela Flores Quetant, Nancy Elliott, Valerie Bethel, Amanda Rivera, Brandon Mahal, Raymond Balise, Elizabeth Franzmann, Erin Kobetz. Identifying neighborhood hot spots of HPV-associated cancers for targeted interventions of HPV vaccination uptake in underserved communities of South Florida [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4805.

Comparative effectiveness of implementation strategies for Accelerating Cervical Cancer Elimination through the integration of Screen-and-treat Services (ACCESS study): protocol for a cluster randomized hybrid type III trial in Nigeria

BackgroundDespite the increased risk of cervical cancer (CC) among women living with HIV (WLHIV), CC screening and treatment (CCST) rates remain low in Africa. The integration of CCST services into established HIV programs in Africa can improve CC prevention and control. However, the paucity of evidence on effective implementation strategies (IS) has limited the success of integration in many countries. In this study, we seek to identify effective IS to enhance the integration of CCST services into existing HIV programs in Nigeria.MethodsOur proposed study has formative and experimental activities across the four phases of the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework. Through an implementation mapping conducted with stakeholders in the exploration phase, we identified a core package of IS (Core) and an enhanced package of IS (Core+) mostly selected from the Expert Recommendations for Implementing Change. In the preparation phase, we refined and tailored the Core and Core+ IS with the implementation resource teams for local appropriateness. In the implementation phase, we will conduct a cluster-randomized hybrid type III trial to assess the comparative effectiveness of Core versus Core+. HIV comprehensive treatment sites (k = 12) will be matched by region and randomized to Core or Core+ in the ratio of 1:1 stratified by region. In the sustainment phase, we will assess the sustainment of CCST at each site. The study outcomes will be assessed using RE-AIM: reach (screening rate), adoption (uptake of IS by study sites), IS fidelity (degree to which the IS occurred according to protocol), clinical intervention fidelity (delivery of CC screening, onsite treatment, and referral according to protocol), clinical effectiveness (posttreatment screen negative), and sustainment (continued integrated CCST service delivery). Additionally, we will descriptively explore potential mechanisms, including organizational readiness, implementation climate, CCST self-efficacy, and implementation intentions.DiscussionThe assessment of IS to increase CCST rates is consistent with the global plan of eliminating CC as a public health threat by 2030. Our study will identify a set of evidence-based IS for low-income settings to integrate evidence-based CCST interventions into routine HIV care in order to improve the health and life expectancy of WLHIV.Trial registrationProspectively registered on November 7, 2023, at ClinicalTrials.gov no. NCT06128304. https://classic.clinicaltrials.gov/ct2/show/study/NCT06128304

Therapeutic HPV Vaccination: A Strategy for Cervical Cancer Elimination in India

Therapeutic HPV Vaccination: A Strategy for Cervical Cancer Elimination in India

'I was able to make a better decision about my health.' Wāhine experiences of colposcopy at a marae-based health clinic: A qualitative study.

Equitable access to colposcopy services is required if we are to realise the benefit of the introduction of human papilloma virus (HPV) screening in Aotearoa New Zealand. We piloted a community colposcopy clinic, co-located at an urban marae health clinic. To describe the experiences of wāhine (women) attending the marae-based colposcopy clinic. An in-depth reflexive thematic analysis from 34 people's accounts was undertaken. Five themes were identified from the experiences of wāhine attending the clinic. Three themes related to how having a local clinic supported access: everyone was welcoming and friendly, the environment was familiar and non-clinical and the clinic was accessible. The fourth theme related to how this contributed to agency. A fifth theme relates to wāhine views about informing the ongoing provision of colposcopy services. The experiences reflected the principles and values practised at the marae health clinic. Wāhine described feeling cared for as soon as they entered the clinic. As the clinic was local, and for some based at their marae, it was a known space where they knew the experience would be safe. Whānau were welcome with spaces for children to play. Being local meant there were fewer logistics to manage, all of which supported access. Prioritising wāhine through the provision of culturally safe and accessible colposcopy is feasible. It has the potential to contribute to the elimination of cervical cancer in Aotearoa, New Zealand.

