Cervical Cancer Screening Strategies Research Articles

Cervical Cancer-Related Knowledge, Attitudes, and Practices of Health Professionals Working in Brazil's Network of Primary Care Units

Brazil's national strategy for cervical cancer screening includes using the Papanicolaou (Pap) test every 3 years among women aged 25-64 years. Comprehensive primary care services are provided through a network of primary health units, but little is known about cervical cancer-related knowledge, attitudes, and practices among health professionals and coordinators working in these facilities. In 2011, we conducted a cross-sectional nationally representative phone survey of 1,600 primary health care units to interview one unit coordinator and one health care professional per unit (either nurse, physician, or community health worker). Responses were obtained from 1,251 coordinators, 182 physicians, 347 nurses, and 273 community health workers. Questionnaires were administered to assess health units' characteristics and capacity for cervical cancer-related services as well as health professionals' perceived effectiveness of the Pap test, preparedness to talk to women about cervical cancer, adherence with screening guidelines, and willingness to recommend human papillomavirus (HPV) vaccination to females. Most units conducted screening (91.9%), used home visits to conduct recruitment and outreach (83.4%), and provided follow-up to women who did not return to discuss Pap test results (88.1%). Approximately 93% of health professionals stated that Pap testing was effective in decreasing death rates from cervical cancer and 65% stated that national guidelines for cervical cancer screening are very influential; 93% of nurses and physicians reported screening women annually and 75% reported beginning to screen women younger than 25 years old. Regarding HPV vaccination, almost 90% of nurses and physicians would recommend the HPV vaccine to their females patients if it were available. A larger proportion of physicians and nurses recommended the HPV vaccine to older girls (13-18 years) and women (19-26 years and even older than 26 years) than to younger girls (12 years or younger). Although Brazil's network of primary care units has significantly increased access to cervical cancer screening, effective strategies are needed to ensure that women get screened at the appropriate ages and intervals. Additionally, this study's baseline data on HPV vaccination may be useful as Brazil embarks on a national HPV vaccination program in 2014.

A comparison of two visual inspection methods for cervical cancer screening among HIV-infected women in Kenya

To determine the optimal strategy for cervical cancer screening in women with human immunodeficiency virus (HIV) infection by comparing two strategies: visual inspection of the cervix with acetic acid (VIA) and VIA followed immediately by visual inspection with Lugol's iodine (VIA/VILI) in women with a positive VIA result. Data from a cervical cancer screening programme embedded in two HIV clinic sites in western Kenya were evaluated. Women at a central site underwent VIA, while women at a peripheral site underwent VIA/VILI. All women positive for cervical intraepithelial neoplasia grade 2 or worse (CIN 2+) on VIA and/or VILI had a confirmatory colposcopy, with a biopsy if necessary. Overall test positivity, positive predictive value (PPV) and the CIN 2+ detection rate were calculated for the two screening methods, with biopsy being the gold standard. Between October 2007 and October 2010, 2338 women were screened with VIA and 1124 with VIA/VILI. In the VIA group, 26.4% of the women tested positive for CIN 2+; in the VIA/VILI group, 21.7% tested positive (P < 0.01). Histologically confirmed CIN 2+ was detected in 8.9% and 7.8% (P = 0.27) of women in the VIA and VIA/VILI groups, respectively. The PPV of VIA for biopsy-confirmed CIN 2+ in a single round of screening was 35.2%, compared with 38.2% for VIA/VILI (P = 0.41). The absence of any differences between VIA and VIA/VILI in detection rates or PPV for CIN 2+ suggests that VIA, an easy testing procedure, can be used alone as a cervical cancer screening strategy in low-income settings.

