Vaginal Self-Sampling for Human Papillomavirus Infection as a Primary Cervical Cancer Screening Tool in a Haitian Population

Assessment of HPV screening modalities within primary care: a systematic review

Introduction

Most cervical cancer precancerous lesions are associated with high-risk human papillomavirus (HPV) subtypes. Early detection through screening is crucial for preventing and managing HPV-related diseases. HPV Self-sample screening is a proposed method that can mitigate socioeconomic disparities, reduce embarrassment and costs of screening. This can possibly reduce the overall disease burden.

Methods

A search strategy was conducted across multiple databases, including PubMed, Cochrane Library, Scopus, and Embase. Data extraction was performed using a standardized form to collect detailed information on study characteristics, participant demographics, and various outcomes. The quality and risk of bias in the articles were assessed using the Critical Appraisal skills programme (CASP) checklist, and the Cochrane Risk of Bias (ROB) tool.

Results

Our review consistently found that HPV self-sampling is comparable to clinician-collected samples in terms of HPV detection rates and sensitivity, supporting the idea that HPV self-sampling can be a viable alternative for cervical cancer screening. Across the studies, self-sampling showed comparable or greater effectiveness to clinician-collected samples in detecting HPV in individuals. Specificity was comparable between both methods, with clinician-collected sampling slightly outperforming HPV self-sampling in some cases. Moreover when analyzing the negative predictive value (NPV) and positive predictive value (PPV) across the studies, it was evident that there was little difference between clinician-collected sampling and HPV self-sampling. 64.3% favored self-sampling over clinician-collected sampling due to increased comfort and privacy. Overall, the evidence suggests that self-sampling is an effective, patient-preferred, and cost-efficient alternative to clinician-collected sampling, particularly in under-screened populations.

Working towards health: A model of cervical cancer screening and treatment for factory employees in Haiti

OBJECTIVE

In Haiti, cervical cancer continues to cause high levels of mortality and morbidity due to lack of resources and political unrest. Haitian women employed in factories are especially vulnerable because they are unable to take time away from work to access health resources. We aimed to describe a low-cost intervention which successfully addressed this need.

METHODS

We present a retrospective review of data gathered through a public-private partnership, in which women working in garment factories near Port-au-Prince, Haiti, were offered health education, clinical breast exam, and free human papillomavirus (HPV) self-swab testing at their place of employment. Women testing positive for HPV were subsequently tested using visual inspection with acetic acid (VIA) to inform treatment referrals, and treated with mobile thermocoagulation in factory infirmaries. Factory-employed healthcare workers were trained on cancer screening, including VIA and clinical breast exam.

RESULTS

A total of 6843 out of 6983 (98%) female factory employees attended free reproductive health education sessions, and 4005 out of 4153 eligible women (97%) were screened using HPV self-swab testing; 5176 women received a clinical breast exam. Of the women screened for HPV, 1001 (25%) tested positive and 905 (90%) of HPV-positive women received VIA testing and thermocoagulation. The intervention had a total cost of US$76 000, over half of which was spent on an HPV testing machine.

CONCLUSIONS

Innovative approaches to the prevention of cervical cancer are especially necessary in very low-resource, politically unstable environments like Haiti. Self-swab and screen-and-treat programs in the workplace were acceptable to employees and factory owners. This low-cost model was reached vulnerable women through a public-private partnership, and tracked them through screening and treatment. It could be implemented elsewhere or extended to include other health services.

Human papillomavirus self-sampling versus provider-sampling in low- and middle-income countries: a scoping review of accuracy, acceptability, cost, uptake, and equity

Introduction

HPV self-sampling is a relatively new, cost-effective and widely accepted method, however, uptake in LMICs remains limited. We aimed to map out the evidence and identify gaps in accuracy, acceptability, cost, equity and uptake of self-sampling vs. provider-sampling in LMICs.

Methods

We searched: MEDLINE, EMBASE, CINAHL, SCOPUS, Web of Science, and Global Index Medicus, from 1946 to July 2023. Inclusion criteria entailed studies focusing on self-sampling alone or compared to provider-sampling for HPV testing and reporting on at least one outcome of interest (accuracy, acceptability, cost, equity, or uptake). Two authors independently screened titles, abstracts, and full texts, resolving disagreements through discussion. Data was extracted by one reviewer independently, with quality checks by senior authors, and results were synthesised narratively.

Results

Our search yielded 3,739 records, with 124 studies conducted on 164,165 women aged 15-88 years between 2000 and 2023 included. Most studies were from the African region (n = 61, 49.2%). Designs included cross-sectional (n = 90, 81.1%), randomised (n = 5, 4.5%), modelling (n = 4, 3.6%), micro-costing (n = 2, 1.8%), and non-randomised crossover (n = 1, 0.9%) studies. Outcomes included; acceptability (n = 79, 63.7%), accuracy (n = 51, 41.1%), cost (n = 7, 5.6%), and uptake (n = 7, 5.6%). Most studies reported that participants preferred self-sampling, with only a few studies (n = 7, 8.9%) studies favouring provider-sampling. The sensitivity and specificity of self-sampling ranged from 37.5-96.8% and 41.6-100.0%, respectively. One study directly compared the sensitivity and specificity of dry self-collected vs. wet provider-collected sample transportation. Laboratory costs were similar, but overall costs were lower for self-sampling. Uptake was higher for self-sampling in five of the seven studies. Most studies (n = 106) mentioned equity factors like age (n = 69, 65.1%), education (n = 68, 64.2%) and place of residence (n = 59, 55.6%) but no analysis of their impact was provided.

