Dr. Mosamat Umma Kulsum, (Masters in Public Health., MBBS).
Can HPV Self Sampling Improve Screening for Cervical Cancer?
Cervical cancer arises in the cervix, the passage between the uterus and the vagina in women. The predominant cause of cervical cancer in about 99% of cases, is infection by high-risk human papilloma-viruses (HPV), a common virus typically transmitted through sexual contact. While most HPV infections resolve without symptoms, persistent infections can lead to cervical cancer in women. Being the fourth most prevalent cancer in women, cervical cancer affected approximately 570,000 women worldwide in 2018, with about 311,000 losing their lives to the disease. However, there is hope in preventing cervical cancer through effective primary measures like HPV vaccination, as well as secondary preventative approaches such as screening and treatment of precancerous lesions. By implementing these strategies, the majority of cervical cancer cases can be averted.
Early detection and efficient management play a crucial role in successfully treating cervical cancer. Even when diagnosed in the later stages, appropriate treatment and palliative care can help control the disease. With a comprehensive approach encompassing prevention, screening and treatment, cervical cancer can be eliminated as a public health concern within a single generation (1). While the majority of HPV infections resolve spontaneously, certain high-risk types have the potential to progress into cervical cancer. As part of cervical cancer screening, HPV testing plays a crucial role in identifying such infections (2). HPV infection in the cervix is the primary and most critical risk factor associated with the development of cervical cancer. In order to combat infection, the body activates an inflammatory response as a defensive mechanism, swiftly triggering the innate immune response to combat pathogens which is the case including viral infections (3).
The self-swab collection method using the FLOQSwab kit for HPV DNA testing which subsequently uses the GeneXpert machine for PCR amplification of the HPV genome stands out as the most effective technique for detecting HPV in cervical-vaginal samples. It has emerged as an extremely effective alternative for women living in remote geographical locations with infrastructural barriers that render visits to clinics or hospitals gynecological examinations difficult(4). Managing both household and professional work leave many Indian women with limited time for physician visits (4). Therefore, door step Self-swab swab collection kit for HPV DNA testing is a valuable solution, that not only reduces the need for travel but also out-of-pocket expenses (4).The implementation of self-sampling for HPV has the capacity to greatly increase the involvement of individuals in cervical cancer screening (4). Additionally, HPV self-sampling can serve as a powerful tool to engage individuals who would otherwise not attend cervical cancer screening programs (4).
Over the course of a year, from June 2022 to July 2023, I had the privilege of working in a project with a team focused on self-swab collection for HPV testing from the cervix within communities living in remote locations and hard-to-reach islands or villages. These villages had a number of houses with family members from 4 to 11. Only eligible women within 30 to 65 years of age were selected for our study. Our approach centered on community engagement, sensitization, education, and building trust to address sensitive health issues. We emphasized the importance of health education, street plays and courtyard sessions in community halls and/or public arenas were some of the means used to raise awareness about cervical health, swab collection and VIA screening.
To ensure the success of our initiative, we collaborated with local leaders, government officials, healthcare professionals, religious preachers, teachers and educators, seeking their support and guidance through workshops, group meetings & one to one sensitization programs. This collaboration was crucial to prevent the misunderstandings that could hinder our swab collection efforts. Efficient resource allocation was also of paramount importance.
We developed a micro plan that involved identifying the target community: women aged between 30 to 65 and meeting the inclusion criteria of the study. Some of the other factors that needed to be planned was the duration of the study, human resources needed, budget, number of swab to be collected, travel time and the capacity of the lab to process the samples. Community Health Workers, who were integral to the project, helped us select the right villages/chars for our activities.
We recognized that many women in the community experienced fear and anxiety about self-swab collection for HPV testing. To address this, we provided counseling sessions that not only explained the procedure but also offered emotional support. A pivotal aspect of our initiative was teaching women how to collect self-swab samples effectively to avoid invalid results. Detailed instructions and demonstrations were provided to boost participants’ confidence. Dealing with invalid test results was disheartening, as re-collecting samples was expensive and some women were reluctant to provide samples again. Seeing the relief on women’s faces when they received negative HPV test results brought a sense of peace and reassurance to their lives. For those who tested positive, we provided counseling for attending the clinic for further screening and treatment. However, some women were hesitant to undergo further screening, leading us to initiate VIA camps in undeserved areas in our regular see and treat project. Unique challenges, such as dealing with menstruating or last-minute refusals, required special consideration and sensitivity in our approach.
We also faced challenges in engaging conservative husbands who insisted on the sampling taking place within their households. To maintain sample quality under high temperatures, we used zip bags and cold boxes with ice packs, sometimes requiring the use of a refrigerator for larger sample collections and storing. As the laboratory was quite far from the communities, our journeys often involved overcoming obstacles like rain, floods, slippery roads and prolonged waits for transportation by road or river. Additionally, inconsistencies arose from incorrect identification marks on sample tubes, which led to the disposal of some collected samples.
Remarkably, some women who initially declined participation later approached us, recognizing the value of knowing the condition of their cervix. Collecting these samples was truly a team effort, and rigorous guidance, training, and monitoring were essential to maintain quality. We categorized our outcomes into HPV Positive, HPV Negative, Invalid, and Errors. This year-long experience in self-swab HPV collection empowered women to take control of their cervical health by building strong community relationships, reducing stigma, and providing support and education.
Our initiative not only detected HPV but also worked to eliminate the associated stigma and fear. As we move forward, we continue to prioritize community engagement and education to ensure that every woman has the knowledge and tools to protect herself from cervical cancer.
Author:
Dr. Mosamat Umma Kulsum, (Masters in Public Health, North South University., MBBS, University of Science and Technology, Chittagong, Chottogram, Bangladesh).
December 1, 2023
References:
1- WHO. World Health Organization. Cervical Cancer 2018. [Internet]. [cited 2023 Jun 6]. Available from: World Health Organization. Cervical Cancer 2018. Available online at: https://www.who.int/cancer/prevention/diagnosis-screening/cervical cancer/en/
2- WHO prequalifies additional HPV test, expanding options as countries pursue cervical cancer elimination. https://www.who.int/news/item/14-06-2023-who-prequalifies-additional-hpv-test-expanding-options-as-countries-pursue-cervical-cancer-elimination
3- The Cervical Cancer (CC) Epidemiology and Human Papillomavirus (HPV) in the Middle East. DOI: https://doi.org/10.55151/ijeedu.v2i2.29
4- HPV DNA Test as Primary Screening Method for Cervical Cancer. https://www.bio-services.org/hpv-dna-test-primary-screening-method-cervical-cancer/
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