Inter- and intra-observer agreement in the assessment of the cervical transformation zone (TZ) by visual inspection with acetic acid (VIA) and its implications for a screen and treat approach: a reliability study.

BACKGROUND: In low-resource countries, interpretation of the transformation zone (TZ) using the classification of the International Federation for Cervical Pathology and Colposcopy (IFCPC), adopted by the World Health Organization, is critical for determining if visual inspection with acetic acid (VIA) screening and thermal ablation treatment are possible. We aim to assess inter- and intra-observer agreement in TZ interpretation. METHODS: We performed a prospective multi-observer reliability study. One hundred cervical digital images of Human papillomavirus positive women (30-49 years) were consecutively selected from a Cameroonian cervical cancer screening trial. Images of the native cervix and after VIA were obtained. The images were evaluated for the TZ type at two time points (rounds one and two) by five VIA experts from four countries (Côte d'Ivoire, Cameroon, Peru, and Zambia) according to the IFCPC classification (TZ1 = ectocervical fully visible; TZ2 = endocervical fully visible; TZ3 = not fully visible). Intra- and inter-observer agreement were measured by Fleiss' kappa. RESULTS: Overall, 37.0% of images were interpreted as TZ1, 36.4% as TZ2, and 26.6% as TZ3. Global inter-observer reliability indicated fair agreement in both rounds (kappa 0.313 and 0.288). The inter-observer agreement was moderate for TZ1 interpretation (0.460), slight for TZ2 (0.153), and fair for TZ3 (0.329). Intra-observer analysis showed fair agreement for two observers (0.356 and 0.345), moderate agreement for two other (0.562 and 0.549), and one with substantial agreement (0.728). CONCLUSION: Interpretation of the TZ using the IFCPC classification, adopted by the World Health Organization, is critical for determining if VIA screening and thermal ablation treatment are possible. However, the low inter- and intra-observer agreement suggest that the reliability of the referred classification is limited in the context of VIA. It's integration in treatment recommendations should be used with caution since TZ3 interpretation could lead to an important referral rate for further evaluation. Trial registration Cantonal Ethics Board of Geneva, Switzerland: N°2017-0110. Cameroonian National Ethics Committee for Human Health Research N°2018/07/1083/CE/CNERSH/SP.

A cross-sectional study exploring triage of human papillomavirus (HPV)-positive women by visual assessment, manual and computer-interpreted cytology, and HPV-16/18-45 genotyping in Cameroon.

BACKGROUND: High-risk human papillomavirus (HPV)-positive women require triage to identify those at higher risk of cervical intraepithelial neoplasia grade 2 or worse (CIN2+). We aimed to compare visual assessment of the cervix, manual cytology and automated cytology as triage tests to screen HPV-positive women, and to assess over-treatment rates after visual assessment and over-referral rates to colposcopy after cytology. METHODS: The present cross-sectional study is nested in a large prospective screening trial in Cameroon. Evaluations of the tests have been conducted individually and in combination with HPV-16/HPV-18/45 genotyping. For the evaluation of over-treatment and colposcopic over-referral, we simulated two screening scenarios: (1) one-visit scenario (test-triage-and-treatment); and (2) two-visit scenario (test-triage-and-colposcopy). RESULTS: 1582 women with a median age of 40 years (IQR 35-45) performed self-sampling for HPV testing, of which 294 (18.6%) were HPV-positive, and 12.2% had CIN2+. Sensitivities for CIN2+ detection were 77.1% for visual assessment, 80.0% for manual cytology, and 84.8% for automated cytology. Sensitivity of combined tests was higher compared with single tests. The highest sensitivity was obtained by the combination of genotyping and automated cytology (91.2%). In the one-visit scenario, the over-treatment rate was 83.9% in referred women, with a ratio of 6.2 treated women per CIN2+. In the two-visit scenario, the lowest over-referral rate would have been under manual cytology (45.0%), with a ratio of 1.8 referred women per CIN2+. Single and combined triage strategies by automated cytology gave rise to over-referral rates of 69.2% and 76.7%, respectively, and a ratio of 3.2 and 4.3 referred women per CIN2+, respectively. DISCUSSION: Triage of HPV-positive women using a combination of genotyping and automated cytology for CIN2+ detection may provide public benefits in low- and middle-income countries.

Case Study: Schistosomiasis of the Endocervical Canal, A Rarely Reported Localization.