Conclusion

HPV self-sampling is acceptable and cost-effective but, evidence of its accuracy shows varying sensitivity and specificity. Evidence on the accuracy of dry self-collected vs. wet provider-collected sample transportation is limited. Research evaluating HPV self-sampling's accuracy, including comparisons of transportation modes, uptake, the impact of equity factors in LMICs and comparisons with high-income countries is essential to inform cervical cancer screening uptake.

Systematic review registration

https://doi.org/10.17605/OSF.IO/34TUY.

Accuracy of self-collected versus healthcare worker collected specimens for diagnosing sexually transmitted infections in females: an updated systematic review and meta-analysis

The use of self-collected specimens as an alternative to healthcare worker-collected specimens for diagnostic testing has gained increasing attention in recent years. This systematic review aimed to assess the diagnostic accuracy of self-collected specimens compared to healthcare worker-collected specimens across different sexually transmitted infections (STIs) including Chlamydia trachomatis (CT), human papillomavirus (HPV), Mycoplasma genitalium (MG), Neisseria gonorrhoea (NG), Treponema pallidum and Trichomonas vaginalis (TV) in females. A rigorous process was followed to screen for studies in various electronic databases. The quality of included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. There were no studies on syphilis that met the criteria for inclusion in the review. A total of six studies for chlamydia, five studies for HPV, four studies for MG, and seven studies for gonorrhoea and trichomoniasis were included in the review. However, not all studies were included in the sub-group meta-analysis. The analysis revealed that self-collected specimens demonstrated comparable diagnostic accuracy to healthcare worker-collected specimens across most STIs. This indicates that the diagnostic accuracy of self-collected specimens can provide accurate results and enhance access to diagnostic testing, potentially improving healthcare service delivery. Future research should further explore the diagnostic accuracy of self-collected specimens in larger and more diverse populations.

Epidemiology of Cervical Cancer in the Caribbean

Cervical cancer (CvC) is considered a preventable disease; however, in the Caribbean, it is still one of the fourth most common causes of death in women. Efforts to overcome obstacles to the treatment and control of this preventable disease are being made by several countries within the Caribbean. However, no health issue can be readily managed without first acquiring an understanding of the dynamics relating to its severity of impact reaching the target population, its clinical pathology, and the availability of treatment and/or preventative measures to control or halt its progression. To assess the status of CvC in the Caribbean, a review of the literature was conducted using PubMed. The Caribbean was defined in the review as comprising nations and islands whose coastlines are touched by the Caribbean Sea. This led to an assessment of the available literature on CvC for 33 Caribbean territories. The review showed a lack of published information on CvC and highlights the need for greater research. This also serves as a template for subsequent investigations.

Concordance of Primary Human Papillomavirus Testing Among Clinicians and Patients: A Systematic Review

Objective: Primary high risk human papilloma virus (hrHPV) testing is recommended as first-line screening for cervical cancer. Testing involves either a clinician-collected or a self-collected cervicovaginal swab. This study examines concordance between methods of collection of primary HPV testing. Methods: Ovid MEDLINE, Ovid Embase, and Cochrane were searched for relevant studies on self-collected and clinician-collected primary HPV testing published before December 31, 2022. English-language studies for primary HPV testing of average-risk patients were included. Studies conducted in screening settings rather than colposcopy clinics, that used standard devices for HPV collection, and that directly compared methods of collection were included. Outcomes were concordance and kappa between paired samples, and rate of HPV detection in self-collected and clinician-collected samples. Results: A total of 2381 studies were screened, of which 228 were included for full-text evaluation. Thirty-six studies, including 23,328 individuals screened, met the inclusion criteria. The rate of HPV detection ranged from 4.7% to 63% for self-collection and from 3.7% to 62% for clinician-collection. The concordance ranged from 78.2% to 96.9%, and kappa had substantial agreement for 26 of the 36 studies and moderate agreement for 7 of the 36 studies. Conclusions: This study directly compares clinician-collected and self-collected primary HPV screening rates. Studies were conducted in methods which are widely reproducible in the primary care setting. Primary HPV self-collection is a reliable and accurate method for cervical cancer screening.

Agreement between Self- and Physician‑Sampling for Detection of High‑Risk Human Papillomavirus Infections in Women Attending Cervical Screening at National Cancer Institute, Thailand

BACKGROUND

We determined testing of self-sampling vagina swabs for Human Papilloma Virus (HPV) can be used to screen for cervical disease in outpatient clinics.

METHODS

In this study, women attending cervical cancer screening clinic and gynecology clinic of the National Cancer Institute were invited to take a vaginal self-sampling and physician-collected cervical sampling.

