A cross-sectional study exploring triage of human papillomavirus (HPV)-positive women by visual assessment, manual and computer-interpreted cytology, and HPV-16/18–45 genotyping in Cameroon

Abstract

BackgroundHigh-risk human papillomavirus (HPV)-positive women require triage to identify those at higher risk of cervical intraepithelial neoplasia grade 2 or worse (CIN2+). We aimed to compare visual assessment of the cervix, manual cytology and automated cytology as triage tests to screen HPV-positive women, and to assess over-treatment rates after visual assessment and over-referral rates to colposcopy after cytology.MethodsThe present cross-sectional study is nested in a large prospective screening trial in Cameroon. Evaluations of the tests have been conducted individually and in combination with HPV-16/HPV-18/45 genotyping. For the evaluation of over-treatment and colposcopic over-referral, we simulated two screening scenarios: (1) one-visit scenario (test-triage-and-treatment); and (2) two-visit scenario (test-triage-and-colposcopy).Results1582 women with a median age of 40 years (IQR 35–45) performed self-sampling for HPV testing, of which 294 (18.6%) were HPV-positive, and 12.2% had CIN2+. Sensitivities for CIN2+ detection were 77.1% for visual assessment, 80.0% for manual cytology, and 84.8% for automated cytology. Sensitivity of combined tests was higher compared with single tests. The highest sensitivity was obtained by the combination of genotyping and automated cytology (91.2%). In the one-visit scenario, the over-treatment rate was 83.9% in referred women, with a ratio of 6.2 treated women per CIN2+. In the two-visit scenario, the lowest over-referral rate would have been under manual cytology (45.0%), with a ratio of 1.8 referred women per CIN2+. Single and combined triage strategies by automated cytology gave rise to over-referral rates of 69.2% and 76.7%, respectively, and a ratio of 3.2 and 4.3 referred women per CIN2+, respectively.DiscussionTriage of HPV-positive women using a combination of genotyping and automated cytology for CIN2+ detection may provide public benefits in low- and middle-income countries.

High prevalence of and factors associated with human papillomavirus infection among women attending a tertiary hospital in Gauteng Province, South Africa

“…Although HPV testing is replacing cytology, particularly in HICs, the test is associated with lower specificity, which hence requires a second test to identify women who are at risk of developing cervical cancer [16]. The low specificity associated with HPV DNA testing may lead to unnecessary colposcopy referral and overtreatment, hence some countries tailor the triage strategy and/or follow-up [17].…”

“…The lack of adequate infrastructure may also pose a challenge to the introduction of liquid-based cytology (LBC). Nevertheless, some LMICs have introduced HPV testing in their national cervical cancer screening programs [17]. In South Africa, in addition to LBC-based cervical cancer screening, the NDoH Cervical Cancer Prevention and Control Policy has recommended HPV DNA-based testing in the public sector [19].…”

Comparison of human papillomavirus‐based cervical cancer screening strategies in Tanzania among women with and without HIV

“…2 The 2021 WHO guidelines also take the link between human immunodeficiency virus (HIV) and HPV into account, 4 and recommend either "screen-andtreat" or "screen-triage-and-treat" for the general population of women, whereas in women living with HIV, "screen-triage-and-treat" is recommended to reduce the risk of overtreatment. 2 Several triage methods for HPV positive women have been evaluated in LMICs, including visual inspection with acetic acid (VIA), [5][6][7][8][9][10] measuring HPV viral load 9,[11][12][13] and partial genotyping for HPV16/18 or HPV16/18/45. [5][6][7][8]11,12,14 However, few studies have directly compared several HPV-based screening strategies in Sub-Saharan Africa.…”

Addition of digital VIA/VILI to conventional naked-eye examination for triage of HPV-positive women: A study conducted in a low-resource setting

“…A lower threshold for VIA positivity than is usually recommended by the International Agency for Research on Cancer criteria was applied [ 22 ]. ABCD criteria as previously reported were used for diagnosis [ 23 ]. Briefly, we considered any acetowhite lesion (faint, translucent, or dense) larger than 5 mm touching the cervical transformation zone, including those that were indeterminate or uncertain, to be positive (or pathological).…”