With a challenging diagnosis, schistosomiasis is a major public health issue worldwide, particularly in low-resource countries. The presence of Schistosoma ova in the female genital tract is a common finding, which may engender considerable suffering among women of child-bearing age. We report the asymptomatic case of endocervical schistosomiasis without visible exocervical lesions in a 41-yr-old Malagasy woman with human papillomavirus-positive status detected during a cervical cancer screening campaign in Andilampanahy, Madagascar. Schistosomiasis involving only the endocervical canal is rarely reported and can be diagnosed histologically with endocervical brushing, which therefore represents a minimally invasive and well-tolerated tool for disease detection.

Cost-effectiveness evaluation of HPV self-testing offered to non-attendees in cervical cancer screening in Switzerland.

OBJECTIVE: About 30% of women who are eligible for cervical cancer (CC) screening remain un-screened or under-screened in Switzerland. HPV testing on self-collected vaginal samples (Self-HPV) has shown to be more sensitive than cytology while also reaching non-attendees. The objective of this study was to explore the cost-effectiveness of offering Self-HPV to non-attendees in Switzerland. METHODS: A recursive decision-tree with one-year cycles was used to model the life-long natural HPV history. Markov cohort simulations were used to assess the expected outcomes from the model. The outcomes of three strategies were compared with the absence of screening: Self-HPV and triage with colposcopy (Self-HPV/colpo), Self-HPV and triage with Pap cytology (Self-HPV/PAP), cytological screening and triage with HPV (PAP/HPV). Sensitivity analyses for the key parameters of the model were conducted to check the robustness of findings. RESULTS: Offering a Self-HPV screening to non-attendees could prevent 90% of CC and 94% of CC-related deaths in the study population. The current cytology-based program could reduce by 83% the number of CC cases and by 88% the number of CC-related deaths over the population's lifetime. Compared to the absence of screening, incremental cost-effectiveness ratios (ICER) were estimated to be, per saved Quality Adjusted Life Year (QALY), 12413US$ for the strategy Self-HPV/colpo, 11138US$ for the strategy Self-HPV/Pap and 22488US$ for the strategy PAP/HPV. CONCLUSIONS: Offering Self-HPV as a CC screening strategy to non-attendees in Switzerland is a cost-effective solution that is associated with a reduction of CC cases and related deaths. Self-HPV is more cost-effective than the currently used cytology-based screening.

Self-sampling to improve cervical cancer screening coverage in Switzerland: a randomised controlled trial.

BACKGROUND: The aim of this study is to evaluate whether self-sampling can increase screening attendance of women who do not attend regular screening in Switzerland. METHODS: Participants were proactively recruited in Geneva between September 2011 and November 2015. Women (25-69 years) who had not undergone CC screening in the last 3 years were considered eligible. Through a 1 : 1 ratio randomisation, enrolled participants were invited to either undergo liquid-based cytology, which was performed by a health-care provider (control group, CG) or to take a self-sample for HPV-testing, which was mailed to their home (intervention group, IG). RESULTS: A total of 331 and 336 women were randomised in the CG and in the IG, respectively. Overall, 7.3% (95% CI: 4.9-10.6) women in the CG and 5.7% (95% CI: 3.6-8.7) women in the IG did not undergo the initial screening (P=0.400). There were 1.95% (95% CI: 0.8-4.3) women in the CG and 5.05% (95% CI: 3.1-8.1) women in the IG with a positive screen who did not attend triage and colposcopy (P=0.036). CONCLUSIONS: The participation in CC screening in women offered self-sampling was not higher than among those offered specimen collection by a clinician. Compliance with further follow-up for women with a positive HPV test on the self-sample requires further attention.

Feasibility of thermocoagulation in a screen-and-treat approach for the treatment of cervical precancerous lesions in sub-Saharan Africa.