RESULTS

Of 268 participants, 20 (7.5%) were HPV-positive on the physician-collected samples. Among these screen-positive women, only two (0.7%) had HPV 18 and/or 45 and none had HPV 16 infections. For the self-collected samples, 4 participants had invalid HPV test results. Of the remaining 264 women with valid test results on self-collected samples, 29 (11.0 %) were HPV-positive, of whom, two (0.8%) were infected with HPV 16 and one (0.4%) with HPV 18 and/or 45 infections. The agreement between self-sampling and physician-sampling HPV test results (when two HPV results categories were considered) was 92. 8% with a moderate Kappa value of 0.57.

CONCLUSION

Overall, self-sampling seems to be a reliable alternative to health-provider collection. However, instructions on proper procedures for sample collection to the women are important step before general roll out.

Mapping Evidence of Self-Sampling to Diagnose Sexually Transmitted Infections in Women: A Scoping Review

BACKGROUND

Sexually transmitted infections (STIs) are a major global healthcare burden, disproportionately affecting women. Self-sampling interventions for diagnostic purposes have the potential to improve STI healthcare management and expand STI services. However, there is currently no published evidence of the global use of self-sampling interventions to diagnose STIs in women. The main aim of this scoping review was to map evidence on the use of self-sampling interventions to diagnose STIs in women.

METHODOLOGY

The methodology of this scoping review was guided by Arksey and O'Malley and Levac. A comprehensive literature search was conducted in PubMed, Scopus, Web of Science, Medline (EBSCO), ProQuest, and Cochrane. For grey literature, a search was conducted in Open Grey, World Health Organization, Google, and conference proceedings and dissertations. All search results were screened and assessed for eligibility. Thereafter data from eligible studies was extracted and analysed. The quality of these studies was appraised using the Mixed Methods Appraisal Tool 2018 version.

RESULTS

A total of 770 articles were retrieved from databases and grey literature sources. A total of 44 studies were eligible for data extraction following title, abstract and full-text screening. Of the included studies, 63% presented evidence of research conducted in high-income countries and 37% presented evidence in low- and middle-income countries. Studies presented evidence on the following: feasibility of self-sampling in remote areas; acceptance and ease of use of self-sampling interventions; types of self-sampled specimens; pooled samples for diagnosing STIs; laboratory diagnostic assays for STI using self-sampled specimens; and self-testing of self-sampled specimens.

CONCLUSIONS

Self-sampling interventions are feasible and easy to use and, therefore, can improve STI management and treatment in women across various age groups and various access levels to good-quality healthcare. Despite this, there is a lack of evidence of self-sampling interventions designed according to user preferences. We recommend studies to collaborate with women to co-develop user-friendly self-sampling interventions to diagnose STIs in women.

Comparative assessment of test characteristics of cervical cancer screening methods for implementation in low-resource settings

Cervical cancer disproportionately affects low-resource settings. Papanicolaou, human papillomavirus (HPV), and visual inspection of cervix with acetic acid (VIA) testing, each with different characteristics, will reduce cervical cancer burden. We conducted a critical literature review using PubMed, Cochrane, WHO, and grey literature from 1994 to 2020. We examined efficacy, harms, and comparative effectiveness of screening methods by age, human immunodeficiency virus, provider characteristics, and assessed implementation challenges in low-resource settings. Comprehensive data on utility and efficacy of screening tests indicates that each screening has strengths and shortcomings but all confer acceptable performance. HPV and VIA appear more promising. Primary HPV test-and-treat, self-testing, and co-testing have been studied but data on triage plans, cost, support system, implementation and sustainability is unclear in low-resource settings. HPV testing could help target subgroups of older or higher risk women. VIA offers local capacity-building and scalability. Quality VIA technique after HPV testing is still required to guide post-screening treatments. VIA competencies decline gradually with current standard trainings. Stationary cervicography improves VIA quality but isn't scalable. Affordable smartphones eliminate this barrier, enhance training through mentorship, and advance continuing education and peer-to-peer training. Smartphone-based VIA facilitates cervical image storage for patient education, health promotion, record-keeping, follow-up care, remote expert support, and quality control to improve VIA reliability and reproducibility and reduce mis-diagnoses and burden to health systems. Rather than ranking screening methods using test characteristics alone in study or higher-resource settings, we advocate for scalable strategies that maximize reliability and access and reduce cost and human resources.

Evaluating Culturally-targeted Fear Appeal Messages for HPV Self-Sampling among Jamaican Women: A Qualitative Formative Research Study

Despite the disproportionate burden of cervical cancer among Caribbean women, evaluations of targeted communication interventions to increase screening behaviors are sparsely represented in extant literature. Informed by data on the cognitive, affective and sociocultural factors associated with low cervical screening in the English-speaking island of Jamaica, the current study aimed to explore how theory-based message design, coupled with innovative solutions, might increase screening. In this formative research study, we first described the process used to develop culturally-targeted fear appeal messages embedded within an HPV self-sampling kit developed by the researchers. Then, we shared the results of an evaluation of the kit, which was reviewed by 36 Jamaican women in 8 focus groups, to understand the potential impact of the messages and the utility of HPV self-sampling to increase screening behaviors in this population. The results provide data on effective messages for cervical cancer prevention among Jamaican women, which may be further applicable to underscreened women in the English-speaking Caribbean. Additionally, results from this research suggest support for HPV self-sampling to address salient cultural and structural barriers to screening, which provides an impetus for experimental research in message design to inform policy and practice.