Women’s cellphone access and ownership in rural Uganda: implications for self-care interventions

BackgroundThe World Health Organization (WHO) call for cervical cancer elimination includes increasing global cervical screening coverage. HPV-based self-collection (HPV-SC) is a promising screening model for low- and middle-income countries (LMICs), and while digital technology, such as cellphones, can be used to streamline HPV-SC, there is limited data on digital technology penetration in LMICs. Determining women’s cellphone access is critical to understanding the feasibility of using cellphones to support HPV-SC.MethodsThis study is a secondary analysis of a larger clinical trial. Participants of a cluster-randomized trial comparing HPV-SC models in Uganda completed a survey, including questions about demographics, cellphone access/ownership, prior cervical cancer screening (CCS), and willingness to receive CCS information by text. A logistic regression model was used to determine adjusted rates of cellphone ownership using survey variables as factors.ResultsOf 2019 participants, 76.1% owned a cellphone. In non-cellphone owners (n = 483), 82.4% had daily cellphone access and 7.3% had no access. Compared to non-cellphone owners, cellphone owners were significantly older, more educated, closer to major health centers, more likely to have prior CCS, and more willing to receive a CCS text. In the logistic regression model, the aforementioned variables were all significantly associated with the odds of owning a cellphone.ConclusionsAs health care systems consider adopting HPV-SC, it is imperative to understand digital technology penetration. The majority of participants were cellphone owners and were willing to receive CCS information by text; however, significant socioeconomic and demographic differences remain between cellphone owners and non-owners. Further investigation is needed to understand whether HPV-SC using cellphones is feasible in similar settings.Trial registrationISRCTN, 12767014. ClinicalTrials.gov, NCT04000503.

Real-World Cervical Cancer Screening Uptake and Predictors of Visual Inspection With Acetic Acid Positivity Among Women Living With HIV in Care Programs in Western Kenya.

To achieve the WHO cervical cancer elimination targets, countries globally must achieve 70% cervical cancer screening (CCS) coverage. We evaluated CCS uptake and predictors of screening positive at two public HIV care programs in western Kenya. From October 2007 to February 2019, data from the Family AIDS Care and Education Services (FACES) and Academic Model Providing Access to Healthcare (AMPATH) programs in western Kenya were analyzed. The study population included women age 18-65 years enrolled in HIV care. Screening uptake was calculated annually and overall, determining the proportion of eligible women screened. Multivariate logistic regression assessed predictors of positive screening outcomes. There were 57,298 women living with HIV (WLWHIV) eligible for CCS across both programs during the study period. The mean age was 31.4 years (IQR, 25.9-37.8), and 39% were on antiretroviral therapy (ART) at the first CCS-eligible visit. Of all eligible women, 29.4% (95% CI, 29.1 to 29.8) underwent CCS during the study period, 27.0% (95% CI, 26.5 to 27.4) in the AMPATH program, and 35.6% (95% CI, 34.9 to 36.4) in the FACES program. Annual screening uptake varied greatly in both programs, with coverage as low as 1% of eligible WLWHIV during specific years. Age at first screening, CD4 count within 90 days of screening, current use of ART, and program (AMPATH v FACES) were each statistically significant predictors of positive screening. CCS uptake at two large HIV care programs in Kenya fell short of the WHO's 70% screening target. Screening rates varied significantly on the basis of the availability of funding specific to CCS, reflecting the limitations of vertical funding programs.

Global perspectives of determinants influencing HPV vaccine introduction and scale-up in low- and middle-income countries.

Achieving WHO cervical cancer elimination goals will necessitate efforts to increase HPV vaccine access and coverage in low-and-middle-income countries (LMICs). Although LMICs account for the majority of cervical cancer cases globally, scale-up of HPV vaccine programs and progress toward coverage targets in LMICs has been largely insufficient. Understanding the barriers and facilitators that stakeholders face in the introduction and scale-up of HPV vaccination programs will be pivotal in ensuring that LMICs are equipped to optimize the implementation of HPV vaccination programs. This qualitative study interviewed 13 global stakeholders categorized as either academic partners or global immunization partners to ascertain perspectives regarding factors affecting the introduction and scale-up of HPV vaccination programs in LMICs. Global stakeholders were selected as their perspectives have not been as readily highlighted within the literature despite their key role in HPV vaccination programming. The results of this investigation identified upstream (e.g., financial considerations, vaccine prioritization, global supply, capacity and delivery, and vaccine accessibility, equity, and ethics) and downstream (e.g., vaccine acceptability and hesitancy, communications, advocacy, and social mobilization) determinants that impact program introduction and scale-up and confirmed that strong political commitment and governance are significant in garnering support for HPV vaccines. As LMICs introduce HPV vaccines into their national immunization programs and develop plans for scaling up vaccination efforts, strategic approaches to communications and advocacy will also be needed to successfully meet coverage targets.

Modeling the Health Impact and Cost-Effectiveness of a Combined Schoolgirl HPV Vaccination and Cervical Cancer Screening Program in Guangdong Province, China.