PRM1 - The Benefit-Harm Frontier of Different Primary Screening Strategies for Cervical Cancer in Germany

PRM1 - The Benefit-Harm Frontier of Different Primary Screening Strategies for Cervical Cancer in Germany

Real-time duplex PCR for simultaneous HPV 16 and HPV 18 DNA quantitation

HPV 16 and HPV 18 are responsible for more than 75% of cervical cancers and high HPV 16 loads are associated with both prevalent and incident lesions. The objective of the present study was to develop a method allowing the detection and quantitation of HPV 16 and 18 DNA to improve future strategies for cervical cancer screening. A duplex real-time PCR allowing the simultaneous quantitation of both HPV 16 and HPV 18 was carried out. Mixes of HPV 16 and HPV 18 whole genome plasmids were prepared to test a wide range of viral DNA concentrations. The values obtained for each mix of plasmids with the simplex and the duplex PCR were very close to the theoretical values except when a HPV type represented only 1:1000 genome equivalent or lower than the concurrent type. Cervical samples harboring HPV 16, HPV 18 or both types were tested by comparing the results with simplex and duplex real-time PCR assays. HPV 16 and HPV 18 genome titers were similar with the two assays. In conclusion, the real-time duplex PCR proved to be robust for HPV 16 and HPV 18 DNA quantitation.

High risk human papillomavirus type 16 and 18 infection in the cervical lesions of women with epithelial cell abnormality in Pap smear: A cytohistomorphologic association in Bangladeshi women

Background:The aim of this study was to find out the extent of high-risk human papillomavirus (hrHPV) type 16/18 infection in the cervical tissue of women with epithelial cell abnormality in Pap smear and to establish an association between hrHPV type 16/18 infection and cytohistomorphology.Materials and Methods:A cross-sectional descriptive study was carried out in 1699 patients who went through Pap smear examination. Prevalence of epithelial cell abnormality was calculated. Forty eight of these women underwent routine histopathology and 47 were evaluated for human papillomavirus (HPV) type 16/18 by polymerase chain reaction assay.Results:Total 139 women revealed epithelial cell abnormality. Histopathology showed simple inflammation to malignancy. HPV type 16/18 infection was detected in 40.42% (19/47) of the patients. Individually type 16 and 18 were positive in 7 (14.9%) cases each and dual infection with type 16 and 18 were seen in 5 (10.6%) cases. While cervical intraepithelial neoplasia grade 1 (CIN 1) and < CIN 1 lesions showed 18.75% (3 out of 16) and 35% (7 out of 20) positivity respectively, ≥CIN 2 lesions revealed positivity of 81.82% (9 out of 11). Eighty percent HPV 16/18 positivity was seen in women of < 30 years of age.Conclusion:The findings of this study will contribute to HPV 16/18 knowledge in Bangladesh that will be useful in assessing the success of current vaccines with limited type spectra and augmenting cervical cancer screening strategies.

From Adolescent Daughter to Mother: Exploring Message Design Strategies for Breast and Cervical Cancer Prevention and Screening

Early detection of breast and cervical cancers is one preventive behavior that may provide the adolescent daughter with a unique opportunity to provide encouragement to her mother or guardian to obtain screening. This study explored the design strategies necessary for developing an effective daughter-initiated message about screening for breast and cervical cancers. Thirty-two (N = 64) African-American mother-daughter dyads were interviewed about parenting style, goodwill, and daughters' credibility and risk behaviors that might influence receptivity toward a screening appeal. Mothers indicated that a tailored, emotional appeal combined with cancer facts delivered in a private setting would be most effective. Daughters were perceived as highly credible messengers and were perceived to have high levels of goodwill toward their mothers, regardless of risk behaviors.

Discussion: ‘Comparison of cervical cancer screening strategies,' by Cox et al

In the roundtable that follows, clinicians discuss a study published in this issue of the Journal in light of its methodology, relevance to practice, and implications for future research.

