Summary

Long-term infection with the human papillomavirus (HPV) can lead to abnormal cells developing in the cervix, which in some cases may progress to cervical cancer.1 HPV vaccinations and cervical screening programmes can help to reduce the incidence and mortality rate of cervical cancer.2 However, low- and middle-income countries may not have the infrastructure and resources needed to implement such programmes.3 The Ministry of Health in El Salvador joined forces with Basic Health International, an NGO, to develop a national HPV testing programme.4 It was found to be safe and cost-effective in lowering women’s risk of developing cervical cancer.5

Challenge

Cervical cancer is the fourth most common cancer among women worldwide.6 It is most often caused by the human papillomavirus (HPV),7 an infection that affects more than 80% of sexually active adults.8 Most HPV infections are cleared by the immune system within two years, but high-risk strains can lead to longer-term infection and abnormal cells in the cervix, which, if left untreated, may progress to cervical cancer within 15 to 20 years.1 6

Comprehensive vaccination and screening programmes can reduce the incidence and mortality rate of cervical cancer.9 Many high-income countries which have introduced such programmes have seen significant reduction in women’s risk of developing cervical cancer.2 For example, in Sweden, women who had been vaccinated against HPV before the age of 17 had an 88% lower risk of developing cervical cancer than women who had never received the vaccine.10

Low- and middle-income countries may not have the infrastructure, resources and specialist workforce needed to implement similar programmes.3 For example, in El Salvador, there is no national HPV vaccination programme and, until recently, cervical screening was not available through the public health system.5 11

Solution

In 2011, the Salvadoran Ministry of Health partnered with Basic Health International to launch the Cervical Cancer Prevention in El Salvador (CAPE) programme.4 12 It introduced HPV testing and treatment for abnormal cervical cells into the public health system.

The programme relies on HPV DNA tests, which offer a low-cost solution to countries that may not have the resources for other screening procedures, such as Pap (cervical) smears and colposcopies.13 HPV DNA tests are portable, do not require refrigeration and return results within three hours. They are more sensitive than Pap smears and do not need to be repeated as regularly, reducing the number of medical appointments needed.14

In El Salvador, the tests are administered by clinic staff.5 Women with an HPV-positive result are offered immediate treatment with cryotherapy, which freezes and removes abnormal cells in the cervix. This treatment approach is safe and cost-effective for low-resource settings.5 It ensures that women receive appropriate care and reduces the need for follow-up appointments.

What has been achieved

The CAPE programme has lowered women’s risk of developing cervical cancer by an estimated 59%.5 In 2017, the Ministry of Health secured USD $1 million to integrate HPV DNA testing and cryotherapy into the public health system,4 15 making El Salvador the first country in Central America to adopt HPV testing at a national level.16

Self-testing is also being trialled for women and transgender men who may not feel comfortable attending a clinic.17 18

Next steps

Women who were tested and treated as part of the CAPE programme are being followed up to further refine the treatment protocol.4

Basic Health International is drawing on its experience in El Salvador to support the Guatemalan government, which is working to expand a similar HPV testing programme.19

Further information

References:

  1. World Health Organization. 2020. Human papillomavirus (HPV) and cervical cancer. [Updated 11/11/20]. Available here: https://www.who.int/news-room/fact-sheets/detail/human-papillomavirus-(hpv)-and-cervical-cancer [accessed: May 2021]
  2. Jansen EEL, Zielonke N, Gini A, et al. 2020. Effect of organised cervical cancer screening on cervical cancer mortality in Europe: a systematic review. European Journal of Cancer 127: 207-23
  3. Ogilvie G, Nakisige C, Huh WK, et al. 2017. Optimizing secondary prevention of cervical cancer: Recent advances and future challenges. International Journal of Gynecology & Obstetrics 138(S1): 15-19
  4. Basic Health International. 2021. CAPE: Cervical Cancer Prevention in El Salvador. Available here: https://www.basichealth.org/our-work/where-we-work/el-salvador/ [accessed: May 2021]
  5. Campos NG, Maza M, Alfaro K, et al. 2019. The cost-effectiveness of implementing HPV testing for cervical cancer screening in El Salvador. International Journal of Gynecology & Obstetrics 145(1): 40-46
  6. World Health Organization. 2021. Cervical cancer. Available here: https://www.who.int/health-topics/cervical-cancer#tab=tab_1 [accessed: May 2021]
  7. Centers for Disease Control and Prevention. 2020. How many cancers are linked with HPV each year? [Updated 03/09/20]. Available here: https://www.cdc.gov/cancer/hpv/statistics/cases.htm [accessed: May 2021]
  8. National Foundation for Infectious Diseases. 2021. Facts about HPV for adults. [Updated 01/01/21]. Available here: https://www.nfid.org/infectious-diseases/facts-about-human-papillomavirus-hpv-for-adults/ [accessed: May 2021]
  9. Peirson L, Fitzpatrick-Lewis D, Ciliska D, et al. 2013. Screening for cervical cancer: a systematic review and meta-analysis. Systematic Reviews 2(1): 35
  10. Lei J, Ploner A, Elfström KM, et al. 2020. HPV Vaccination and the Risk of Invasive Cervical Cancer. New England Journal of Medicine 383(14): 1340-48
  11. World Health Organization. 2020. El Salvador Cancer Country Profile 2020. Geneva: World Health Organization
  12. Cremer ML, Maza M, Alfaro KM, et al. 2016. Introducing a High-Risk HPV DNA Test Into a Public Sector Screening Program in El Salvador. J Low Genit Tract Dis 20(2): 145-50
  13. Qiagen. 2018. Reaching every woman - The careHPV Test. Hilden, Germany: Qiagen
  14. Alfaro K, Maza M, Felix JC, et al. 2020. Outcomes for Step-Wise Implementation of a Human Papillomavirus Testing–Based Cervical Screen-and-Treat Program in El Salvador. JCO Glob Oncol: 10.1200/GO.20.00206 (6): 1519-30
  15. Basic Health International. 2017. Annual Report 2017. Pittsburgh, PA: Basic Health International
  16. Basic Health International. 2019. Basic Health International 2019 Annual Report. Pittsburgh, PA: Basic Health International
  17. Maza M, Meléndez M, Herrera A, et al. 2020. Cervical Cancer Screening with Human Papillomavirus Self-Sampling Among Transgender Men in El Salvador. LGBT Health 7(4): 174-81
  18. Maza M, Melendez M, Cremer M, et al. 2018. High Acceptability of Human Papillomavirus Self-Sampling Among Nonattenders of a Public Cervical Cancer Screening Program in El Salvador. Journal of Global Oncology 4(Supplement 1): 13s-13s
  19. Basic Health International. 2021. Guatemala, Peru & Paraguay. Available here: https://www.basichealth.org/our-work/where-we-work/guatemala-peru-paraguay/ [accessed: May 2021]