AVIVA: a telehealth tool to improve cervical cancer screening in resource-constrained settings

Abstract

Cervical cancer accounts for 21.7% of all cancer deaths in the sub-Saharan Africa with a case fatality rate of 68%. Nigeria's Federal Ministry of Health has adopted cervical cancer screening (CCS) using visual inspection with acetic acid or Lugol's iodine (VIA/VILI) and cryotherapy treatment for precancerous lesions as the preferred screening and treatment strategy. Using the Exploration, Preparation, Implementation and Sustainment Framework, our study documents our experience during the development, piloting and roll-out of the APIN Public Health Initiatives (APIN)-developed VIA Visual Application (AVIVA) for CCS using the VIA method in 86 APIN-supported health facilities across 7 states in Nigeria. Between December 2019 and June 2022, with the aid of 9 gynaecologists and 133 case finders, a total of 29 262 women living with HIV received VIA-based CCS and 1609 of them were VIA-positive, corresponding to VIA positivity rate of 5.5%. Over the 30 months duration and the 5 phases of CCS scale-up, AVIVA development and expansion, a total of 1247 cases were shared via the AVIVA App (3741 pictures), with 1058 of such cases undergoing expert review, corresponding to a reviewer rate of 84.8%. Overall, the use of the AVIVA App improved both the VIA-positive and VIA-negative concordance rates by 16 percentage points each (26%-42% and 80%-96%, respectively) from baseline to the end of the study. We concluded that the AVIVA App is an innovative tool to improve CCS rates and diagnostic precision by connecting health facility staff and expert reviewers in resource-limited settings.

Keywords: Cancer; HIV; Screening.

Figure 1

Cervical cancer screening algorithm for WLHIV. VIA, visual inspection with acetic acid; WLHIV, women living with HIV.

Figure 2

Implementation milestones for AVIVA project. AVIVA, APIN developed VIA Visual Application; SMS, short message service. UCH, University College Hospital, Ibadan, Nigeria

Figure 3

Cervical cancer screening clinic flow chart for WLHIV. WLHIV-women living with HIV, ARV-.Antiretroviral, TB-Tuberculosis, ART-Antiretroviral therapy, VL-Viral load, UCH- University College Hospital, Ibadan, Nigeria.

Figure 4

(A) Positive concordance trend pre-AVIVA to phase 3 scale up. (B) Negative concordance trend post-AVIVA phases 1–3. AVIVA, APIN developed VIA Visual Application.

Figure 5

Flow chart of cases from trained healthcare workers (HCWs) to expert reviewers. AVIVA, APIN developed VIA Visual Application; VIA, visual inspection with acetic acid; WLHIV, women living with HIV.

Figure 6

(A) Landing page for AVIVA App. (B) Sample AVIVA consultation. AVIVA, APIN developed VIA Visual Application.