Risk factors for VIA positivity and determinants of screening attendances in Dar es Salaam, Tanzania

BackgroundTanzania is among the countries in the world where the cervical cancer incidence is estimated to be highest. Acknowledging an increase in the burden of cervical cancer, VIA was implemented as a regional cervical cancer screening strategy in Tanzania in 2002. With the aim of describing risk factors for VIA positivity and determinants of screening attendances in Tanzania, this paper present the results from a comparative analysis performed among women who are reached and not reached by the screening program”.Methods14 107 women aged 25–59 enrolled in a cervical cancer screening program in Dar es Salaam in the period 2002 – 2008. The women underwent VIA examination and took part in a structured questionnaire interview. Socioeconomic characteristics, sexual behavior, HIV status and high-risk (HR) HPV infection were determined in a subpopulation of 890 who participated and 845 who did not participate in the screening.ResultsBeing widowed/separated OR=1.41 (95% CI: 1.17-1.66), of high parity OR=3.19 (95% CI: 1.84-5.48) of low education OR= 4.30 (95% CI: 3.50-5.31) and married at a young age OR=2.17 (95% CI: 1.37-3.07) were associated with being VIA positive. Women who participated in the screening were more likely to be HIV positive OR= 1.59 (95% CI. 1.14-2.25) in comparison with women who had never attended screening, while no difference was found in the prevalence of HR-HPV infection among women who had attended screening and women who had not attended screening.ConclusionWomen who are widowed/separated, of high parity, of low education and married at a young age are more likely to be VIA positive and thus at risk of developing cervical cancer. The study further documents that a referral linkage between the HIV care and treatment program and the cervical cancer screening program is in place in the setting studied, where HIV positive were more likely to participate in the cervical cancer screening program than HIV negative women.

Comparison of cervical cancer screening strategies incorporating different combinations of cytology, HPV testing, and genotyping for HPV 16/18: results from the ATHENA HPV study

The objective of the study was to compare 9 cervical cancer screening strategies to the current screening standard (cytology with human papillomavirus [HPV] triage of atypical squamous cells of undetermined significance) for the detection of high-grade cervical disease. Women (n = 34,254) aged 30 years or older from the Addressing the Need for Advanced HPV Diagnostics (ATHENA) study underwent screening with cytology and HPV testing with simultaneous HPV16/18 genotyping; those with atypical squamous cells of undetermined significance cytology or greater or HPV-positive status were referred for colposcopy. In general, screening strategies that offered greater sensitivity also required more referral to colposcopy. HPV testing was more sensitive than cytology for detection of cervical intraepithelial neoplasia grade 2 or greater, but strategies that depended on cytology for triage of HPV-positive women decreased this sensitivity. Various strategies of cotesting with cytology increased sensitivity but did so by increasing testing. Strategies that included integrated HPV16/18 testing provided more efficient referral to colposcopy. Strategies that maximize detection of women at greatest risk of cervical intraepithelial neoplasia grade 3 or greater by immediate referral to colposcopy, with follow-up testing of women at intermediate risk, maximize the benefits of cervical cancer screening while decreasing the potential harm. Incorporating screening with HPV and triage of HPV-positive women by a combination of genotyping for HPV16/18 and cytology provided a good balance between maximizing sensitivity (benefit) and specificity by limiting the number of colposcopies (potential harm).

WS15-3 - New Cervical Cancer Screening Strategy with Contesting of Cytology and HPV Testing