Long term results of follow-up after HPV self-sampling with devices Qvintip and HerSwab in women non-attending cervical screening programme

Background

We are presenting the results of the Slovenian human papillomaviruses (HPV) self-sampling pilot study in colposcopy population of National Cervical Cancer Screening Programme ZORA for the first time. One-year and four-year follow-up results are presented for two different self-sampling devices.

Participants and methods

A total of 209 women were enrolled in the study at colposcopy clinic. Prior to the gynaecological examination, all women performed self-collected vaginal swab at the clinic; 111 using Qvintip and 98 using HerSwab self-sampling device. After self-sampling, two cervical smears were taken by a clinician; first for conventional cytology and second for HPV test. After that, all women underwent colposcopy and a cervical biopsy if needed. We compared sensitivity, specificity, and predictive values of cytology (at the cut-off atypical squamous cells of undetermined significance or more [ASC-US+]) and HPV test (on self- and clinician-taken samples) for the detection of cervical intraepithelial neoplasia grade 2 or more (CIN2+) after one and four years of follow-up. Hybrid Capture 2 (HC2) assay was used for all HPV testing.

Results

The mean age of 209 women was 37.6 years and HPV positivity rate 67.0% (140/209), 36.9 years and 70.3% (78/111) in the Qvintip group and 38.4 years and 63.3% (62/98) in the HerSwab group, respectively. Overall, percent agreement between self and clinician-taken samples was 81.8% (kappa 0.534) in the Qvintip and 77.1% (kappa 0.456) in the HerSwab group. In the Qvintip group, the longitudinal sensitivity, specificity, positive and negative predictive values were 71.8%, 75.0%, 83.6%, 60.0% for cytology; 83.1%, 51.3%, 75.6% and 62.5% for HPV test of self-taken samples and 94.4%, 57.5%, 79.8% and 85.2% for HPV test on clinician-taken samples. In the HerSwab group, the corresponding results were 71.7%, 46.7%, 61.3%, 58.3% for cytology; 75.0%, 47.7%, 62.9% and 61.8% for HPV test on self-taken samples and 94.3%, 44.4%, 66.7% and 87.0% for clinician-taken samples, respectively.

Conclusions

The results confirm that HPV self-sampling is not as accurate as clinician sampling when HC2 is used. All HPV tests showed a higher sensitivity in detecting CIN2+ compared to cytology. Due to non-inferior longitudinal sensitivity of HPV self-sampling compared to cytology, HPV self-sampling might be an option for non-attenders to the National Cancer Screening Programme.

Human Papilloma Virus self-sampling performance in low- and middle-income countries

Background

Screening for HPV has led to significant reductions in cervical cancer deaths in high-income countries. However, the same results have not been achieved in low- and middle-income countries (LMICs). HPV self-sampling is a novel approach that could improve screening rates.

Methods

This study’s objective is to summarize the recent literature on HPV self-sampling in LMICs, focusing on sensitivity/specificity, and feasibility/acceptability of self-sampling compared to traditional screening methods. We conducted a PubMed search for articles published in English within the last 10 years on self-sampling in LMICs.

Results

Fifty eligible articles from 26 countries were included, 19 of which came from sub-Saharan Africa and 18 from Latin America/Caribbean. Seven studies examined sensitivity, with five reporting rates higher than 91%. Six reported on specificity, which was also very high at 86–97.8%. Six studies examined self-sampling concordance with provider-collected sampling, with concordance rates ranging from 87 to 97.5%. A total of 38 studies examined the feasibility/acceptability of HPV self-sampling. Participation rates were very high in all studies, even when self-sampling was done at participants’ homes (over 89% participation). Overall, participants reported that HPV self-sampling was easy to perform (75–97%, 18 studies), painless (60–90%, nine studies), and preferred over provider-collected sampling (57–100%, 14 studies). Eight studies reported follow-up rates for participants who completed self-sampling; however, these rates varied widely-from 13.7 to 90%. The major benefits of self-sampling include convenience of screening from home, less embarrassment, and less travel. Improved education and awareness of self-sampling, combined with support from community health workers, could reduce perceptions of self-sampling being inferior to provider-collected sampling. Improving follow-up of abnormal results and improving linkages to treatment are also essential.

Conclusion

Our literature review highlights HPV self-sampling is a well-performing test that shows promise in terms of expanding screening efforts for the prevention of cervical cancer-related deaths in LMICs.

A systematic review and meta-analysis of diagnostic accuracy of HPV tests for the screening of cervical cancer in low-resource settings

BACKGROUND

HPV tests for the screening of cervical cancer in low-income countries (LICs) might improve early detection and preventive efforts.

OBJECTIVES

To determine the diagnostic accuracy of HPV tests for detecting cervical intraepithelial neoplasia grade 2 or worse (CIN 2+) in LICs.

SEARCH STRATEGY

The Cochrane Library, MEDLINE, and CINAHL databases were searched on June 1, 2020. References of relevant studies were hand-searched.

