‘Screen and treat’ approaches to cervical screening offer the best hope for population-based screening in LMIC. Visual inspection with acetic acid (VIA) is recommended by WHO but is limited by lack of trained personnel and maintenance of quality skills. An objective test such as Hr-HPV detection as the first stage of screening would be beneficial.
Our objective was to assess the utility of Xpert® HPV as a primary screening tool in a rural setting where screening using VIA is the norm and an inexpensive intervention.
Following Malawian approvals and buy-in from regional and village chiefs, the Nkhoma cervical screening programme was established1. VIA providers attended Malawian Ministry of Health VIA course, supplemented by additional practical training in interpretation, treatment options and taking specimens for HPV testing. Laboratory staff performed Xpert® HPV according to manufacturer’s instructions using Preservcyt collection. Attempts were made to reduce the cost of HPV testing by reducing the volume of collection fluid, using alternative collection fluids and devices and also by introducing self-collection.
Hr-HPV prevalence was established as 19.9% in 750 routinely screened women2. Hr-HPV ‘other’ was much more frequent than HPV 16 or 18/45, with HPV 31+ (P3) most commonly found. While lesions assessed as ‘suspicious’ cancers were nearly always Hr-HPV positive, there was considerable discrepancy between Hr-HPV positivity and VIA ‘positive’ results. These differences will be described in detail.
Xpert® HPV proved to be straightforward, had rapid turnaround and training was easily cascaded to more junior lab staff and to clinic staff. It is suitable as a point of care test. Hr-HPV results were different from VIA results and considerable education is required to convince clinical providers that Hr-HPV testing is more specific. Steps could be taken to reduce costs of testing, particularly at the sample collection stage, but the cost per HPV test needs to be greatly reduced before it could be used as a primary screening tool in LMIC. At present, Nkhoma CCSP could not afford to replace VIA same day ‘screen and treat’ with Hr-HPV testing.
REFERENCES
1. Campbell C, Kafwafwa S, Brown H et al. IJC 2016;139:908-15.
2. Cubie HA, Morton D, Kawonga E et al. J CV 2017; 87:1-4.
ACKNOWLEDGEMENT
We are grateful to the Scottish Government International Development Fund for Malawi for funding 2013-2016 (MW01).