Single visit screen-triage-treat strategy using GeneXpert-based HPV testing of self-collected cervicovaginal samples and thermal ablation treatment for cervical cancer prevention among women in Lilongwe, Malawi

Abstract

Human papillomavirus (HPV) testing is now recommended for primary screening for invasive cervical cancer (ICC) among women. We evaluated same-day completion of an HPV screen-triage-treat algorithm consisting of: (1) GeneXpert high-risk HPV testing of self-collected vaginal samples, (2) visual inspection with acetic acid (VIA) and colposcopy for HPV+ women, and (3) thermal ablation (TA) treatment for HPV+ women with acetowhite cervical lesions eligible for TA by colposcopy, in Lilongwe, Malawi. We calculated same-day completion rates of the screening algorithm as the proportion of: (a) HPV+ women who had VIA the same day, and (b) HPV+ women with ablation-eligible lesions by colposcopy who received TA the same day. Between June 2020 and February 2022, we enrolled 1250 participants: 625 women living with HIV (WLWH) and 625 without HIV. Participant median age was 35 years (IQR 30-40). A total of 698 (55.8%) had no prior ICC screening, and 589 (99.7%) of WLWH were on antiretroviral therapy. HPV DNA positivity overall was 38.1% (n = 476) and higher among WLWH (n = 295, 47.2%) than those without HIV (n = 181, 29.0%). Overall, 469 (98.5%) of the 476 HPV+ women had VIA performed. Most HPV+ women had VIA performed the same day (96%, 95% confidence interval [CI]: 94%, 98%). Similarly, most HPV+ women with ablation-eligible lesions by colposcopy received TA the same day (99%, 95% CI: 95%, 100%). VIA performed similarly to colposcopy in eligibility determination for TA. A single visit approach is achievable with an Xpert-based screen-triage-treat strategy for ICC prevention in Malawi, a reassuring finding for HPV-based primary screening scale-up.

Keywords: HIV; HPV testing; cervical cancer; screen‐triage‐treat; thermal ablation.