SELECTION CRITERIA

Diagnostic test accuracy studies were included if women had an HPV test for cervical cancer screening, followed by verification with colposcopy and colposcopy-directed biopsy. The primary target was CIN2+.

DATA COLLECTION AND ANALYSIS

Two authors independently screened studies, extracted data, and assessed methodological quality. Bivariate diagnostic random-effects meta-analysis was used.

MAIN RESULTS

Eleven studies including 82 556 women were eligible, most of which were at low risk of bias. The pooled diagnostic odds ratio of hybrid capture test of samples collected from the cervix by healthcare providers for detecting CIN2+ and CIN3+ was 42.0 (95% confidence interval [CI] 20.7-76.3) and 97.1 (95% CI 35.3-215.0), respectively.

CONCLUSIONS

Evidence indicates that hybrid capture tests can be used for screening of cervical cancer in LICs. Future studies are warranted for self-sampling and for low-cost HPV tests.

The Acceptability and Preference of Vaginal Self-sampling for Human Papillomavirus (HPV) Testing among a Multi-ethnic Asian Female Population

Vaginal self-sampling for human papillomavirus (HPV) testing can potentially increase cervical screening coverage. This study aimed to investigate the acceptability of vaginal self-sampling for HPV testing and factors that might influence a woman's preference for this as a cervical screening method. This was a cross-sectional study that recruited 725 women from the urban and suburban areas of Selangor, Malaysia. All study participants were instructed to self-collect vaginal sample using a dry flocked swab before responding to a detailed questionnaire documenting their experience and preference for self-sampling. Most of the study participants (>80%) perceived vaginal self-sampling as easy, convenient, not embarrassing, comfortable, and were confident in performing the test. This suggests high acceptability toward vaginal self-sampling for HPV testing. Of the 725 women, 83% preferred self-sampling HPV testing over healthcare personnel sampling HPV testing and Pap test. Women with higher household income and full-time employment status were more likely to prefer self-sampling. Those who had not undergone Pap test also expressed preference for self-sampling HPV testing. Convenience and women's confidence in performing a vaginal self-sampling for HPV testing were the independent key factors that influenced the preference for self-sampling method. Vaginal self-sampling for HPV testing is highly acceptable among Malaysian women. It is the preferred choice as a primary cervical screening method and serves as an alternative to healthcare-acquired sample for Pap test. PREVENTION RELEVANCE: Organized cervical cancer screening remains unachievable in many countries. Self-sampling HPV testing is an evidence-based method that can remove barriers to cervical screening. This is particularly important for developing countries in order to achieve the WHO global strategy to accelerate cervical cancer elimination.

Whole Slide Imaging: Technology and Applications

Pathology has benefited from advanced innovation with novel technology to implement a digital solution. Whole slide imaging is a disruptive technology where glass slides are scanned to produce digital images. There have been significant advances in whole slide scanning hardware and software that have allowed for ready access of whole slide images. The digital images, or whole slide images, can be viewed comparable to glass slides in a microscope, as digital files. Whole slide imaging has increased in adoption among pathologists, pathology departments, and scientists for clinical, educational, and research initiatives. Worldwide usage of whole slide imaging has grown significantly. Pathology regulatory organizations (ie, College of American Pathologists) have put forth guidelines for clinical validation, and the US Food and Drug Administration have also approved whole slide imaging for primary diagnosis. This article will review the digital pathology ecosystem and discuss clinical and nonclinical applications of its use.

A systematic review of self-sampling for HPV testing in Africa

BACKGROUND

Human papillomavirus (HPV) testing may be feasible for primary cervical cancer screening in low-resource countries.

OBJECTIVE

To compare self-sampling by women with clinician-performed sampling for HPV testing in Africa.

SEARCH STRATEGY

MEDLINE, Google scholar, EMBASE, and several journals were searched from 2000 until 2015 using relevant terms.

SELECTION CRITERIA

Selected studies compared self-sampled and clinician-sampled HPV tests.

DATA COLLECTION AND ANALYSIS

Data extraction forms included description of the type of HPV screening, description of any additional intervention components, study design, sample size, follow-up periods, analytic approach, reported numerical outcomes, results, and limitations.

RESULTS

Twenty-five studies were identified. Women of a wide age range were successful at self-sampling in many African countries. More than 95% of self-samples yielded HPV DNA results. The concordance in test results between self-collected samples and clinician-collected samples was reasonably high in most studies. In all studies, the quality of cytology from self-sampling matched that of clinician-sampling. Women were generally positive about self-collection, but noted some concerns.

CONCLUSION

Self-sampling for HPV DNA testing seems to represent a feasible alternative to the Pap test. Further research is needed to provide a solid evidence base to inform using of self-sampling for HPV DNA testing for primary cervical cancer screening.

Social innovation in diagnostics: three case studies

Background

Diagnostics are essential for identifying and controlling diseases. However, limited access to diagnostics hinders public health efforts in many settings. Social innovation may provide a framework for expanding access to diagnostics in the global south. Here social innovation is defined as implementing a known public health tool via a novel, community-driven technique.

