Implementation of HPV testing in Latin America

doi:10.1016/j.jcv.2015.11.035

Journal of Clinical Virology

Volume 76, Supplement 1, March 2016, Pages S69-S73

https://doi.org/10.1016/j.jcv.2015.11.035 Get rights and content

Highlights

•
Experience from pilot programs inform Latin America’s transition to HPV testing.
•
El Salvador, Guatemala, Honduras, Nicaragua beginning population-level HPV testing.
•
Latin America has regional advantages that facilitate transition to HPV testing.

Abstract

Cervical cancer is one of the leading killers among women in Latin America, a region where most countries have not been successful in implementing population-level cytology-based screening programs. This disease is caused by persistent infection with oncogenic HPV; in recent years, more HPV tests have become available and prices have dropped significantly, making it possible for countries to adopt these technologies. Pilot programs that took place in Nicaragua, Mexico, and Argentina showed a high level of efficacy in detecting precancerous cervical lesions and good feasibility and acceptance of self-sampling. El Salvador, Guatemala, Honduras, and Nicaragua are beginning to institutionalize HPV testing at the population level. The experience from the different countries has created rich information about the barriers and requirements for implementing HPV screening at large scale in these resource-constrained countries. There are several challenges for implementation, including a need to update screening guidelines, strengthen treatment capacity, and develop a comprehensive quality assurance plan for the HPV testing. At the same time, there are several opportunities in Latin America that make the process more feasible and faster than in other regions of the world: most Latin American countries already have screening programs funded by their national governments, several countries in the region are already implementing HPV testing, and there is a regional pooled procurement mechanism that could facilitate the purchase of HPV tests at an accessible price. We envision that most countries in the region will include HPV testing in their national program within the next three to five years.

Section snippets

Background

Cervical cancer is the second most common neoplasia and one of the leading killers among women in Latin America [1]. This neoplasia is related to chronic infection with any of the oncogenic types of human papillomavirus (HPV). There are more than 200 genotypes of HPV, but approximately 14 of them are related to this neoplasia; for this reason, cervical cancer is considered a neoplasia related to a sexually transmitted infection [2]. Screening programs based on cervical cytology (Pap smear) have

Experiences of HPV implementation in Latin America

Over the last decade, there have been multiple experiences with HPV testing in Latin America; some as part of research studies, others to pilot the implementation of HPV tests in the public system, and more recently, actual implementation of HPV testing as part of the regular services provided by the ministry of health facilities.

Opportunities for implementation

Approximately 6 countries in Latin America (Argentina, El Salvador, Guatemala, Honduras, Mexico, and Nicaragua) have started to implement HPV DNA testing in their national cervical cancer screening programs, and more countries will follow this path. There are several opportunities in Latin America that are making the process more feasible and faster than in other regions. The first opportunity is that most Latin American countries already have cervical cancer screening programs funded and led

Conflict of interest

Jose Jeronimo was the director of the study in Masaya, Nicaragua, and received all the tests used in the study as donations from the manufacturing company (QIAGEN). Jose Jeronimo was also the co-owner and deputy manager of Onco Prev International, a Peruvian company that offered cervical cancer screening services including Pap smear, HPV testing, colposcopy and surgical treatment. Francesca Holme has presented at a meeting of QIAGEN’s shipping and logistics department, for which her travel

Ethical approval

Not required.

Funding

Not required.

References (16)

N. Munoz et al.
Chapter 1: HPV in the etiology of human cancer
Vaccine
(2006)
R. Murillo et al.
Cervical cancer screening programs in Latin America and the Caribbean
Vaccine
(2008)
S. Arrossi et al.
Effect of self-collection of HPV DNA offered by community health workers at home visits on uptake of screening for cervical cancer (the EMA study): a population-based cluster-randomised trial
Lancet Global Health
(2015)
L.A. Torre et al.
Global cancer statistics
CA Cancer J. Clin.
(2015)
L. Gustafsson et al.
International incidence rates of invasive cervical cancer before cytological screening
Int. J. Cancer
(1997)
M.H. Mayrand et al.
Human papillomavirus DNA versus papanicolaou screening tests for cervical cancer
N. Engl. J. Med.
(2007)
S. Terrazas et al.
Human papillomavirus testing in cervical cancer screening at a public health service of Santiago, Chile
Rev. Med. Chile
(2015)
M. Almonte et al.
Cervical screening by visual inspection, HPV testing, liquid-based and conventional cytology in Amazonian Peru
Int. J. Cancer
(2007)

There are more references available in the full text version of this article.

