HPV-based cervical cancer screening in Nicaragua: from testing to treatment

Abstract

Background: In Nicaragua, cervical cancer is the leading cause of cancer death among women. Human papillomavirus (HPV) testing, primarily using self-sampling, was introduced between 2014 and 2018 in three provinces. We analyzed data from the HPV screening program with the goal of describing key characteristics including reach, HPV prevalence, triage and treatment, and factors associated with follow-up completion. Methods: We analyzed individual-level data from routinely collected forms for women attending HPV-based cervical cancer screening. HPV-positive women were triaged with Pap or visual inspection with acetic acid (VIA) prior to treatment. Logistic regression was used to identify factors associated with receiving triage and treatment; analyses were adjusted for province, age, and self-vs. provider-collected sampling. Results: Forty-four thousand six hundred thirty-five women were screened with HPV testing; 96.6% of women used self-sampling. Six thousand seven hundred seventy-six women were HPV positive (15.2%), 54.0% of screen-positive women received triage, and 53.1% of triage-positive women were treated, primarily with cryotherapy. If women lost at triage are included, the overall treatment percentage was 27.8%. Province and provider sampling were significantly associated with completing triage. Province and triage type were significantly associated with receiving treatment. The odds of receiving treatment after Pap triage as compared to VIA was significantly lower (aOR: 0.05, 95% CI: 0.04-0.08, p < 0.001), and the relative proportion of women receiving treatment after Pap triage versus VIA was 0.29. Conclusions: Introduction of HPV testing resulted in a substantial number of women screened, and acceptance of selfsampling was high. Management of screen-positive women remained a challenge, particularly with Pap triage. Our results can inform other developing countries as they work to reach World Health Organization (WHO) elimination targets.

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

“…The highest adherence rates were found in studies with direct referral to colposcopy, and/or intensive follow-up protocols (e.g., in Denmark HPV test results and follow-up recommendations were mailed to the women and their GPs). However, limited compliance to cytology triage has been reported among women with self-collected test from Argentina [ 13 , 21 ], France [ 19 ], Italy [ 29 ] and Nicaragua [ 20 ]. In a study carried out in France among non-attenders of low socio-economic level, 41% of women had a Pap smear after a positive HPV self-collected test [ 19 ].…”

“…In a study carried out in France among non-attenders of low socio-economic level, 41% of women had a Pap smear after a positive HPV self-collected test [ 19 ]. A study in Nicaragua carried out to analyse the key characteristics of an HPV-screening programme showed that 54% of women adhered to triage [ 20 ]. In Argentina, a study showed that 18% and 30% completed triage 60 and 120 days after a positive HPV result, respectively [ 21 ].…”

“…Studies assessing adherence to triage in programmatic contexts in low and middle resource settings are scarce, but few available studies have shown that adherence to triage for women with self-collected tests is a challenge [8,13,[19][20][21]. A study in Nicaragua showed that the odds of completing triage were almost three times higher for women who had a provider-collected sample compared to women who collected their own sample for HPV testing [20]. In Jujuy, Argentina, only 18% of women with self-collected tests completed triage 60 days after an HPV+ result [21].…”

Assessing the implementation fidelity of HPV self-collection offered by Community Health Workers during home visits (the EMA strategy): a case study in a low-middle resource setting in Argentina

“…Limited compliance to triage has been reported in Argentina, 11,23,37,38 and other countries. [39][40][41] Studies that analyzed why screen-positive women failed to complete follow-up found that in most cases it was due to problems related to the health services organization [42][43] (i.e., delays or failures in result delivery, lack of appropriate guidance concerning the steps to follow after receiving a positive test, etc.). The EMA strategy is a complex intervention consisting of several steps that address multifaceted processes within interpersonal, organizational, and community contexts that may affected implementation delity.…”

Knowledge and perceptions regarding triage among human papillomavirus–tested women: A qualitative study of perspectives of low-income women in Argentina

“…However, adhering to triage and treatment can be challenging, especially among women with SC tests, who in general may not be regular health care system users, and therefore are at greater risk of not being able to continue with triage procedures. 10,11 In Argentina, clinician-collected screening involves taking two samples for HPV screening and Pap triage. Evidence has shown that women using SC have lower triage adherence.…”