BACKGROUND: The use of thermocoagulation for the treatment of cervical precancerous lesions has recently generated a great deal of interest. Our aim was to determine the feasibility of this outpatient procedure in the context of a cervical cancer (CC) screen-and-treat campaign in sub-Saharan Africa. METHODS: Between July and December 2015, women living in the area of Dschang (Cameroon) aged between 30 and 49 years, were enrolled in a CC screening study. HPV self-sampling was performed as a primary screening test and women who were either "HPV 16/18/45-positive" or "positive to other HPV types and to VIA" were considered screen-positive, thus requiring further management. The primary outcome was the percentage of screen-positive patients who met the criteria to undergo thermocoagulation. The secondary outcome was the assessment of the procedure's side effects immediately after treatment and at the 1-month follow-up visit. RESULTS: A total of 1012 women were recruited in the study period. Among 121 screen-positive women, 110 of them (90.9%) were eligible to be treated with thermocoagulation. No patients discontinued treatment because of pain or other side effects. The mean ± SD (Standard Deviation) score measured on the 10-point Visual Analogue Scale (VAS) was 3.0 ± 1.6. Women having less than 2 children were more likely to report a higher pain score than those with more than two (4.2 ± 2.0 versus 2.9 ± 1.5, respectively; p value = 0.016). A total of 109/110 (99.1%) patients came to the 1-month follow-up visit. Vaginal discharge was reported in 108/109 (99.1%) patients throughout the month following treatment. Three patients (2.8%) developed vaginal infection requiring local antibiotics. No hospitalizations were required. CONCLUSION: The majority of screen-positive women met the criteria and could be treated by thermocoagulation. The procedure was associated to minor side effects and is overall feasible in the context of a CC screen-and-treat campaign in sub-Saharan Africa. TRIAL REGISTRATION: The trial was retrospectively registered on November 11, 2015 with the identifier: ISRCTN99459678 .

Human papillomavirus (HPV) contamination of gynaecological equipment.

OBJECTIVE: The gynaecological environment can become contaminated by human papillomavirus (HPV) from healthcare workers' hands and gloves. This study aimed to assess the presence of HPV on frequently used equipment in gynaecological practice. METHODS: In this cross-sectional study, 179 samples were taken from fomites (glove box, lamp of a gynaecological chair, gel tubes for ultrasound, colposcope and speculum) in two university hospitals and in four gynaecological private practices. Samples were collected with phosphate-buffered saline-humidified polyester swabs according to a standardised pattern, and conducted twice per day for 2 days. The samples were analysed by a semiquantitative real-time PCR. Statistical analysis was performed using Pearson's χ(2) test and multivariate regression analysis. RESULTS: Thirty-two (18%) HPV-positive samples were found. When centres were compared, there was a higher risk of HPV contamination in gynaecological private practices compared with hospitals (OR 2.69, 95% CI 1.06 to 6.86). Overall, there was no difference in the risk of contamination with respect to the time of day (OR 1.79, 95% CI 0.68 to 4.69). When objects were compared, the colposcope had the highest risk of contamination (OR 3.02, 95% CI 0.86 to 10.57). CONCLUSIONS: Gynaecological equipment and surfaces are contaminated by HPV despite routine cleaning. While there is no evidence that contaminated surfaces carry infectious viruses, our results demonstrate the need for strategies to prevent HPV contamination. These strategies, based on health providers' education, should lead to well-established cleaning protocols, adapted to gynaecological rooms, aimed at eliminating HPV material.

Barriers to Cervical Cancer Screening in Geneva (DEPIST Study).

OBJECTIVES: Cervical screening is only efficient if a large part of eligible women participate. Our aim was to identify sociodemographic barriers to cervical screening and consider self-reported reasons to postpone screening. METHODS: Between September 2011 and June 2015, a questionnaire addressing reasons for nonparticipation in cervical screening was completed by 556 women who had not undergone a Pap test in the preceding 3 years. Pearson χ test was used to analyze differences between subgroups. Logistic regression was used to explore the association between sociodemographic characteristics and reasons for nonparticipation. RESULTS: The main reasons for nonparticipation in cervical cancer screening were practical barriers, such as lack of time and the cost of screening. These barriers were more likely to be reported by working women, women who were not sexually active, and those without health insurance. Younger women, non-European women living in Switzerland, and childless women were more likely to have never participated in a screening program before (adjusted odds ratio [aOR], 3.15; 95% CI, 1.41-6.98; aOR, 2.76; 95% CI, 1.48-5.16; aOR, 1.74; 95% CI, 1.03-2.99, respectively). CONCLUSIONS: Practical considerations seem to play a more important role in screening participation than emotional reasons and other beliefs. Particular attention should be paid to immigrant communities, where women seem more likely to skip cervical screening.

Effectiveness of a two-stage strategy with HPV testing followed by visual inspection with acetic acid for cervical cancer screening in a low-income setting.