Main Body

In this article, we discuss three diverse cases that show the potential for using social innovation in diagnostics. The cases chosen for inclusion here demonstrate the importance of social innovation in diagnostics across different geographic, cultural, and health system contexts. They include malaria testing via schools in Malawi, cervical human papillomavirus (HPV) sample self-collection in Peru, and crowdsourcing human immunodeficiency virus (HIV) testing in China. For each case, we present the public health problem and the impact of using social innovation to increase accessibility of diagnostics. We discuss implications of each diagnostic approach and the importance of social innovation in creating these potential solutions. We argue that social innovation is useful in improving the delivery of essential diagnostic tools in low- and middle-income countries.

Conclusions

Interventions in Malawi, Peru, and China suggest social innovation increases uptake of diagnostics. The same tools and principles utilized in these cases can be adapted for use in other contexts. Such diagnostic innovations may help improve identification of and linkage to care for many diseases. The approach presents a unique opportunity to better address public health issues and increase accessibility in LMIC health systems.

Barriers to cervical cancer screening and acceptability of HPV self-testing: a cross-sectional comparison between ethnic groups in Southern Thailand

BACKGROUND

Cervical cancer rates are higher in low-resourced countries than high, partly due to lower rates of screening. Incidence in Thailand is nearly three times higher than in the USA (16.2 vs 6.5 age-standardised incidence), even with Thailand's universal health coverage, which includes screening, suggesting that alternative methods are needed to reduce the burden. We investigated barriers to screening, as well as acceptability of self-collection human papillomavirus (HPV) testing as a primary form of cervical cancer screening among Buddhist and Muslim communities in Southern Thailand.

METHODS

267 women from the Buddhist district of Ranot and Muslim district of Na Thawi, Songkhla were recruited to complete a survey assessing knowledge and risk factors of HPV and cervical cancer. Participants were offered an HPV self-collection test with a follow-up survey assessing acceptability. Samples were processed at Prince of Songkhla University and results were returned to participants.

RESULTS

267 women participated in the study (132 Buddhist, 135 Muslim), 264 (99%) self-collecting. 98% reported comfort and ease, and 70% preferred it to doctor-facilitated cytology. The main predictor of prior screening was religion (92% Buddhist vs 73% Muslim reporting prior Pap). After adjustment with multivariate logistic models, Muslim women had an OR of prior Pap of 0.30 compared with Buddhist (95% CI: 0.12 to 0.66).

CONCLUSIONS

Self-collection HPV testing was highly acceptable across religious groups, suggesting that it could be beneficial for cervical cancer reduction in this region. Focus should be put into educating women from all backgrounds about the importance of screening to further improve screening rates among Thai women.

Acceptability and Feasibility of Self-Collecting Biological Specimens for HIV, Sexually Transmitted Infection, and Adherence Testing Among High-Risk Populations (Project Caboodle!): Protocol for an Exploratory Mixed-Methods Study

BACKGROUND

Men who have sex with men (MSM) in the United States experience a disproportionate burden of HIV and bacterial sexually transmitted infections (STIs), such as gonorrhea and chlamydia. Screening levels among MSM remain inadequate owing to barriers to testing such as stigma, privacy and confidentiality concerns, transportation issues, insufficient clinic time, and limited access to health care. Self-collection of specimens at home and their return by mail for HIV and bacterial STI testing, as well as pre-exposure prophylaxis (PrEP) adherence monitoring, could be a resource-efficient option that might mitigate some of these barriers.

OBJECTIVE

Project Caboodle! is a mixed-methods study that explores the acceptability and feasibility of self-collecting and returning a bundle of 5 different specimens for HIV and bacterial STI testing, as well as PrEP adherence monitoring, among sexually active HIV-negative or unknown status MSM in the United States aged 18 to 34 years.

METHODS

Participants will be recruited using age, race, and ethnicity varied advertising on social networking websites and mobile gay dating apps. In Phase 1, we will send 100 participants a box containing materials for self-collecting and potentially returning a finger-stick blood sample (for HIV testing), pharyngeal swab, rectal swab, and urine specimen (for gonorrhea and chlamydia testing), and hair sample (to assess adequacy for potential PrEP adherence monitoring). Specimen return will not be incentivized, and participants can choose to mail back all, some, or none of the specimens. Test results will be delivered back to participants by trained counselors over the phone. In Phase 2, we will conduct individual in-depth interviews using a video-based teleconferencing software (VSee) with 32 participants from Phase 1 (half who returned all specimens and half who returned some or no specimens) to examine attitudes toward and barriers to completing various study activities.

RESULTS

Project Caboodle! was funded in May 2018, and participant recruitment began in March 2019. The processes of designing a study logo, creating advertisements, programming Web-based surveys, and finalizing step-by-step written instructions accompanied by color images for specimen self-collection have been completed. The boxes containing 5 self-collection kits affixed with unique identification stickers are being assembled, and shipping procedures (for mailing out boxes to participants and for specimen return by participants using prepaid shipping envelopes) and payment procedures for completing the surveys and in-depth interviews are being finalized.

