Malawi has the highest incidence of cervical cancer in the world. The practical and sustainable ‘screen and treat’ programme has been introduced in the Nkhoma region based on VIA and thermo-coagulation for treatment of early lesions(1). Here we present our experience with HPV testing of women presenting for VIA using self-collected vaginal samples and Xpert HPV (Cepheid) test. We have previously (2015) clinically validated the self- sampling in Scottish cervical screening hence had confidence in introducing it to Malawi. We aimed to establish feasibility of self-vaginal sampling and compare HPV prevalence of different collection protocols / devices / media with a view to validation of a cost-effective solution for low-income countries.
Provider-taken cervical and self-collected vaginal specimens were obtained from women attending routine VIA clinics in Nkhoma Hospital and associated Health Centres. The cervical HR-HPV prevalence was established(2). Women provided self-collected specimens in the clinic following verbal and diagrammatic instructions. Collections using swabs suspended with 5ml of Preservcyt (PC) or saline were carried out in June 2015. During 2016, Quintips® and Vibabrush devices were trialled for self-collection with 4-5ml of PC being added.
Women were open to HPV testing provided sufficient information had been given. Cervical HR-HPV prevalence was established as 19.9% (2). HR-HPV “other” was much more frequent than HPV 16 or 18/45, with HPV 31+ (P3) most commonly found. Self-collected specimens using swabs in PC showed the highest HR-HPV positivity. However, when saline was used as the medium, the prevalence was lower (21.4%). The comparison of HR-HPV detection obtained with self-collected vaginal samples using swabs, Quintips and Vibabrushes resulted in 29.6%, 26.9% and 18.1% detection respectively. No invalid specimens were obtained with either swabs or Quintips when suspended in PC.
Three self-sampling methods offered were universally acceptable. All but Vibabrush self-sampling resulted in higher HR-HPV detection in comparison to cervical sampling. Dry vaginal swab suspended in 5 ml of saline within less than 2 hours from collection had the closes to cervical sampling detection rate. The HR-HPV detection with Xpert® HPV is straightforward, has rapid turnaround and should now be validated with larger numbers using self-taken vaginal samples and low cost collection systems in LMIC.
1. Campbell C, Kafwafwa S, Brown H et al. IJC 2016; 139:908-15.
2. Cubie HA, Morton D, Kawonga E et al. JCV 2017; 87:1