The World Health Organization recently advocated a two-stage strategy with human papillomavirus (HPV) testing followed by visual inspection of the cervix with acetic acid (VIA) as a suitable option for cervical cancer screening. However, its accuracy has never been directly assessed in the context of primary screening. To evaluate effectiveness of HPV testing on self-obtained specimens (self-HPV) followed by VIA (sequential testing) in a low-income setting, we recruited 540 women aged between 30 and 65 years in two Cameroonian periurban areas. Eligible women were counseled about cervical cancer and how to perform self-sampling. HPV positive and a random sample of HPV-negative women were called back for VIA and biopsy. Disease was defined by interpretation of cervical intraepithelial neoplasia Grade 2 or worse (CIN2+). Performances of VIA, self-HPV and sequential testing were determined after adjustment for verification bias. HPV prevalence was 27.0%. VIA positivity was 12.9% and disease prevalence was 5%. Sensitivity and specificity of VIA for CIN2+ were 36.4% [95% confidence interval (CI): 15.2-64.6%] and 90.4% (95% CI: 85.4-93.7%), respectively. Sensitivity of self-HPV [100.0% (95% CI: 79.6-100.0%)] was 66% higher than that of sequential testing [33.3% (95% CI: 15.2-58.3%)]. Meanwhile, specificity of self-HPV [74.5% (95% CI: 70.6-78.1%)] was 22% lower than that of sequential testing [96.7% (95% CI: 94.8-97.9%)]. A two-stage screening strategy with self-HPV followed by VIA improves specificity of cervical cancer screening, but at the cost of an important loss of sensitivity. Ways to improve VIA performance or other tools are needed to increase positive predictive value of HPV testing.

Cervical cancer screening in sub-Saharan Africa: a randomized trial of VIA versus cytology for triage of HPV-positive women.

Developing countries are interested in using human papillomavirus (HPV) testing as a primary screening test for cervical cancer prevention programs. The low specificity of the HPV assay requires triage testing of HPV-positive women. The aim of the study is to compare visual inspection with acetic acid (VIA) and cytology as triage testing methods in HPV-positive women to detect cervical intraepithelial neoplasia or Grade 2 or higher (CIN2+). The study was conducted in two Cameroonian towns (Yaoundé and Edea) and included 846 eligible women aged 25 to 65 years. All participants performed self-HPV testing. HPV-positive women (n = 259) were randomly assigned to be tested either by VIA (VIA group) or cytology (cytology group). HPV-positive women had both cervical biopsy and endocervical curettage to detect biopsy-confirmed CIN2+. All statistical tests were two-sided. The prevalence of HPV was 38.5%, and the mean age of HPV-positive women was 41.5 ± 10.1 years. One hundred ninety-eight women (97 in the VIA group and 99 in the cytology) were randomly assigned to one of the two testing arms. The sensitivity of VIA was 25.0% (95% CI, 7.1-59.1%), and the sensitivity of cytology was 90.0% (59.6-98.2%). The specificity was 74.2% (95% CI, 64.2-82.1%) for VIA and 85.2% (76.3-91.2%) for cytology. ROC area for cytology was 0.910 against the 0.496 area for VIA. In this trial, VIA was inferior to cytology as a triage test among HPV-positive women. Further investigations are needed to determine the optimal triage method for HPV-positive women.

Feasibility of at-home self-sampling for HPV testing as an appropriate screening strategy for nonparticipants in Switzerland: preliminary results of the DEPIST study.

OBJECTIVE: Nonattendees to cervical cancer screening are at a higher risk of developing cervical cancer. This study assessed women's willingness to perform a home-based self-sampling for human papillomavirus testing (Self-HPV) and explored the feasibility of establishing a home-based Self-HPV screening strategy in Switzerland. MATERIALS AND METHODS: Underscreened women (n = 158) who had not underwent a Pap test in the preceding 3 years were recruited between September 2011 and September 2013. Participants completed 2 questionnaires evaluating reasons for non-attendance at a screening program, sociodemographic issues, and satisfaction with and acceptability of the Self-HPV. Descriptive data and multivariate logistic regression were used to identify variables associated with women's willingness to perform at-home self-sampling for HPV testing. RESULTS: Lack of time because of work or childcare was the most common reason for nonattendance at a screening program. One hundred six women (82%) preferred the Self-HPV because it is easy to perform, convenient, comfortable, and private. Women were more likely to accept the Self-HPV as a future screening strategy if they had missed cervical cancer screening in the past because of lack of time (odds ratio [OR] = 6.2, 95% confidence interval [CI] = 1.6-23.6; p < .01). Twenty-six women felt pain during self-sampling. Previous negative experiences with screening and stress during sampling were associated with higher risk for pain (OR = 7.14, 95% CI = 2.0-25.3, p < .01 and OR = 4.73, 95% CI = 1.5-14.5, p < .01, respectively). CONCLUSIONS: The Self-HPV was accepted by nonattendees of cervical cancer screening programs. Self-sampling may promote screening among the unscreened and underscreened population of women in Switzerland while overcoming some practical barriers.