Low human papillomavirus (HPV) vaccine uptake is a key barrier to cervical cancer elimination. We aimed to evaluate the health impact and cost-effectiveness of introducing different HPV vaccines into immunization programs and scaling up the screening program in Guangdong. We used a dynamic compartmental model to estimate the impact of intervention strategies during 2023-2100. We implemented the incremental cost-effectiveness ratio (ICER) in costs per averted disability-adjusted life year (DALY) as an indicator to assess the effectiveness of the intervention. We used an age-standardized incidence of 4 cases per 100,000 women as the threshold for the elimination of cervical cancer. Compared with the status quo, scaling up cervical cancer screening coverage alone would prevent 215,000 (95% CI: 205,000 to 227,000) cervical cancer cases and 49,000 (95% CI: 48,000 to 52,000) deaths during 2023-2100. If the coverage of vaccination reached 90%, domestic two-dose 2vHPV vaccination would be more cost-effective than single-dose and two-dose 9vHPV vaccination. If Guangdong introduced domestic two-dose 2vHPV vaccination at 90% coverage for schoolgirls from 2023 and increased the screening coverage, cervical cancer would be eliminated by 2049 (95% CI 2047 to 2051). Introducing two doses of domestic 2vHPV vaccination for schoolgirls and expanding cervical cancer screening is estimated to be highly cost-effective to accelerate the elimination of cervical cancer in Guangdong.

Scientific approaches toward improving cervical cancer elimination strategies.

At the 2023 EUROGIN workshop scientific basis for strategies to accelerate the elimination of cervical cancer and its causative agent, human papillomavirus (HPV) were reviewed. Although some countries have reached key performance indicators toward elimination (>90% of girls HPV vaccinated and >70% of women HPV screened), most are yet to reach these targets, implying a need for improved strategies. Gender-neutral vaccination, even with moderate vaccination coverage was highlighted as a strategy to achieve elimination more rapidly. It is more resilient against major disturbances in vaccination delivery, such as what happened during the coronavirus pandemic. Further, an analysis of ethical/legal issues indicated that female-restricted vaccination is problematic. Extended catch-up of vaccination with concomitant screening, and outreach to vulnerable groups were highlighted. Although birth cohorts with high coverage of HPV vaccination at school are protected against HPV, and HPVs have a very low reproductive rate in women above age 35, adult women below age 30 have inadequate direct protection. In addition to herd protection from gender-neutral vaccination, this group can be protected by offering concomitant catch-up HPV vaccination and HPV screening. Furthermore, hepatitis B vaccination experiences indicate that elimination cannot be achieved without prioritizing vulnerable/migrant populations. The long-lasting durability of vaccination-induced antibody responses suggests prolonged protection with HPV vaccines when adequately administrated. Finally, cost-effectiveness modelling suggests that high-coverage HPV vaccination in multiple population segments will be resource-saving due to reduced need for screening. In summary, the workshop found that strategically optimal deployment of vaccination will accelerate elimination of HPV and cervical cancer.

Feasibility and acceptability of an HPV self-testing strategy: lessons from a research context to assess for ability to implement into primary care at a national level in Botswana.

The WHO strategy for cervical cancer elimination strives to achieve 70% coverage with high-performance cervical screening. While few low- and middle-income countries have achieved this, high-risk human papillomavirus (hrHPV) self-testing creates the possibility to rapidly upscale access to high-performance cervical screening across resource settings. However, effective hrHPV screening requires linkage to follow-up, which has been variable in prior studies. This study developed and tested an implementation strategy aimed at improving screening and linkage to follow-up care in South East District in Botswana. This study performed primary hrHPV self-testing; those with positive results were referred for a triage visit. Withdrawals for any reason, loss-to follow-up between hrHPV test and triage visit, and number of call attempts to give hrHPV results were also documented. Acceptability of the program to patients was measured as the proportion of patients who completed a triage visit when indicated, meeting the a priori threshold of 80%. Feasibility was defined as the proportion of participants receiving the results and attending follow-up. To assess the associations between participant characteristics and loss-to-follow-up we used log-binomial regressions to estimate risk ratios and 95% confidence intervals (CI). Enrollment of 3,000 women occurred from February 2021 to August 2022. In total, 10 participants withdrew and an additional 33 were determined ineligible after consent, leaving a final cohort of 2,957 participants who underwent self-swab hrHPV testing. Half (50%) of participants tested positive for hrHPV and nearly all (98%) of participants received their hrHPV results, primarily via telephone. Few calls to participants were required to communicate results: 2,397 (82%) required one call, 386 (13%) required 2 calls, and only 151 (5%) required 3-5 calls. The median time from specimen collection to participant receiving results was 44 days (IQR, 27-65). Of all hrHPV positive participants, 1,328 (90%) attended a triage visit. In a large cohort we had low loss-to-follow-up of 10%, indicating that the strategy is acceptable. Telephonic results reporting was associated with high screening completion, required few calls to participants, and supports the feasibility of hrHPV self-testing in primary care followed by interval triage.