ABSTRACT The Japan Association of Obstetricians and Gynecologists (JAOG) recommended screening for cervical cancer in women age 20 to 65 years with a combination of cytology and human papillomavirus (HPV) testing every 3 years in 2011. The US Preventive Services Task Force (USPSTF) and a multidisciplinary partnership among the American Cancer Society/American Society for Colposcopy and Cervical Pathology/American Society for Clinical Pathology (ACS/ASCCP/ASCP) recommendations are published in 15 March 2012. The recommendations are based on a systematic evidence review. The new screening recommendations address age-appropriate screening strategies, including the use of cytology and high-risk human papillomavirus (HPV) testing. Although the two sets of guidelines were developed independently, they are generally consistent. Screening with cytology and HPV testing every 5 years or cytology alone every 3 years in women age 21 to 65 years is recommended. On the other hand, HPV testing alone as a primary screening approach will be planed in Europe. Recommended screening practices should not change on the basis of HPV vaccination status. Specifically, co-testing has increased sensitivity for detecting cervical intraepithelial neoplasia grade 3 or greater (CIN3+), and women who have undergone co-testing have a lower risk of CIN3+ and invasive cancer. Because of this improved performance, co-testing can be used for screening at less frequent intervals than cytology alone. In addition, co-testing offers greater risk reduction than cytology alone for adenocarcinoma of the cervix and its precursors. However, Guideline of Japanese Ministry of Health, Labor and Welfare (MHLW) still shows a screening with cytology every 2 years. Now, we are keen to change the guideline of cervical cancer screening based on the latest evidences in Japan. Our new recommendation will be shown with data based on the medico-economic analysis in this work shop.

Effectiveness and health economic analysis of strategies on cervical cancer screening and early diagnosis and treatment

To explore the appropriate strategies which are suitable for the areas with diverse health and economic resource settings in China by estimating the life outcomes and cost-effectiveness of several cervical cancer screening strategies. Markov model was used to calculate the long-term effectiveness, utility, benefit and cost among screened and unscreened cohorts in rural and urban areas, and then analyses of cost-effectiveness, cost-utility and cost-benefit were performed. The assessed screening strategies were acetic acid of visual inspection combined with Lugol's iodine staining (VIA/VILI), conventional Pap smear and simple HPV DNA testing (careHPV) in rural areas, and conventional Pap smear, simple HPV DNA testing (careHPV), HPV DNA testing (HC2) and liquid-based cytology (LBC) alone or combined with HPV DNA testing (LBC+HC2) in urban areas. We estimated the life outcomes and cost-effectiveness of the above screening strategies at one-year, 3-year and 5-year intervals. All of the screening strategies were effective to decrease cervical cancer mortality and to increase life years, with a trend of shorter screening interval having better effectiveness. However, no matter in urban or rural areas, compared with careHPV testing at 5-year interval, the costs of other screening strategies were 1.28 - 13.86 folds, 1.31 - 14.14 folds, and 1.27 - 12.80 folds higher to avoid one death, to save a year of life, and a QALY, and the benefit per cost of other screening strategies was 9.9%-90.2%. careHPV testing at 5-year interval has the best cost-effectiveness performance and the highest benefit-cost ratio with the moderate life outcomes. It is the optimal cervical cancer screening strategy to be generalized in our country. careHPV testing at 3 years interval can be considered in more developed areas to achieve better effectiveness.

Systems strategies to support cancer screening in U.S. primary care practice.

Although systems strategies are effective in improving health care delivery, little is known about their use for cancer screening in U.S. primary care practice. We assessed primary care physicians' (N = 2,475) use of systems strategies for breast, cervical, and colorectal cancer (CRC) screening in a national survey conducted in 2007. Systems strategies included patient and physician screening reminders, performance reports of screening rates, electronic medical records, implementation of in-practice guidelines, and use of nurse practitioners/physician assistants. We evaluated use of both patient and physician screening reminders with other strategies in separate models by screening type, adjusted for the effects of physician and practice characteristics with multivariate logistic regression. Fewer than 10% of physicians used a comprehensive set of systems strategies to support cancer screening; use was greater for mammography and Pap testing than for CRC screening. In adjusted analyses, performance reports of cancer screening rates, medical record type, and in-practice guidelines were associated with use of both patient and physician screening reminders for mammography, Pap testing, and CRC screening (P < 0.05). Despite evidence supporting use of systems strategies in primary care, few physicians report using a comprehensive set of strategies to support cancer screening. Current health policy initiatives underscore the importance of increased implementation of systems strategies in primary care to improve the use and quality of cancer screening in the United States.

