Cervical screening for carcinogenic human papillomavirus (HPV) infection is being considered for low income countries. Effectiveness requires targeted screening in older women in whom prevalent infections are more likely to be persistent and predictive of precancer. Some studies in West Africa have found unusually high HPV prevalences across all adult ages, that may reduce the positive predictive value (PPV) of HPV-based screening, if positivity in older women does not sufficiently predict elevated risk. We conducted a population-based study in rural Nigeria to identify HPV prevalence and associated cervical abnormalities. Using stratified random sampling, we enrolled women age 15+. Non-virgins had a cervical exam including liquid-based cytology and PCR HPV DNA testing from residual cytology specimens. Two-thirds of invited women participated, and 14.7% had detectable carcinogenic HPV, a proportion that did not decline with age (p-trend=.36) and showed slight peaks in the 15–29 and 60–69 age groups. Among women of the age typically considered for screen-and-treat programs (30–49 years), 12.8% were HPV-positive and the PPV for high-grade or worse cytology was 16.4%. Comparatively, women age <30, were more likely to be HPV-positive (18.9%, p=.03) with a lower PPV (4.2% p=.05). Among women age 50+ (typically excluded from screening in resource-poor settings because inexpensive treatment is not available), HPV positivity was 14.2% with a PPV of 13.9%. In Irun and similar settings where HPV does not decline with age, HPV-based screen-and-treat programs might be feasible for mid-adult women, since prevalence is sufficiently low, positivity predicts elevated risk of more easily treated precancer.

OBJECTIVE Cervical cancer is the most common gynaecological cancer in developing countries. Visual Inspection with Acetic Acid (VIA) was introduced to screen for cervical premalignant lesions in developing countries due to the inability of many countries to implement high quality cytologic services. We sought to compare VIA performance among different health workers in Nigeria. METHODS In a population-based project, seven health workers working who had been screening women with VIA for about two years at local government health centers in rural Nigeria were retrained in a two-week program using the IARC training manual. Women from a rural village who had never had cervical cancer screening were recruited into the study. Each woman had cervical cancer screening by VIA, liquid-based cytology and oncogenic human Papillomavirus (HPV) DNA testing. RESULTS Despite similar participant characteristics, across all age groups, providers had wide ranges of VIA results; 0–21% suspect cancer and 0–25% VIA positive. VIA was insensitive compared to a combination of cytology and HPV testing. CONCLUSION In our study, VIA was not reproducible nor was it sensitive compared to cytology and HPV testing.

Success of the new HPV DNA test for low-resource settings (careHPV™ test, QIAGEN Gaithersburg, Inc.; Gaithersburg, MD) requires good test performance when operated by personnel with limited laboratory experience. We evaluated the transferability, reliability, and accuracy of the careHPV test nested within a cervical screening project in a large Nigerian village. CareHPV testing was performed on screen-positive (n=345) and screen-negative (n=42) women attending colposcopy (68.3% of referred). Biopsies of abnormal-appearing areas were processed and read in the U.S. CareHPV specimens taken immediately before colposcopy were processed up to four times [in the field] by two secondary school graduates without laboratory experience, trained for this study. Specifically, QIAGEN Gaithersburg trained a laboratory-inexperienced U.S. researcher, who trained the first local technician who, in turn, trained the second. Residual specimens were sent to the U.S. for MY09/MY11 PCR testing for 13 carcinogenic genotypes (HPV16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) plus HPV66 (included in careHPV). Intra-rater agreement was 98.8% (Kappa=.97) and 98.9% (Kappa=.97) for technicians 1 and 2, respectively while inter-rater agreement was 96.3% (Kappa=.90). Agreement with MY09/MY11 PCR (virologic reference standard) was 89.3% (Kappa=.73) with 74.2% sensitivity and 95.7% specificity. The careHPV test detected 12 (80%) of 15 histologically-confirmed cervical intraepithelial neoplasia grade 2 (CIN2) or worse lesions, with an estimated 83.0% specificity to detect < CIN2. In a challenging low-resource setting with minimal intervention, the careHPV test performed adequately with high specificity but possibly lower sensitivity than HPV DNA tests currently used in controlled situations.

Background We propose an economical cervical screening research and implementation strategy designed to take into account the typically slow natural history of cervical cancer and the severe but hopefully temporary impact of COVID-19. The commentary introduces the practical validation of some critical components of the strategy, described in three manuscripts detailing recent project results in Asia and Africa. The main phases of a cervical screening program are 1) primary screening of women in the general population, 2) triage testing of the small minority of women that screen positive to determine need for treatment, and 3) treatment of triage-positive women thought to be at highest risk of precancer or even cancer. In each phase, attention must now be paid to safety in relation to SARS-CoV-2 transmission. The new imperatives of the COVID-19 pandemic support self-sampled HPV testing as the primary cervical screening method. Most women can be reassured for several years by a negative test performed on a self-sample collected at home, without need of clinic visit and speculum examination. The advent of relatively inexpensive, rapid and accurate HPV DNA testing makes it possible to return screening results from self-sampling very soon after specimen collection, minimizing loss to follow-up. Partial HPV typing provides important risk stratification useful for triage of HPV-positive women. A second “triage” test is often useful to guide management. In lower-resource settings, visual inspection with acetic acid (VIA) is still proposed but it is inaccurate and poorly reproducible, misclassifying the risk stratification gained by primary HPV testing. A deep-learning based approach to recognizing cervical precancer, adaptable to a smartphone camera, is being validated to improve VIA performance. The advent and approval of thermal ablation permits quick, affordable and safe, immediate treatment at the triage clinic of the majority of HPV-positive, triage-positive women. Conclusions Overall, only a small percentage of women in cervical screening programs need to attend the hospital clinic for a surgical procedure, particularly when screening is targeted to the optimal age range for detection of precancer rather than older ages with decreased visual screening performance and higher risks of hard-to-treat outcomes including invasive cancer.

Urinary incontinence affects more than a quarter of pregnant women; with substantial lifestyle changes; and sexual relation is the most affected activity. Health care providers should endeavor to enquire about symptoms of UI among pregnant women. Efficacy of interventions needs to be investigated in this population.