The Possible Effects on Socio-Economic Inequalities of Introducing HPV Testing as Primary Test in Cervical Cancer Screening Programs

Abstract

Background: Screening with HPV is more effective than Pap test in preventing cervical cancer. HPV as primary test will imply longer intervals and a triage test for HPV positive women. It will also permit the development of self-sampling devices. These innovations may affect population coverage, participation, and compliance to protocols, and likely in a different way for less educated, poorer, and disadvantaged women.Aim: To describe the impact on inequalities, actual or presumed, of the introduction of HPV-based screening.Methods: The putative HPV-based screening algorithm has been analyzed to identify critical points for inequalities. A systematic review of the literature has been conducted searching PubMed on HPV screening coverage, participation, and compliance. Results were summarized in a narrative synthesis.Results: Knowledge about HPV and cervical cancer was lower in women with low socio-economic status and in disadvantaged groups. A correct communication can reduce differences. Longer intervals will make it easier to achieve high-population coverage, but higher cost of the test in private providers could reduce the use of opportunistic screening by disadvantaged women. There are some evidences that inviting for HPV test instead of Pap increases participation, but there are no data on social differences. Self-sampling devices are effective in increasing participation and coverage. Some studies showed that the acceptability of self-sampling is higher in more educated women, but there is also an effect on hard-to-reach women. Communication of HPV positivity may increase anxiety and impact on sexual behaviors, the effect is stronger in low educated and disadvantaged women. Finally, many studies found indirect evidence that unvaccinated women are or will be more probably under-screened.Conclusion: The introduction of HPV test may increase population coverage, but non-compliance to protocols and interaction with opportunistic screening can increase the existing inequalities.

To what extent will women accept HPV self-sampling for cervical cancer screening? A qualitative study conducted in Switzerland

“…The participants represented a mix of socioeconomic circumstances and the focus groups integrated both regularly screened and under-screened women. Beyond the equity issues that are often addressed in relation to studies on self-HPV acceptability, 1 , 4 our results suggest that previous experience with a gynecologist plays an important role. In addition, women who had not tested self-HPV, but who were in favor of it, indicated over the course of the discussion that for safety reasons, they preferred a gynecological examination to self-HPV, as observed in previous studies.…”

“… 1 Self-HPV was expected to improve the overall screening rate and reduce inequity in access to screening. The medical literature presents self-HPV as an innovative, promising, and effective alternative to the traditional Pap smear test, 2 – 4 offering a less intrusive procedure and increasing screening rates in previously under-screened women. 3 – 6 According to the results of recent randomized controlled trials, invitations for self-HPV are more often accepted than Pap smear invitations, 4 , 5 indicating that screening participation is increased.…”

“… 7 Women with higher education levels are more in favor of self-HPV than those with a disadvantaged or migration background. 2 , 4 Studies conducted with hard-to-reach groups, composed mainly of migrants, concluded that self-HPV is a culturally acceptable method for cervical cancer screening, 1 , 8 but possibly not universally accepted. 11 A number of factors against this method have been identified, including the fear of incorrectly performing the test, hurting oneself, lack of confidence in the efficacy of the method, and the need to talk with a gynecologist.…”

Barriers to cervical cancer screening exist despite integrating HIV and gynaecological services for HIV-positive women in Poland

“…It is therefore worrying that even in the presence of gynaecological services at the HIV clinic these women who are not yet on cART are less likely to receive consultations. A special focus should be put on patients entering care to make sure they understand the importance of gynaecological screening and of following the physician's recommendations [17].…”

Editorial: HPV-Associated Cancers, Socio-Economic Disparity, and Vaccination

“…Giorgi Rossi and colleagues present an algorithm to model the impact on inequalities of introducing HPV-based screening of cervical cancer ( 1 ). They found that knowledge about HPV and cervical cancer was lower in women with low socio-economic status and in disadvantaged groups.…”