Cervical cancer screening by visual inspection and HPV testing in Eswatini

Abstract

In 2009, visual inspection with acetic acid (VIA) followed by cryotherapy (VIA-and-cryotherapy), was introduced into the Eswatini cervical cancer prevention programme. We present screening results of 654 women attending VIA-and-cryotherapy who participated in a sexually transmitted infections prevalence study, at which samples for HPV DNA testing and liquid-based cytology (LBC) were also collected. VIA positives (VIA+) ineligible for cryotherapy, suspected cancers and women with high-grade squamous intraepithelial or worse lesions (HSIL+) on LBC were referred for diagnosis and treatment. Women with negative VIA who were HPV positive (HPV+) and those VIA+ treated with cryotherapy were recalled for another VIA one-year later. The positivity rates of VIA, HPV, atypical squamous cells of undetermined significance or worse cytology abnormalities (LBC ASCUS+) and low-grade squamous intraepithelial or worse lesions (LBC LSIL+) were 9.7%, 42.6%, 13.2% and 5.3%, respectively. HPV testing detected 29 of 31 LSIL+ (93.6%, 95%CI: 78.6-99.2) while VIA only detected 11 (35.6%, 95%CI: 19.2-54.6). The HIV prevalence was 43% (95%CI: 39.2-46.9). HIV positives were at increased risk of being VIA+ (age-adjusted odds ratio: 2.5, 95%CI: 1.5-4.3), HPV+ (3.7, 2.6-5.3) and having LSIL+ (16.3, 4.9-54.8). The ineligibility rates for cryotherapy were 38% (24 of 63 VIA+), and 46% among HIV positives (18 of 39 VIA+). HPV testing was substantially more sensitive than VIA, thus, HPV followed by ablative treatment may be more effective. However, the high ineligibility for cryotherapy highlights the need for improving the assessment of eligibility for ablative treatment and for strengthening colposcopy, particularly in populations with high HIV prevalence.

Keywords: Cervical cancer screening; Eswatini; HIV; HPV testing; Screen-and-treat; WHO guidelines on cervical screening and treatment.

Fig. 1

Flowchart of the cervical screening process. VIA: visual inspection after acetic acid; NEG: Negative; POS: Positive; HPV: human papillomavirus testing; LBC: liquid-based cytology; HSIL: high-squamous intraepithelial lesions on LBC; HSIL+: HSIL or worse lesions on LBC.

Fig. 2

Prevalence of high-risk HPV among HIV negative and HIV positive women by cytology grade within different age groups. ASCUS: includes atypical squamous cells of undetermined significance (ASC-US) and atypical glandular cells of undetermined significance (AGUS) LBC results. LSIL+: low-grade squamous intraepithelial lesions or worse LBC results.