Background Human papillomavirus (HPV) testing for cervical cancer prevention was introduced in Argentina through the Jujuy Demonstration Project (2011-14). The programme tested women aged 30 years and older attending the public health system with clinician-collected HPV tests. HPV self-collection was introduced as a programmatic strategy in 2014. We aimed to evaluate the effectiveness of programmatic HPV testing to detect cervical intraepithelial neoplasia (CIN) of grade 2 or worse (CIN2+) in comparison with cytology-based screening. Methods We did a population-based, before-and-after retrospective cohort study using data from the National Cervical Cancer Prevention Program for the Jujuy province in northwest Argentina. We obtained data for the cytology-based screening period from Jan 1, 2010, until Dec 31, 2011, and for the HPV-based screening period from Jan 1, 2012, until Dec 31, 2014. The primary outcome was detection of histologically diagnosed CIN2+ among women aged 30 years and older. To assess the outcomes in all individuals included in the study, we used multivariable logistic regression and propensity score matching. The reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework was used for the before-and-after analysis of programmatic dimensions. Findings Of the 29 631 women who underwent cytology-based screening in 2010-11, CIN2+ was detected in 236 (0•8%) individuals. Of the 49 565 women HPV tested in 2012-14 (clinician-collected tests, n=44 700; self-collection tests, n=4865), 693 (1•4%; 658 clinician-collected tests; 35 self-collection tests) were found to have CIN2+ after the first round of screening. Compared with cytology-based screening, the odds ratio of being diagnosed with a CIN2+ lesion was 2•34 (95% CI 2•01-2•73; p<0•0010) with clinician-collected tests, and 1•08 (0•74-1•52; p=0•68) when screened with self-collection tests, after controlling for age and health insurance status. Screening coverage was similar in both periods (52•7% vs 53•2%); improvements of programmatic indicators were observed in the HPV testing period in relation to laboratory centralisation, lower overscreening (6•6% vs 0•0%), higher adherance to age recommendations (79•3% vs 98•8%), and a decrease of inadequate samples (3•6% vs 0•2%). Interpretation HPV testing in middle-income settings increases detection of CIN2+ lesions and allows for improvement of programmatic indicators. Evidence suggests that the introduction of HPV testing will accelerate the reduction of cervical cancer burden.

BackgroundSelf-collection has been proposed as a strategy to increase cervical screening coverage among hard-to-reach women. However, evaluations of the implementation of this strategy on a large scale are scarce. This paper describes the process and measurement of the scaling-up of self-collection offered by community health workers during home visits as a strategy to reach under-screened women aged 30+ with public health coverage, defined as the target women.MethodsWe used an adaptation of the Health System Framework to analyze key drivers of scaling-up. A content analysis approach was used to collect and analyze information from different sources. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) model was used to evaluate the impact of the strategy.ResultsHPV self-collection was scaled-up in the province of Jujuy in 2014 after a RCT (Self-collection Modality Trial, initials EMA in Spanish) was carried out locally in 2012 and demonstrated effectiveness of the strategy to increase screening uptake. Facilitators of scaling-up were the organizational capacity of the provincial health system, sustainable funding for HPV testing, and local consensus about the value of the technology. Reach: In 2014, 9% (2983/33,245) of target women were screened through self-collection in the Jujuy public health sector. Effectiveness: In 2014, 17% (n = 5657/33,245) of target women were screened with any HPV test (self-collected and clinician-collected tests) vs. 11.7% (4579/38,981) in 2013, the pre-scaling-up period (p < 0.0001). Implementation: Training about the strategy was provided to 84.2% (n = 609/723) of total community health workers (CHWs). Of 414 HPV+ women, 77.5% (n = 320) had follow-up procedures. Of 113 women with positive triage, 66.4% (n = 75) had colposcopic diagnosis. Treatment was provided to 80.7% of CIN2+ women (n = 21/26). Adoption: Of trained CHWs, 69.3% (n = 422/609) had at least one woman with self-collection; 85.2% (n = 315/368) of CHWs who responded to an evaluation survey were satisfied with self-collection strategy. Maintenance: During 2015, 100.0% (723/723) CHWs were operational and 63.8% (461/723) had at least one woman with self-collection.ConclusionsThe strategy was successfully scaled-up, with a high level of adoption among CHWs, which resulted in increased screening among socially vulnerable under-screened women.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-017-0548-1) contains supplementary material, which is available to authorized users.

The aim of this article is to present results of programmatic introduction of HPV testing with cytologic triage among women 30 years and older in the province of Jujuy, Argentina, including description of the planning phase and results of program performance during the first year. We describe the project implementation process, and calculate key performance indicators using SITAM, the national screening information system. We also compare disease detection rates of HPV testing in 2012 with cytology as performed during the previous year. HPV testing with cytology triage was introduced through a consensusbuilding process. Key activities included establishment of algorithms and guidelines, creating the HPV laboratory, training of health professionals, information campaigns for women and designing the referral network. By the end of 2012, 100% (n 5 270) of public health care centers were offering HPV testing and 22,834 women had been HPV tested, 98.5% (n 5 22,515) were 301. HPV positivity among women over 30 was 12.7%, 807 women were HPV1 and had abnormal cytology, and 281 CIN21 were identified. CIN21 detection rates was 1.25 in 2012 and 0.62 in 2011 when the program was cytology based (p 5 0.0002). This project showed that effective introduction of HPV testing in programmatic contexts of low-middle income settings is feasible and detects more disease than cytology.Cervical cancer remains a serious public health problem in developing countries where almost 90% of cases occur 1 and where cytological screening has been ineffective, due to a complex interaction of lack of organized programs, embedded inequity in availability of human resources and services, and lack of coordination among health services and professionals. [2][3][4] In this context, cytology screening adds to the problem, as it requires frequent examinations and rigorous quality controls to compensate for its low negative predictive value. 5 Recently, HPV testing has changed the scenario. Processing and interpretation of the test is automated, reducing the need for cytotechnicians and quality controls. Also, its high sensitivity and negative predictive value allows extension of the screening interval, 6,7 which can facilitate screening and treatment coverage. Finally, it is more suitable where HPV vaccination has been introduced. 5 Thus, HPV testing is expected to become the preferred test for cervical cancer screening. 8 However, HPV testing will still need to be applied in health system contexts, where promotion activities are

screening in Argentina is mainly opportunistic, characterized by an estimated low coverage, coexisting with over-screening of women with access to health services, and an absence of quality control procedures. Policies for cervical cancer screening in the provinces vary and, most often, deviate from the national recommendation of one Pap smear every 3 years for women 35-64 years of age. Ensuring compliance with national program guidelines is an essential step toward significantly reducing the burden of cervical cancer.