Cited by (45)

Self-sampling for HPV testing in cervical cancer screening: A scoping review
2024, European Journal of Obstetrics and Gynecology and Reproductive Biology
Cervical cancer is the third most common gynecological cancer worldwide. Its origin is linked to intraepithelial lesions caused by high-risk Human Papillomavirus (HPV) types, detected in 99.7% of cases. Early screening is essential to prevent cancer development from these lesions. Molecular methods are more specific and offer the possibility of being performed through a self-collected sample by the patient, thus contributing to increasing screening coverage for this pathology. This study aim was to map the medical-scientific literature on existing protocols for self-sampling for HPV testing in cervical cancer screening. A search strategy was developed using the following keywords and their synonyms: “self-sampling,” “professional sampling,” and “HPV”, on the databases: MEDLINE, Cochrane Library, Virtual Health Library - BVS, Scopus, National Institute for Health Research NHS EED, Web of Science, and EMBASE. The search strategy was formulated to identify relevant studies and describe their main characteristics, such as patient acceptance of self-sampling, cost differences between the tests used, and the accuracy of self-sampling compared to the gold standard test. A total of 876 studies were found, and 33 of those studies were included in this review. Out of these, 10 studies were domized clinical trials involving 46,751 patients, and 23 observational studies included 142,795 patients. Regarding acceptance, most studies reported a preference for self-sampling. Sensitivity analyses from various studies also showed that the low cost of self-sampling kits generally increased cost-effectiveness. The study concluded that using HPV testing on self-collected samples is a viable strategy for monitoring women with HPV.
Development and validation of the cervical cancer knowledge scale and HPV testing knowledge scale in a sample of Canadian women
2022, Preventive Medicine Reports
Citation Excerpt :
Furthermore, the possibility of self-collection of cervical samples (i.e., self-sampling) presents a promising option for those who experience barriers to in-person screening (Nelson et al., 2017). Several organizations (e.g., the World Health Organization, United States Preventive Services Task Force) (World Health Organization, 2021; United States Preventive Services Task Force, 2018) and countries (Maver and Poljak, 2020; Jeronimo et al., 2016; Canadian Partnership Against Cancer, 2020) have now updated their cervical cancer screening recommendations to incorporate HPV testing. Knowledge of cervical cancer and HPV testing varies and is associated with sufficient screening for cervical cancer (Tatar et al., 2020; Kasting et al., 2017).
Knowledge of cervical cancer and HPV testing are important factors in proactive and continued engagement with screening and are critical considerations as countries move towards the implementation of HPV-based primary screening programs. However, existing scales measuring knowledge of both cervical cancer and HPV testing are not up to date with the current literature, lack advanced psychometric testing, or have suboptimal psychometric properties. Updated, validated scales are needed to ensure accurate measurement of these factors. Therefore, the aim of this study was to develop and validate two scales measuring cervical cancer knowledge and HPV testing knowledge. A pool of items was generated by retaining relevant existing items identified in a 2019 literature search and developing new items according to themes identified in recent systematic reviews. Items were assessed for relevance by the research team and then refined through seven cognitive interviews with Canadian women. A web-based survey including the remaining items (fourteen for each scale development) was administered to a sample of Canadian women in October and November of 2021. After data cleaning, N = 1027 responses were retained. Exploratory and Confirmatory Factor Analysis were conducted, and Item Response Theory was used to select items. The final cervical cancer knowledge scale (CCKS) and HPV testing knowledge scale (HTKS) were unidimensional, and each consisted of eight items. CFA demonstrated adequate model fit for both scales. The developed scales will be important tools to identify knowledge gaps and inform communications about cervical cancer screening, particularly in the context of HPV-based screening implementation.
Introduction of HPV testing for cervical cancer screening in Central America: The Scale-Up project
2020, Preventive Medicine
Citation Excerpt :
HPV tests were provided to the countries through project funds. The Scale-Up project was planned in three phases: preparation, pilot testing, and expansion; project details have been described previously (Jeronimo et al., 2016). Each country adapted its own guidelines for cervical cancer screening based on WHO 2013 recommendations (World Health Organization (WHO) website, n.d.-a) to include HPV testing, specifying target age groups, management of HPV screen-positive women, and follow-up (Table 1 and Fig. 2).