Pre-vaccination prevalence and distribution of high-risk human papillomavirus (HPV) types in Slovenian women: A cervical cancer screening based study

To estimate the pre-vaccination prevalence of cervical infections with 14 high-risk human papillomavirus (hr-HPV) types among 20-64 years old Slovenian women screened for cervical cancer in 2010, we consecutively enrolled 4431 women in 16 outpatient gynaecology services. All were screened with Digene Hybrid Capture 2 HPV DNA Test and Abbott Real Time High Risk HPV Test and all positive specimens genotyped. Prevalence of cervical infection with any hr-HPV type examined was 12.9% with HPV16 3.5% and with HPV18 1.0%. Age specific prevalence estimates were the highest among 20-24 years old women and decreased with age. HPV16 prevalence was lowest among women without evidence of cervical disease and increased with the severity to 41.9% in women with high grade squamous intraepithelial lesion. Our results provide baseline data for monitoring the impact of Slovenian HPV vaccination program and development of future cervical cancer screening strategies in cohorts eligible for free HPV vaccination.

Cervical cancer screening among HIV‐infected women: An economic evaluation in a middle‐income country

Due to the recent widespread availability of highly active antiretroviral therapy (HAART) in middle-income countries, there has been an increase in life expectancy for women on HAART, but no corresponding decrease in cervical cancer incidence. This study evaluates the optimal cervical cancer screening strategy for HIV-infected women in a middle-income country. We developed a mathematical model, which simulates the natural history of the HPV infection, as well as the HIV-mediated immunosupression among women in Brazil. Our model was calibrated using data from the IPEC/FIOCRUZ Women's HIV-infected cohort. The model compares the lifetime effects, costs and cost-effectiveness of strategies combining cytology, HPV DNA test and colposcopy at different screening intervals for different CD4 count strata (27 strategies in total). We found that the strategy with the best cost-effectiveness profile (cost-effectiveness ratio-U$4,911/year of life saved [YLS] and probability of being cost-effective-86%) was HPV testing followed by cytology triage every year for all HIV infected women, considering a very cost-effective threshold given by Brazil's GDP per capita (US$8,625/YLS). The results were robust to changes in the input parameters as demonstrated in one-way, scenario, threshold and probabilistic sensitivity analysis. Our study indicates that annual HPV testing followed by cytology triage for all HIV-infected women is likely to be very cost-effective in a middle-income country like Brazil. The results reflect the synergic effect of using a highly sensitive screening test (HPV DNA test) in sequence with a highly specific test (cytology).

Economic evaluation of three populational screening strategies for cervical cancer in the county of Valles Occidental: CRICERVA clinical trial

BackgroundA high percentage of cervical cancer cases have not undergone cytological tests within 10 years prior to diagnosis. Different population interventions could improve coverage in the public system, although costs will also increase. The aim of this study was to compare the effectiveness and the costs of three types of population interventions to increase the number of female participants in the screening programmes for cancer of the cervix carried out by Primary Care in four basic health care areas.Methods/DesignA cost-effectiveness analysis will be performed from the perspective of public health system including women from 30 to 70 years of age (n = 20,994) with incorrect screening criteria from four basic health care areas in the Valles Occidental, Barcelona, Spain. The patients will be randomly distributed into the control group and the three intervention groups (IG1: invitation letter to participate in the screening; IG2: invitation letter and informative leaflet; IG3: invitation letter, informative leaflet and a phone call reminder) and followed for three years. Clinical effectiveness will be measured by the number of HPV, epithelial lesions and cancer of cervix cases detected. The number of deaths avoided will be secondary measures of effectiveness. The temporal horizon of the analysis will be the life expectancy of the female population in the study. Costs and effectiveness will be discounted at 3%. In addition, univariate and multivariate sensitivity analysis will be carried out.DiscussionIG3 is expected to be more cost-effective intervention than IG1 and IG2, with greater detection of HPV infections, epithelial lesions and cancer than other strategies, albeit at a greater cost.Trial RegistrationClinical Trials.gov Identifier NCT01373723

