The Bhutanese Screening Programme recommends a Pap smear every three years for women aged 25–65 years, and coverage ranges from 20% to 60%, being especially challenging in rural settings. The “REACH-Bhutan” study was conducted to assess the feasibility and outcomes of a novel approach to cervical cancer screening in rural Bhutan based on the careHPV test on self-collected samples.
Cross-sectional, population-based study. Women were recruited in rural primary health care centres, i.e. Basic Health Units (BHU), across Bhutan. Overall, 3,648 women aged 30–60 were invited from 15 BHUs differing in accessibility, size, and ethnic composition of the population. Participants provided a self-collected cervico-vaginal sample and were interviewed. Samples were tested using careHPV in Thimphu (the Bhutanese capital) referral laboratory. Main outcome measures were screening participation by geographic area, centre, age, and travelling time, as well as previous screening history and careHPV-positivity by selected characteristics of the participants.
In April/May 2016, 2,590 women (median age: 41) were enrolled. Study participation was 71% and significantly heterogeneous by BHU (range: 31%–96%). Participation decreased with increase in age (81% in 30–39 year-old women; 59% in ≥50 years), and travelling time (90% in women living <30 minutes from the BHU versus 62% among those >6 hours away). 50% participants reported any previous screening. 265 women (10%; 95%CI 9%–11%) were careHPV-positive, with a significant variation by BHU (range: 5%–19%) and number of sexual partners (prevalence ratio for ≥3 vs. 0–1=1.55; 95% CI: 1.05–2.27). On the technical side, although the central laboratory in Thimphu was able to deliver careHPV results to each BHU in a median of 11 days, the careHPV platform turned out to be less reliable than hoped and, even after completion of the initial training period, there still continued to be substantial wastage due to invalid careHPV runs. In addition, the original plan of rapidly recalling women and offering them cryotherapy in each BHU was hindered by difficulties in transport and/or malfunction of cryotherapy equipment.
Community-based cervical cancer screening, by testing self-collected samples for careHPV, can achieve high coverage in rural Bhutan. Nevertheless, implementation was characterised by logistic and technological challenges both with careHPV and treatment technology.