The Scale-Up project introduced vaginal self-sampling and low-cost human papillomavirus (HPV) testing as the primary approach for cervical cancer screening in selected public health centers in Guatemala, Honduras, and Nicaragua. We evaluate the country-specific accomplishments in screening: target-coverage, triage, and treatment. Between 2015 and 2018, cervical cancer screening was offered to women at least 30 years of age. Triage of HPV-positive women was based on visual inspection with acetic acid or Pap. Aggregated data included total women screened, use of self-sampling, age, time elapsed since last screening, HPV results, triage tests, triage results, and treatment. A total of 231,741 women were screened for HPV, representing 85.8% of the target populations within the project. HPV positivity was lower in Guatemala (12.4%) compared to Honduras and Nicaragua (14.5% and 14.2%, respectively, p < 0.05). A follow-up triage test was completed for 84.2%, 85.8%, and 50.1% of HPV-positive women in Guatemala, Nicaragua, and Honduras, respectively. Of those with a positive triage test, 84.7%, 67.1%, and 58.8% were treated in Guatemala, Nicaragua, and Honduras, respectively. First-time screening was highest in Nicaragua (55.8%) where self-sampling was also widely used (97.1%). The Scale-Up project demonstrated that large-scale cervical cancer screening and treatment intervention in a high-burden, low-resource setting can be achieved. Self-sampling and ablative treatment were key to the project's achievements. Data monitoring, loss to follow-up, and triage methods of screen- positive women remain critical to full success.
Psycho-social impact of positive human papillomavirus testing in Jujuy, Argentina results from the Psycho-Estampa study
2020, Preventive Medicine Reports
Citation Excerpt :
World Health Organization, 2014) Worldwide, more than 15 countries have introduced HPV testing in primary screening; (Cervical Cancer Action, 2017) in the Latin American region, Argentina and Mexico are using it as public health policy for cervical cancer prevention, and in most other countries in the region, pilot or demonstration projects are being implemented in order to move forward towards national implementation. ( Jerónimo et al., 2016; Arrossi et al., 2019) High screening coverage as well as high adherence to follow-up recommendations and treatment are necessary in order to achieve a reduction in cervical cancer incidence. ( World Health Organization, 2014)
Human papillomavirus (HPV) testing can have a negative impact on women’s lives which might also result in abandoning the follow-up and treatment process. This study measured the psycho-social impact of HPV-positivity among HPV-tested women from Jujuy, Argentina, a middle-low income setting.
In this cross-sectional study (2015–2016), the psycho-social impact of HPV-positivity was measured using the Psycho-Estampa Scale, specifically designed and validated to be used in screening contexts. We measured mean scores for each of the five scale domains, and the Overall Impact score (Values from 1: No impact to 4: Heavy impact). We compared scores according to cytology triage diagnosis using ordinal logistic regression.
A total of 163 HPV-positive women were recruited at the Centro Carlos Alvarado hospital and included in the study sample; of these, 124 (76.1%) had normal triage cytologies. The overall Impact score was between low and moderate (mean:2.56, SD:0.65). The highest psycho-social impact was measured in the Worries about cancer and treatment domain (mean score:3.60, SD:0.60), followed by Sexuality domain (mean:2.50; SD:1.00). The Uncertainty about information provided by health providers domain had the lowest mean score (mean:2.14, SD:0.73). Compared to women with normal cytologies (n = 124), women with abnormal cytologies (n = 39) had a higher likelihood of greater overall Psycho-social Impact (OR: 2.91; p = 0.0036). No statistically significant differences were found in scores of specific domains according to cytology results.
It is important to devise specific counseling interventions to reduce the psycho-social impact of HPV-Testing as primary screening and its potential effect on completion of the diagnosis/ treatment process.
High-risk HPV prevalence and vaccination coverage among Indigenous women in the Colombian Amazon: Implications for cervical cancer prevention. Cross-sectional study
2024, PLoS ONE
Assessing generalizability of an AI-based visual test for cervical cancer screening
2023, medRxiv

View all citing articles on Scopus

View full text

ReviewImplementation of HPV testing in Latin America

Highlights

Abstract

Section snippets

Background

Experiences of HPV implementation in Latin America

Opportunities for implementation

Conflict of interest

Ethical approval

Funding

Vaccine

Vaccine

Lancet Global Health

Global cancer statistics

CA Cancer J. Clin.

International incidence rates of invasive cervical cancer before cytological screening

Int. J. Cancer

Human papillomavirus DNA versus papanicolaou screening tests for cervical cancer

N. Engl. J. Med.

Human papillomavirus testing in cervical cancer screening at a public health service of Santiago, Chile

Rev. Med. Chile

Cervical screening by visual inspection, HPV testing, liquid-based and conventional cytology in Amazonian Peru

Int. J. Cancer

Review
Implementation of HPV testing in Latin America