Adherence to triage among women with HPV-positive self-collection: a study in a middle-low income population in Argentina

Abstract

Introduction Screening for cervical cancer (CC) prevention has substantially changed with the introduction of human papillomavirus (HPV) tests. This technology compared to cytology has increased the detection of pre-malignant and malignant cervical lesions in real-world programmes in different settings. Very importantly, through self-collection, HPV testing can reduce barriers to screening and increase coverage. However, when using HPV self-collection, triage tests are a key step in the CC prevention process, and high adherence to triage has been difficult to obtain in low-middle income settings. The aim of this study was to measure adherence to triage among women with HPV+ self-collection and analysed factors associated with this adherence in a middle-low resource setting in Argentina. We also evaluated key indicators related to the implementation of the HPV self-collection strategy. Methods We analysed data on screening/triage/diagnosis/treatment from women aged 30+ who performed self-collection between 2015 and 2017 ( n = 15,763), in the public health system in Tucuman, Argentina. We analysed secondary data from the national screening information system. The primary outcomes were: 1) adherence to cytology triage within the recommended timeframe (120 days) and 2) overall adherence to cytology triage including data at 18 months after screening. Multivariable regression was used to examine the association between age group, year of the screening test, record of the previous Pap-based screening and health insurance status with adherence to triage test as a primary outcome. We reported odds ratios, 95% confidence intervals and p -value of 0.05, which was considered the threshold for p -values). Results We analysed data of 2,389 HPV+ women. The overall adherence to triage at 18 months was 42.9%. The percentage of women completing cytology triage within the recommended timeframe of 120 days was lower (25.2%). Women with the record of a previous Pap-based screening had 1.86 times the odds of having a triage compared to women without a record of a previous Pap-based screening (95% CI: 1.64–2.64, p <0.001). Furthermore, the probability of having triage at the recommended timeframe was higher among women who were older and women with public health insurance. Conclusions Our results showed that adherence to triage in the recommended timeframe was low. In addition, the probability of having triage at the recommended timeframe was higher among women with a record of a previous Pap-based screening, a proxy of the use of health services. Our results showed that adherence to triage in the context of the HPV-self-collection strategy is challenging. The implementation of alternative approaches that might facilitate adherence to triage should be further investigated.

Effectiveness of an mHealth intervention to increase adherence to triage of HPV DNA positive women who have performed self-collection (the ATICA study): A hybrid type I cluster randomised effectiveness-implementation trial

“…This is coincident with routine programmatic data from Argentina showing that adherence to triage increased with time, from 18·0% at 60 days to 42·9% at 18 months. 10 Secondly, many women who did not have triage at day 60 might be facing barriers that could not be solved by CHW visits (e.g., socio-structural barriers such as work, domestic or childcare barriers), reducing the effect of the second component on the effectiveness of the multicomponent intervention. Evidence has shown that socio-structural barriers are more difficult to address by the health system, needing intersectoral action and social participation.…”

“… 9 Though self-collection has been deemed as particularly appropriate to increase screening among socially disadvantaged women, it may actually further decrease adherence to follow-up, as women with reduced contact with the healthcare system are less likely to adhere to screening/follow-up recommendations. 10 …”

“…In Argentina, programmatic HPV self-collection offered by CHWs during home visits was introduced in 2014 to increase uptake among socially disadvantaged women and at present 7 provinces have implemented it. However, adherence to triage remains a challenge, 8 , 10 with an estimated 25% of women attending triage at 120 days after the HPV result. 10 We hypothesized that a real difference could be made in adherence to triage in CC screening by combining HPV self-collection and a multi-component mHealth intervention (SMS messages sent to HPV-positive women and SMS message sent to CHWs to visit those HPV+ women who, at 60 days since the HPV result, have not attended triage).…”

“…However, adherence to triage remains a challenge, 8 , 10 with an estimated 25% of women attending triage at 120 days after the HPV result. 10 We hypothesized that a real difference could be made in adherence to triage in CC screening by combining HPV self-collection and a multi-component mHealth intervention (SMS messages sent to HPV-positive women and SMS message sent to CHWs to visit those HPV+ women who, at 60 days since the HPV result, have not attended triage). 19 This paper presents results from the ATICA study (Application of Information and Communication Technologies to HPV Self-collection, for its initials in Spanish), a hybrid type I trial set in Jujuy, Argentina.…”

HPV Self-Sampling for Cervical Cancer Screening among Women Living with HIV in Low- and Middle-Income Countries: What Do We Know and What Can Be Done?

“…Efforts should be made to encourage women to follow up with treatment. It will be counterproductive if women with HIV are encouraged to participate in cervical cancer screening, but women with positive screening results are not properly managed [ 14 , 76 , 77 , 78 ]. However, the cost of treatment may discourage most women from following up, as most of these women may not have insurance or cannot afford it.…”