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E Starr (August 2022). Launching HPV Self-testing Programs in Rural Communities in Low-and Middle- Income Countries. www.HPVWorld.com, 210

Cervical cancer prevention in low- and middle-income countries (LMICs) presents one of the greatest opportunities to reduce health disparities and improve healthcare equity globally. Over the next 15 years, six million women will die from cervical cancer. Nearly 90% of those deaths will occur in LMICs.¹ The wide disparities in cervical cancer cases and mortality are not due to differences in cervical infection with high-risk HPV strains or to differences in the pathogenesis of cervical cancer, but rather a matter of access to high-quality screening and treatment.²

HPV self-sampling is considered the gold standard screening technique for effective diagnosis of cervical precancer. This tool provides a great opportunity to achieve the WHO’s Strategic Goal of 70% of women screened with a high-performance test by 35 and 45 years of age, while maintaining a 90% treatment rate.²

Grounds for Health (GfH) is an international non-profit organisation with the mission to prevent cervical cancer in coffee-growing communities, some of the most rural and underserved regions of the world. We have 25 years’ experience in on-the-ground implementation of cervical cancer screen-and-treat programs for women, building local capacity in the provision of high-quality clinical care, and supporting communities in developing sustainable, comprehensive cervical cancer prevention programs.

In response to the WHO Call to Action, we are currently shifting our screening approach from visual inspection with acetic acid (VIA) to HPV self-sampling to improve patient recruitment in rural, underserved areas, and scale our programs with enhanced efficiency, effectiveness, and quality. We will focus on identifying best practices for implementing a cervical cancer prevention program in rural communities using HPV self-sampling.

As we introduce HPV self-sampling for screening and thermal ablation for treatment, we have taken the critical first step of fostering relationships with regional and federal government entities. Through partnerships with the local and national Ministries of Health, we ensure that new technologies, such as HPV self-sampling, are integrated into existing healthcare services. When possible, input is given in the development of national guidelines. Prior to actual implementation, key players such as representatives from Regional or County Health Departments were engaged through critical stakeholder meetings, demonstration opportunities and program launch events. In our case there has been minimal resistance to the introduction of HPV self-sampling. Most administrators have requested speedy program implementation and project and MOU agreements have been relatively fast-tracked.

A hallmark of Grounds for Health programs is our development of strong community-based partnerships. This has proven to be an essential step in preparation for introducing a new screening method. We expect to reach more women and provide them with patient-centred care that offers them autonomy, confidentiality, dignity, and respect. That said, the concept of self-sampling could result in stigma and misinformation if culturally-responsive community leaders and health promoters aren’t educated and engaged prior to implementation. Quality training of clinical providers and community health promoters has resulted in women in our communities being receptive to the approach and eager to register for screening. In recruitment for our first HPV self-sampling campaign in Ethiopia, for example, 218 women who did not previously seek VIA services (though they were available) signed up to self-test.

Health administrators and community partners continue to participate in and champion our programs. They help us establish realistic objectives based on community needs and resources, address barriers to implementation, and identify opportunities for innovation, impact, and sustainability.

As a relatively small organisation, Grounds for Health is in the unique position to implement a program, evaluate it and adapt the approach to ensure success. We define success by key indicators such as recruitment rates, the number of women lost to follow-up for treatment program efficiency, and patient satisfaction. We are working with ClickMedix in developing a software algorithm that will allow staff to collect the data necessary to evaluate various approaches taken in the introduction of HPV self-sampling. For example, rather than assuming that women will prefer collecting samples in their homes, we will evaluate various testing sites such as community facilities, local health centres and campaign settings, and use recruitment and screening data to identify the model that will result in the highest treatment rates.

Lessons learned will not only improve our programs but will be shared with other organisations around the globe addressing the implementation challenges specific to the most rural regions in LMICs, the communities where so many women live. It is an exciting time with the potential for ensuring that we reach our goal of preventing all women across the globe from dying from cervical cancer.


DISCLOSURE
The Author has no conflict of interest to disclose.


References

1. Bray F, Ferlay J, Soerjomataram I et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in185 countries. CA Cancer J Clin. 2018;68(6):394–424. Available from: https://doi.org/10.3322/caac.21492

2. WHO. Global strategy to accelerate the elimination of cervical cancer as a public health problem. November 2020. Available from: https://www.who.int/publications/i/item/9789240014107 (last accessed: 17 July 2022)


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