GfH Attending Grand Challenges Annual Meeting 2023

Grounds for Health has been accepted to present at the Bill & Melinda Gates Foundation Global Grand Challenges meeting in Dakar, Senegal. The overall theme of this year’s annual meeting is “Science Saves Lives” and we are honored to share our research on HPV self-sampling and cervical cancer prevention in low and lower-middle income countries.

The following is an abstract presented by Dagmawi Iyasu (MSC/MCES), our Africa Program Manager, titled “An Implementation Model for Integration and Scale-up of HPV Self-sampling in LMICs”.

The meeting is held 8-11 October and the abstract is below.

“An implementation model to successfully integrate HPV DNA testing and scale-up cervical cancer prevention in LMICs”

The global health community, under the leadership of the World Health Organization, is committed to the elimination of cervical cancer through an HPV vaccination rate of 90% of girls before the age of 15, a the screening of 70% of age  eligible women with high performance HPV testing, and a 90% treatment rate for those who screen positive. Until recently, the single visit approach (SVA) involving visual inspection with acetic acid (VIA) for screening and ablative treatment of precancerous lesions, was considered the most impactful approach to secondary prevention in low-and middle- income (LMIC) countries. Efforts to integrate HPV DNA testing as a high-performance screening method are underway. However, the cost of HPV test kits and operational barriers to follow-up, continue to present challenges in bringing the effective, efficient, and sustainable integration of HPV DNA testing to scale with a 90% treatment rate in LMICs. 

Grounds for Health (GfH) has been working in cervical cancer prevention in some of the most rural regions in Latin America and Africa where coffee is grown since 1996. In August 2022, GfH introduced HPV DNA testing through self-sampling into its programs in Ethiopia and Kenya using the Atila Ampfire System. Given the challenges specific to our relatively remote communities, the hub and spoke approach was adopted which involved capacity building of lab personnel in a centralized hospital that is linked to surrounding public health facilities that currently deliver VIA screening and ablation treatment. Our robust VIA program continues as we introduce HPV self-sampling and address barriers to success.

A total of 1,232 and 1,036 samples have been collected for HPV testing from eligible women in Ethiopia and Kenya respectively. The HPV positivity rates were 23.4% in Ethiopia and 30.1% in Kenya. Of those that were HPV positive, 86.1% for Ethiopia and 79.1% for Kenya successfully reached health facilities for screening by VIA for triage, or VAT (visual assessment for treatment). In both countries, patient follow-up efforts continue to bear fruit and the programs expect to exceed the 90% treatment rate for all those who screen positive by the end of September 2023.     

In Ethiopia, per government guidelines, VIA screening is used for triage and only HPV+ and VIA+ women are eligible for treatment. Of the women screened by VIA,  28.2% were eligible for treatment and 97.1% of these received ablation treatment at that time while 2.9% were referred for LEEP treatment and/or suspicious for cancer follow-up. In Kenya, VIA is used as an assessment of eligibility for treatment by ablation (VAT). Of the women who tested HPV+, 79.1% underwent visual inspection for treatment (VAT), 98.4% of these women received treatment and the remaining were referred for LEEP treatment. 

In both countries, follow-up efforts and changes in our service delivery model continue to bear fruit and the programs expect to exceed the 90% treatment rate for all those eligible for screening and treatment by the end of September 2023. Confidence in this expected outcome is driven by the fact that an average of 90% of women who screened positive in both countries in June and July (which represents close to 30% of those screened thus far) returned for further assessment and treatment. It was during this time that we shifted our service delivery from a multi-visit or same-day approach to what we call a single clinic visit model.

We found it cumbersome and challenging for women to require two visits for assessment and treatment and we found it to be both difficult and inefficient to successfully conduct sampling, testing, assessment and treatment in a single day screen and treat approach. After evaluating outcomes, we shifted to a single clinic visit model whereby sample collection can happen over multiple days within a community setting, then batched and transported to the lab for testing within the following week. Result notification occurs and women who test positive are then able to go to a nearby health facility for assessment (using VIA or VAT) and treatment or referral, thereby only requiring a single clinic visit. 

We will continue to collect data from our programs in Ethiopia and Kenya and evaluate the relative success of the implementation models as we move forward, with the primary indicator of success being treatment rates of women testing positive for HPV. Strong partnerships with community health stakeholders within the public health system will continue to facilitate and ensure success in education, mobilization, sample collection, follow-up (tracking) of women, assessment and treatment. 

Lessons learned about ideal models of service delivery using HPV self-sampling will be critical to the success of programs in the secondary prevention of cervical cancer in low-and middle- income countries around the world. Bringing programs to scale will be an elusive goal if we don’t successfully reach women in rural and medically under-served communities around the globe.

*Note: The data has been updated since original posting.