Summary

Over 300,000 people die from cervical cancer annually around the world, with 90% of deaths occurring in low- and middle-income countries.1 It is often thought that this is partly due to a lack of access to human papillomavirus (HPV)-based cervical screening programmes, which have been shown to reduce mortality due to cervical cancer by almost 50%.2 Uganda has one of the highest levels of mortality due to cervical cancer in the world, at 41.4 deaths per 100,000 cases – compared with the global average of 7.3 deaths per 100,000.3 To combat this, the Advances in Screening and Prevention in Reproductive Cancers (ASPIRE) Mayuge – a community-integrated, self-collected HPV testing programme – was trialled in the rural Mayuge district in Uganda. The programme assesses the effectiveness of different screening models to ensure adherence to screening, follow-up and treatment for cervical cancer.4 The trial increased screening participation from 5% to 100%, and had over 65% uptake of follow-up treatments.4 5 The trial was so successful that since its conclusion, household-based cervical cancer screening by community healthcare workers are being implemented across Uganda.5

Challenge

Globally, cervical cancer is one of the most common cancers in women.1 The majority of cases are caused by a human papillomavirus (HPV) infection that is usually acquired through sexual contact.6 Annually, there are 604,200 new cases and 342,000 deaths due to cervical cancer; 90% of these deaths are in low- and middle-income countries.1 7 This is attributed to low rates of screening, follow-up and treatment, and a lack of access to the HPV vaccine.7

An HPV-based cervical screening programme has been shown to reduce deaths due to cervical cancer by almost 50%.2 The screening programme tests for the presence of HPV, and provides referral for treatment and follow-up care for those who test positive.8 An HPV screening test also allows for samples to be self-collected, meaning healthcare staff are not needed for testing, which makes it more accessible to those in low-resource, isolated settings.9 However, even when populations are captured within a screening programme, adherence to follow-up and/or treatment after an HPV-positive result can be as low as 48%.10 This can be attributed to a delay in receiving results, long waiting times, lack of access to care, fear and distress, lack of information about disease risks, and inability to seek treatment due to multiple barriers such as costs, distance and time to travel­.11 12

Uganda has one of the highest levels of mortality due to cervical cancer in the world, at 41.4 deaths per 100,000 cases – compared with the global average of 7.3 deaths per 100,000.3 13 This is attributed to a high prevalence of HPV in the female population and low uptake of screening.9 Uganda has no national cervical cancer screening programme, and the small-scale screening programmes implemented in certain regions have screening rates as low as 4.8%. This is despite a study showing that 99% of people are satisfied with HPV screening via self-collection. This low uptake is attributed to long distances to health centres, a lack of transportation, ill-equipped health facilities and a perception of low risk of disease.14

Solution

Between 2019 and 2021, Advances in Screening and Prevention in Reproductive Cancers (ASPIRE) Mayuge – a community-integrated, self-collected HPV testing programme – was trialled in the rural Mayuge district in Uganda to assess the effectiveness of two different screening models to ensure adherence to screening, follow-up and treatment for cervical cancer. One model offered self-collected screening by door-to-door (DtD) community health workers, while the other model used self-collected screening at a Community Health Day (CHD).4 17

Over 2,000 women participated in the trial. They were divided into two groups, and both groups were provided with information about the study, as well as HPV, cervical cancer and screening education.4 5

Once samples were taken, they were tested and results were disseminated to the trial participants. People in the DtD group were provided with their results in the home, and those in the CHD group received their results in a community setting at a subsequent CHD. Anyone who tested positive for HPV was scheduled for follow-up and/or treatment at a local clinic.4 5

What has been achieved?

The trial increased participation in cervical screening from 5% to 100%.4 5 There was no difference in screening uptake between the DtD and CHD groups. Using self-collected samples was also found to have no effect on screening uptake.

Treatment adherence in those testing positive for HPV was 75% and 67% in the DtD and CHD groups respectively.4 This slight difference was attributed to a more tailored one-on-one approach by community heath workers during the recruitment and dissemination phase in the DtD group.

A process evaluation of the trial showed that both groups had high level of efficacy, adoption, implementation and maintenance.5 It shows that outreach by DtD community health workers and at a CHD are successful in low-resource rural settings at increasing participation in HPV-based cervical screening and treatment coverage.5

Next steps

The findings from the trial have been incorporated into the draft Uganda National Cervical Cancer Guidelines, particularly focusing on the use of self-collected samples and community health workers to screen at the household- and community-level in rural areas.5 The implementation of household-based cervical cancer screening through community health workers has begun since the conclusion of the trial.5

References:

  1. International Agency for Research on Cancer. 2023. Cancer Today: Estimated age-standardized incidence rates (World) in 2020, World, both sexes, all ages (excl. NMSC). Available here: https://gco.iarc.fr/today/online-analysis-multi-bars [accessed: October 2023]
  2. Sankaranarayanan R, Nene BM, Shastri SS, et al. 2009. HPV Screening for Cervical Cancer in Rural India. New England Journal of Medicine 360(14): 1385-94 [accessed: October 2023]
  3. International Agency for Research on Cancer. 2023. Estimated age-standardized mortality rates (World) in 2020, Uganda, females, all ages (excl. NMSC). Available here: https://gco.iarc.fr/today/online-analysis-multi-bars [accessed: October 2023]
  4. Gottschlich A, Payne BA, Trawin J, et al. 2023. Community-integrated self-collected HPV-based cervix screening in a low-resource rural setting: a pragmatic, cluster-randomized trial. Nature Medicine 29(4): 927-35 [accessed: October 2023]
  5. Mithani N, Gottschlich A, Payne BA, et al. 2023. A process evaluation of integrated service delivery of self-collected HPV-based cervical cancer screening using RE-AIM in the ASPIRE Mayuge pragmatic randomized trial. medRxiv: 10.1101/2023.05.17.23290046: 2023.05.17.23290046 [accessed: October 2023]
  6. World Health Organization. 2022. Cervical cancer. Available here: https://www.who.int/news-room/fact-sheets/detail/cervical-cancer [accessed: October 2023]
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  11. Gago J, Paolino M, Arrossi S. 2019. Factors associated with low adherence to cervical cancer follow-up retest among HPV+/ cytology negative women: a study in programmatic context in a low-income population in Argentina. BMC Cancer 19(1): 367 [accessed: October 2023]
  12. Hui S-kA, Miller SM, Wen K-Y, et al. 2014. Psychosocial Barriers to Follow-up Adherence After an Abnormal Cervical Cytology Test Result Among Low-Income, Inner-City Women. Journal of Primary Care & Community Health 5(4): 234-41 [accessed: October 2023]
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  14. Ndejjo R, Mukama T, Musabyimana A, et al. 2016. Uptake of Cervical Cancer Screening and Associated Factors among Women in Rural Uganda: A Cross Sectional Study. PLoS One 11(2): e0149696 [accessed: October 2023]
  15. World Health Organization. 2021. Uganda: Cervical Cancer Profile. Available here: https://cdn.who.int/media/docs/default-source/country-profiles/cervical-cancer/cervical-cancer-uga-2021-country-profile-en.pdf?sfvrsn=f3991794_38&download=true
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