Performance of carcinogenic human papillomavirus (HPV) testing and HPV16 or HPV18 genotyping for cervical cancer screening of women aged 25 years and older: a subanalysis of the ATHENA study

The ATHENA study was designed to assess the performance of carcinogenic human papillomavirus (HPV) testing and HPV16 or HPV18 genotyping compared with liquid-based cytology for cervical cancer screening in a large US population aged 21 years and older. We did a subanalysis of this population to compare the screening performance of the cobas HPV test versus liquid-based cytology in women aged 25 years and older, and assess management strategies for HPV-positive women. Women aged 25 years or older who were attending routine cervical screening were enrolled from 61 clinical centres in 23 US states. Cervical specimens were obtained for liquid-based cytology and HPV DNA testing with two first-generation assays (Amplicor HPV test and Linear Array HPV genotyping test) and the second-generation cobas HPV test (with individual HPV16 and HPV18 detection). Colposcopy and diagnostic biopsies were done on women with atypical squamous cells of undetermined significance (ASC-US) or worse cytology, those who tested positive with either first-generation HPV test, and a random sample of women who tested negative for HPV and cytology. All women not selected for colposcopy received their results and exited the study. Participants and colposcopists were masked to cytology and HPV test results until the colposcopy visit was completed. The primary endpoint for this substudy was histologically confirmed cervical intraepithelial neoplasia grade 3 (CIN3) or worse. This study is registered with ClinicalTrials.gov, number NCT00709891; the study is in the follow-up phase, which is due to be completed in December, 2012. From May 27, 2008, to Aug 27, 2009, 47,208 women were enrolled, of whom 41,955 met our eligibility criteria. Valid cobas HPV and liquid-based cytology test results were available for 40,901 women (97%), who were included in this analysis. Of these, 4275 women (10%) tested cobas HPV positive and 2617 (6%) had abnormal cytology. 431 women were diagnosed with CIN2 or worse and 274 with CIN3 or worse. In women who had colposcopy, the cobas HPV test was more sensitive than liquid-based cytology for detection of CIN3 or worse (252/274 [92·0%, 95% CI 88·1-94·6] vs 146/274 [53·3%, 95% CI 47·4-59·1]; difference 38·7%, 95% CI 31·9-45·5; p<0·0001). Addition of liquid-based cytology to HPV testing increased sensitivity for CIN3 or worse to 96·7% (265/274, 95% CI 93·9-98·3), but increased the number of screen positives by 35·2% (5783/40,901 vs 4275/40,901) compared with HPV testing alone. As a triage test to identify CIN3 or worse in HPV-positive women, detection of HPV16, HPV18, or both alone was equivalent to detection of ASC-US or worse alone in terms of sensitivity (150/252 [59·5%] vs 133/252 [52·8%]; p=0·11) and positive predictive value (PPV) (150/966 [15·5%] vs 133/940 [14·1%]; p=0·20). Among HPV-positive women, detection of HPV16, HPV18, or both or low-grade squamous intraepithelial lesion or worse cytology had better sensitivity (182/252 [72·2%]; p<0·0001) and similar PPV (182/1314 [13·9%]; p=0·70) for detection of CIN3 or worse than ASC-US or worse cytology alone. Furthermore, detection of HPV16, HPV18, or both or high-grade squamous intraepithelial lesion or worse cytology had higher sensitivity (165/252 [65·5%]; p=0·0011) and PPV (165/1013 [16·3%]; p=0·031) for detection of CIN3 or worse than ASC-US or worse cytology alone. HPV testing with separate HPV16 and HPV18 detection could provide an alternative, more sensitive, and efficient strategy for cervical cancer screening than do methods based solely on cytology. Roche Molecular Systems.