CONCLUSIONS

Self-collection of biological specimens at home and their return by mail for HIV and bacterial STI testing, as well as PrEP adherence monitoring, might offer a practical and convenient solution to improve comprehensive prevention efforts for high-risk MSM. The potentially reduced time, expense, and travel associated with this approach could facilitate a wider implementation of screening algorithms and remote monitoring strategies.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/13647.

Detecting cervical precancer and reaching underscreened women by using HPV testing on self samples: updated meta-analyses

OBJECTIVE

To evaluate the diagnostic accuracy of high-risk human papillomavirus (hrHPV) assays on self samples and the efficacy of self sampling strategies to reach underscreened women.

DESIGN

Updated meta-analysis.

DATA SOURCES

Medline (PubMed), Embase, and CENTRAL from 1 January 2013 to 15 April 2018 (accuracy review), and 1 January 2014 to 15 April 2018 (participation review).

REVIEW METHODS

Accuracy review: hrHPV assay on a vaginal self sample and a clinician sample; and verification of the presence of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) by colposcopy and biopsy in all enrolled women or in women with positive tests. Participation review: study population included women who were irregularly or never screened; women in the self sampling arm (intervention arm) were invited to collect a self sample for hrHPV testing; women in the control arm were invited or reminded to undergo a screening test on a clinician sample; participation in both arms was documented; and a population minimum of 400 women.

RESULTS

56 accuracy studies and 25 participation trials were included. hrHPV assays based on polymerase chain reaction were as sensitive on self samples as on clinician samples to detect CIN2+ or CIN3+ (pooled ratio 0.99, 95% confidence interval 0.97 to 1.02). However, hrHPV assays based on signal amplification were less sensitive on self samples (pooled ratio 0.85, 95% confidence interval 0.80 to 0.89). The specificity to exclude CIN2+ was 2% or 4% lower on self samples than on clinician samples, for hrHPV assays based on polymerase chain reaction or signal amplification, respectively. Mailing self sample kits to the woman's home address generated higher response rates to have a sample taken by a clinician than invitation or reminder letters (pooled relative participation in intention-to-treat-analysis of 2.33, 95% confidence interval 1.86 to 2.91). Opt-in strategies where women had to request a self sampling kit were generally not more effective than invitation letters (relative participation of 1.22, 95% confidence interval 0.93 to 1.61). Direct offer of self sampling devices to women in communities that were underscreened generated high participation rates (>75%). Substantial interstudy heterogeneity was noted (I²>95%).

CONCLUSIONS

When used with hrHPV assays based on polymerase chain reaction, testing on self samples was similarly accurate as on clinician samples. Offering self sampling kits generally is more effective in reaching underscreened women than sending invitations. However, since response rates are highly variable among settings, pilots should be set up before regional or national roll out of self sampling strategies.

Impact of operational factors on HPV positivity rates in an HPV-based screening study in Colombia

OBJECTIVE

To assess the effect of operational factors on the positivity rates of three HPV assays.

METHODS

Within the cross-sectional ESTAMPA study, women aged 30-64 years were recruited at healthcare centers from Soacha, Colombia, during 2012-2015. Cervical samples were collected for cotesting with Hybrid Capture 2 (HC2; Qiagen, Gaithersburg, MD, USA), and either Aptima (Hologic, Marlborough, MA, USA) or Cobas 4800 (Roche Diagnostics, Indianapolis, IN, USA). The effect of operational factors on assay performance was assessed using adjusted positivity rates obtained from logistic regression models.

RESULTS

There were 4168 women included. For samples collected in assay-specific medium, positivity rate differences were associated with the expertise of the nurse collecting the sample (P=0.014 HC2; P=0.091 Aptima) and if sample collection occurred after an initial cytology (P=0.025 HC2; P=0.033 Aptima). If PreservCyt medium (Hologic) was used, HC2 positivity differences were observed depending on the time between sample collection and processing (P=0.026) and on the laboratory technician processing the samples (P=0.003). No differences were observed for PreservCyt samples processed with Aptima or Cobas.

CONCLUSION

Nurse expertise, collection of previous cytology, processing time, and laboratory technician could influence HPV assay performance. Suitable quality assurance protocols for HPV-based screening programs are required. ClinicalTrials.gov: NCT01881659.

Self-Sampling for Human Papillomavirus Testing: Increased Cervical Cancer Screening Participation and Incorporation in International Screening Programs

In most industrialized countries, screening programs for cervical cancer have shifted from cytology (Pap smear or ThinPrep) alone on clinician-obtained samples to the addition of screening for human papillomavirus (HPV), its main causative agent. For HPV testing, self-sampling instead of clinician-sampling has proven to be equally accurate, in particular for assays that use nucleic acid amplification techniques. In addition, HPV testing of self-collected samples in combination with a follow-up Pap smear in case of a positive result is more effective in detecting precancerous lesions than a Pap smear alone. Self-sampling for HPV testing has already been adopted by some countries, while others have started trials to evaluate its incorporation into national cervical cancer screening programs. Self-sampling may result in more individuals willing to participate in cervical cancer screening, because it removes many of the barriers that prevent women, especially those in low socioeconomic and minority populations, from participating in regular screening programs. Several studies have shown that the majority of women who have been underscreened but who tested HPV-positive in a self-obtained sample will visit a clinic for follow-up diagnosis and management. In addition, a self-collected sample can also be used for vaginal microbiome analysis, which can provide additional information about HPV infection persistence as well as vaginal health in general.

