Prospective cohort study examining cervical cancer screening methods in HIV-positive and HIV-negative Cambodian Women: a comparison of human papilloma virus testing, visualization with acetic acid and digital colposcopy

• Published in: BMJ open 2019-02, Vol.9 (2), p.e026887-e026887
• Main Authors: Thay, Sovannara, Goldstein, Andrew, Goldstein, Lena Sophia, Govind, Vaishnavi, Lim, Kruy, Seang, Chanthou
• Format: Article
• Language: English
• Subjects: Acetic Acid; Adult; Biopsy; Cambodia - epidemiology; Cervical cancer; Cervical Intraepithelial Neoplasia - diagnosis; Cervical Intraepithelial Neoplasia - epidemiology; Cervical Intraepithelial Neoplasia - virology; Cohort analysis; Colposcopy - economics; Disease prevention; Early Detection of Cancer - methods; Female; HIV; HIV Seronegativity; HIV Seropositivity - complications; HIV Seropositivity - epidemiology; Human immunodeficiency virus; Human papillomavirus; Humans; Mass Screening - methods; Middle Aged; Obstetrics and Gynaecology; Papillomaviridae - genetics; Papillomaviridae - isolation & purification; Papillomavirus Infections - complications; Papillomavirus Infections - diagnosis; Prospective Studies; Public health; Specimen Handling; Systematic review; Uterine Cervical Neoplasms - diagnosis; Uterine Cervical Neoplasms - epidemiology; Uterine Cervical Neoplasms - virology; Vaginal Smears - economics; Visualization; Womens health
• ISSN: 2044-6055; 2044-6055
• DOI: 10.1136/bmjopen-2018-026887

ObjectivesLogistical and economic issues make traditional cytology-based cervical cancer screening challenging in developing countries. Alternative, cost-effective, screening strategies must be developed to screen millions of women in resource-poor countries such as Cambodia.DesignA prospective cohort study during which all women underwent four cervical cancer screening methods: (1) self-sampled human papilloma virus (HPV) testing (careHPV system), (2) clinician-collected HPV testing, (3) visualization with acetic acid (VIA) and (4) digital colposcopy (DC) with the Enhanced Visual Assessment System (EVA).SettingA referral hospital in Phnom Penh, Cambodia.ParticipantsTwo hundred and fifty Cambodian women (129 HIV+, 121 HIV-). Subjects were recruited from the National Center for HIV/AIDS Dermatology and sexually transmitted disease (STD) cohort, the Sihanouk Hospital Center of Hope’s Rural Outreach Teams and the Pochentong Medical Center.ResultsFifty six of the 250 (22.4%) patients tested positive for high-risk HPV (hrHPV+). Thirty seven of the 129 HIV+ women were hrHPV+ (28.6%) whereas 19/121 HIV- women were hrHPV+ (15.7%) p=0.0154. Self-sampling HPV specimens identified 50/56 (89%) whereas physician-collected specimens identified 45/56 (80%) p=0.174. 95.2% of the patients felt comfortable obtaining HPV self-samples. Thirty seven of 250 women were VIA+. Thirty of 37 VIA+ women underwent confirmatory biopsies for cervical intraepithelial neoplasia (CIN) (26 CIN1, 4 CIN2+). The rate of confirmed dysplasia in the HIV+ group was 20/129 (15.5%) compared with 10/121 (8.26%) in HIV- women p=0.0291. The contemporaneous physician impressions of the DC images accurately differentiated between CIN1 and CIN2+ lesions in all 30 women having confirmatory biopsies.ConclusionsThe results of this study suggest potential modifications of the current cervical screening strategy that is currently being employed in Cambodia. The first step in this new strategy would be self-swabbing for hrHPV. Subsequently, hrHPV+ patients would have DC and immediate treatment based on colposcopic findings: cryotherapy for suspected CIN1 and loop electrosurgical excision procedure (LEEP) for suspected CIN2+.