Risk factors for high‐risk human papillomavirus infection in unscreened Malian women

To investigate the epidemiology of human papillomavirus (HPV) infection in Malian women, for whom cervical cancer is the most common cancer and the second most common cause of cancer-related mortality. Pilot study of 202 women aged 15-65 to determine the prevalence rate of high-risk HPV infection among unscreened Malian women. Information on risk factors was collected through a standardized, structured interview and clinical examination. High-risk (HR) HPV DNA was detected using signal amplification methods (hybrid capture II). High-risk HPV DNA was detected in 12% of unscreened women, while visual inspection after application of acetic acid and Lugol's iodine (VIA/VILI) identified suspicious abnormalities in 2.5% of unscreened women. Histopathological evaluation of VIA/VILI-positive biopsies revealed no evidence of cervical intraepithelial neoplasia or cervical cancer. The majority of infections occurred among women in the 15-24 year old range. Compared to women who were married or widowed, single women were 3.5 times more likely to be infected with HR HPV. The prevalence of infection with cancer causing types of HPV in this study was 12%. These prevalence estimates are consistent with what has been reported previously for other West African countries.

P1-S1.54 High-risk Human Papilloma Virus (HPV) types prevalence in 20–64-years-old Women; Slovenian National HPV Prevalence Study, 2010

BackgroundTo estimate prevalence of 14 high-risk human papilloma virus (HPV) types among Slovenian women screened for cervical cancer.MethodsIn 2010, we conducted a cross-sectional study in a convenience sample of 4469...

Building capacity for cervical cancer screening in outpatient HIV clinics in the Nyanza province of western Kenya

Objective To evaluate outcomes of cervical cancer screening within HIV care and treatment clinics in Kenya. Methods Beginning in October 2007, visual inspection with acetic acid (VIA), colposcopy, and loop electrosurgical excision procedure (LEEP) were added to the clinical services offered at Family AIDS Care and Education Services (FACES) clinics in Kisumu, Kenya, after a systematic campaign to build capacity and community awareness. Results From October 2007 to October 2010, 3642 women underwent VIA as part of routine HIV care. Cervical intraepithelial neoplasia 2/3 was identified in 259 (7.1%) women, who were offered excisional treatment by LEEP in the clinic. Among those women offered screening, uptake was 87%. Clinical staff reported a high level of satisfaction with training for and implementation of cervical cancer screening strategies. Conclusion Cervical cancer screening and prevention are feasible, acceptable, and effective within HIV care and treatment clinics. Screening test performance characteristics need to be defined for an HIV-positive population to determine the cost/benefit ratio of lower cost strategies that will ultimately be necessary to provide universal access to cervical cancer screening in low-resource settings.

Looking ahead: A case for human papillomavirus testing of self‐sampled vaginal specimens as a cervical cancer screening strategy

Even in the era of highly effective human papillomavirus (HPV) prophylactic vaccines, substantial reduction in worldwide cervical cancer mortality will only be realized if effective early detection and treatment of the millions of women already infected and the millions who may not receive vaccination in the next decade can be broadly implemented through sustainable cervical cancer screening programs. Effective programs must meet three targets: (i) at least 70% of the targeted population should be screened at least once in a lifetime, (ii) screening assays and diagnostic tests must be reproducible and sufficiently sensitive and specific for the detection of high-grade precursor lesions (i.e., CIN21), and (iii) effective treatment must be provided. We review the evidence that HPV DNA screening from swabs collected by the women in their home or village is sufficiently sound for consideration as a primary screening strategy in the developing world, with sensitivity and specificity for detection of CIN21 as good or better than Pap smear cytology and VIA. A key feature of a self-collected HPV testing strategy (SC-HPV) is the move of the primary screening activities from the clinic to the community. Efforts to increase the affordability and availability of HPV DNA tests, community education and awareness, development of strong partnerships between community advocacy groups, health care centers and regional or local laboratories, and resource appropriate strategies to identify and treat screen-positive women should now be prioritized to ensure successful public health translation of the technologic advancements in cervical cancer prevention.