Agreement of self- and physician-collected samples for detection of high-risk human papillomavirus infections in women attending a colposcopy clinic in Thailand

Objective

To study the concordance between vaginal self- and endocervical physician-collected high-risk (hr) HPV testing in Thai women who attended a colposcopy clinic. Vaginal samples were obtained by self-sampling with a dry brush before endocervical samples were obtained by physicians. Both specimens were analyzed for hrHPV by Cobas4800 HPV test.

Results

Of the 247 pairs of samples, overall hrHPV prevalence from self- and physician-collected samples was 41.3 and 36.0%, respectively. The overall agreement between the methods was 74.5% with κ 0.46 (P < 0.001). Our study revealed moderate agreement between self- and physician-collected methods for hrHPV testing.

Acceptability of Human Papillomavirus Self-Sampling for Cervical Cancer Screening in an Indigenous Community in Guatemala

PURPOSE

Cervical cancer rates in Latin America are higher than those in developed countries, likely because of the lower prevalence of screening. Specifically, less than 40% of women in Guatemala are regularly screened and even fewer women are screened in indigenous communities. Current screening strategies-Pap smears and visual inspection with acetic acid-might not be the most effective methods for controlling cancer in these settings. We thus investigated the potential of self-collection of cervical samples with testing for human papillomavirus (HPV) to help prevent cervical cancer in an indigenous community in Guatemala.

PATIENTS AND METHODS

A community representative random sample of 202 indigenous women age 18 to 60 years residing in Santiago Atitlan, Guatemala, were surveyed to assess knowledge of and risk factors for HPV and cervical cancer. Women were then invited to self-collect a cervical sample using HerSwab collection kits to assess the prevalence of HPV and the acceptability of self-sampling.

RESULTS

Of 202 women who completed the survey, 178 (89%) provided a self-sample. In all, 79% of these women found the test comfortable, 91% found the test easy to use, and 100% reported they were willing to perform the test periodically as a screening method. Thirty-one samples (17%) were positive for at least one of 13 high-risk HPV types, and eight (4.5%) were positive for HPV 16/18.

CONCLUSION

HPV testing by using self-collected samples was well accepted, suggesting that it is a plausible modality for cervical cancer screening in indigenous communities. Further studies are needed to assess rates of follow-up after a positive test and to determine whether these findings extend to other indigenous and nonindigenous communities in Guatemala and Latin America.

Awareness of Cervical Cancer Causes and Predeterminants of Likelihood to Screen Among Women in Haiti

OBJECTIVES

Cervical cancer is the leading cause of cancer deaths among women in Haiti. Given this high disease burden, we sought to better understand women's knowledge of its causes and the sociodemographic and health correlates of cervical cancer screening.

MATERIALS AND METHODS

Participants were 410 adult women presenting at clinics in Léogâne and Port-au-Prince, Haiti. We used bivariate and multivariate logic regression to identify correlates of Pap smear receipt.

RESULTS

Only 29% of respondents had heard of human papillomavirus (HPV), whereas 98% were aware of cervical cancer. Of those aware of cervical cancer, 12% believed that sexually transmitted infections (STIs) cause it, and only 4% identified HPV infection as the cause. Women with a previous sexually transmitted infection were more likely to have had Pap smear (34% vs 71%, odds ratio = 3.45; 95% CI = 1.57-7.59). Screening was also more likely among women who were older than the age of 39 years, better educated, and employed (all p < .05). Almost all women (97%) were willing to undergo cervical cancer screening.

CONCLUSIONS

This sample of Haitian women had limited awareness of HPV and cervical cancer causes; but when provided with health information, they saw the benefits of cancer screening. Future initiatives should provide health education messages, with efforts targeting young and at-risk women.

The acceptability of vaginal smear self-collection for screening for cervical cancer: a systematic review

Cervical cancer is a major cause of death in adult women. However, many women do not undergo cervical cancer screening for the following reasons: fear, shame, physical limitations, cultural or religious considerations and lack of access to health care services. Self-collected vaginal smears maybe an alternative means of including more women in cervical cancer screening programs. The objective of this systematic review was to evaluate the acceptability of vaginal smear self-collection for cervical cancer screening. We selected articles from PubMed, the Cochrane Library and Embase that were published between January 1995 and April 2016. Studies written in English, French, Italian, Portuguese or Spanish that involved women between 18 and 69 years of age who had engaged in sexual intercourse were included in this review. The review was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Nineteen studies were ultimately evaluated in this review. Most of the included studies (n=17) demonstrated that the self-collection method exhibited outstanding acceptability among women with respect to cervical cancer screening, and only two studies indicated that self-collection exhibited low acceptability among women in this context. The acceptability of self-collection was determined subjectively (without standardized questionnaires) in 10 studies (53%) and via structured and validated questionnaires in the remaining studies. The results of our review suggest that the self-collection method is well-accepted and may therefore encourage greater participation in cervical cancer screening programs. However, additional studies are required to verify these results.