The HPV-Automated Visual Evaluation (PAVE) Consortium is validating a cervical screening strategy enabling accurate cervical screening in resource-limited settings. A rapid, low-cost HPV assay permits sensitive HPV testing of self-collected vaginal specimens; HPV-negative women are reassured. Triage of positives combines HPV genotyping (four groups in order of cancer risk) and visual inspection assisted by automated cervical visual evaluation (AVE) that classifies cervical appearance as severe, indeterminate, or normal. Together, the combination predicts which women have precancer, permitting targeted management to those most needing treatment.

We analyzed CIN3+ yield for each PAVE risk level (HPV genotype crossed by AVE classification) from nine clinical sites (Brazil, Cambodia, Dominican Republic, El Salvador, Eswatini, Honduras, Malawi, Nigeria, and Tanzania). Data from 1832 HPV-positive participants confirmed that HPV genotype and AVE classification each strongly and independently predict risk of histologic CIN3+. The combination of these low-cost tests provided excellent risk stratification, warranting pre-implementation demonstration projects.

BACKGROUND

In Mali, cancer patients are often diagnosed at stage III or IV. Tumor wounds are more frequent and associated with malodorous exudates, responsible for an altered quality of life and stigmatization of patients. Cinesteam® Cinnamon Dressing is an adsorbent dressing designed to reduce odors. This study aimed at demonstrating the feasibility of routine use of cinnamon dressing in the Malian context, and to assess its effect on tumor wound odors.

PATIENTS AND METHODS

This is a prospective observational pilot study conducted jointly by the oncology department of the Point G University hospital in Bamako and Médecins Sans Frontières France. Included patients suffered from a malignant malodourous wound and were treated with cinnamon dressing. The primary endpoint was wound odor. Secondary endpoints were appetite, duration of dressing efficacy and ease of use.

RESULTS

Forty patients were included in this pilot study. Complete data and follow-up were available for 19 patients only. The odor score reported by patients was significantly decreased after 10 days of cinnamon dressing (odor score 1.7 versus 3.3, t-test 0.00003). Seventeen patients reported that the CINESTEAM® dressing was easy to use, even for patients receiving home-based palliative care in remote areas. The dressing provided an odor control that lasted more than 24 h. One year after inclusion, more than half of the patients had died of their cancer, indicating a very advanced stage at diagnosis. The cinnamon dressing had no effect on appetite, but most of the patients were undergoing palliative chemotherapy, which may account for this result.

CONCLUSION

The use of innovative dressings is feasible, even in very deprived contexts, and might decrease the discomfort linked with unpleasant odors in tumoral wounds. Odor management is crucial to restore self-esteem and to prevent patients' stigma and isolation.

INTRODUCTION

MSF is providing cervical cancer screening in Blantyre and Chiradzulu districts in Southern Malawi in the catchment area of 10 health centres. Improved screening strategies under diverse recruitment models are introduced to increase HPV screening coverage at health centres and with outreach activities.

METHODS

Under PAVE study, self-collected vaginal swabs are tested by an isothermal amplification PCR assay followed byvisual inspection, imaging, and histological assessment for HPV +ve women. Women living <5km from health centers are recruited opportunistically during routine visits. After HPV test, they are advised either to wait onsite (test-and-wait model) or called back in two days’ time (test-and-call model) for triage and treatment visit.Women living>10km from health centers are offered HPV test, triage, and treatment in community settings by outreach teams (mobile-clinic model). A fourth model for women living 5-10km from a health center with HPV testing in their communities followed by a triage and treatment visit at respective health centers (mobile-lab model) is not yet implemented.

RESULTS

As of April 2024, over 2000 women have undergone HPV screening across all active sites. Key insights from the experience are focused at: i)streamlining patient flow during opportunistic recruitment at health centers,ii)improving HPV results communication, iii)effectively tracing women back for triage and treatment visits using phone and community based tracing, iv)ensuring provision of stable internet for effective and real time data collection and synchronization, v)reducing gaps in logistics and quality assurances at HPV lab particularly in mobile lab setup, vi)ensuring real-time quality histopathology review of cervical biopsies for case management,and vii)continuous monitoring of patients and data flow to ensure quality of screening, compliance, and effective case management.

CONCLUSIONS

Diverse HPV-based screening strategies are key to achieve good screening coverage, and subsequently reducethe cervical cancer morbidity and mortality in southern Malawi.

INTRODUCTION

Since November 2019, Medecins Sans Frontieres (MSF) and the Malawian Ministry of Health have provided a comprehensive range of cervical cancer care services. Initially, all consultations, pathological diagnoses, chemotherapy, surgery, and patient support activities were centralized at the tertiary hospital. To address the overwhelming surge in demand for these services, an innovative decentralisation approach was introduced to alleviate the workload and enhance patient care quality.

METHODS

The decentralization strategy involves triaging patients at the district level and categorizing them by type of lesion (Fig 1). Patients with early or locally advanced cancer, as well as those in need of palliative chemotherapy, are referred to the tertiary hospital for further evaluation and treatment. Those with premalignant lesions or advanced cancer are treated at the district level by trained surgical and palliative care teams. Quality is ensured through provision of medications, equipment and allowances, as well as monthly mentoring sessions for about 120 providers.

RESULTS

During the first months of comprehensive care provision, the number of palliative consultations at the tertiary hospital increased way above the threshold of 150 manageable consultations. Using the new decentralized system from August 2021, 818 palliative patients were referred to 45 palliative sites at district level, leading to a reduction in monthly consultations at central level from a high of 226 (2021) to a high of only 134 (2023) (Fig 2). Among the new patients presenting at the tertiary hospital, an average of 45% presented with benign or pre-malignant lesions. Therefore, from July 2023, 561 women started to be biopsied and managed at their district hospitals instead of the tertiary level.

CONCLUSIONS

It is feasible to provide a comprehensive package of cervical cancer care in low resource settings without overburdening services when a decentralization strategy is used to ensure manageable workload and high quality of care.