Use of Smartphones as Adjuvant Tools for Cervical Cancer Screening in Low-Resource Settings.

OBJECTIVES: Our aim was to evaluate the feasibility and performance of smartphone digital images for the detection of cervical intraepithelial neoplasia of grade 2 or worse (CIN2+) as an adjunct to a conventional visual inspection approach with acetic acid (VIA) and Lugol's iodine (VILI), in comparison with detection by histopathologic examination. METHODS: Three hundred women were primarily screened for human papillomavirus (HPV) using self-collected vaginal specimens. Human papillomavirus-positive women were then invited for VIA and VILI, which were interpreted as (i) nonpathological, (ii) pathological or, (iii) inconclusive. Cervical smearing, endocervical brushing, and cervical biopsies were performed. Digital images of the cervix were taken with a smartphone and evaluated offsite by experienced health care providers. Sensitivity and specificity for CIN2+ were compared between on-site and off-site observers, using histopathological diagnosis as the criterion standard. RESULTS: Eighty-eight HPV-positive women were screened for cervical cancer. Overall, 7 cases of CIN2+ (8.0%) were diagnosed using biopsy specimens. The on-site physician obtained a sensitivity of 28.6% (95% confidence interval [95% CI], 3.7-71) and a specificity of 87.2% (95% CI, 77.7- 93.7). The off-site physicians obtained a sensitivity ranging between 42.9% (95% CI, 9.9-81.6; p = 1) and 85.7% (95% CI, 42.1-99.6; p = .13) and a specificity between 48.1% (95% CI, 36.5- 59.7; p < .001) and 79.2% (95% CI, 68.5-87.6; p = .10). Comparison between observers did not reach significance. Observers assessed 95.6% of all images as very good or acceptable for interpretation purpose. CONCLUSION: Smartphone images may be a useful adjunct to conventional VIA and VILI for the detection of CIN2+ and improve cervical cancer screening in low-resource settings.

Sleepiness and sleep-disordered breathing in truck drivers : risk analysis of road accidents.

BACKGROUND: Portugal has one of the highest road traffic fatality rates in Europe. A clear association between sleep-disordered breathing (SDB) and traffic accidents has been previously demonstrated. This study aimed to determine prevalence of excessive daytime sleepiness (EDS) and other sleep disorder symptoms among truck drivers and to identify which individual traits and work habits are associated to increased sleepiness and accident risk. METHODS: We evaluated a sample of 714 truck drivers using a questionnaire (244 face-to-face interviews, 470 self-administered) that included sociodemographic data, personal habits, previous accidents, Epworth Sleepiness Scale (ESS), and the Berlin questionnaire (BQ). RESULTS: Twenty percent of drivers had EDS and 29 % were at high risk for having obstructive sleep apnea syndrome (OSAS). Two hundred sixty-one drivers (36.6 %) reported near-miss accidents (42.5 % sleep related) and 264 (37.0 %), a driving accident (16.3 % sleep related). ESS score ≥ 11 was a risk factor for both near-miss accidents (odds ratio (OR)=3.84, p<0.01) and accidents (OR=2.25, p<0.01). Antidepressant use was related to accidents (OR=3.30, p=0.03). We found an association between high Mallampati score (III-IV) and near misses (OR=1.89, p=0.04). CONCLUSION: In this sample of Portuguese truck drivers, we observed a high prevalence of EDS and other sleep disorder symptoms. Accident risk was related to sleepiness and antidepressant use. Identifying drivers at risk for OSAS should be a major priority of medical assessment centers, as a public safety policy.

Can a 3 months treatment with oral Desogestrel prior to insertion of the etonogestrel-releasing contraceptive implant improve continuation rate at 1 year? A randomized trial.

OBJECTIVE: To evaluate if daily oral 75 µg of Desogestrel (DSG) for 3 months prior to the insertion of etonogestrel-releasing contraceptive implant (ENG-IMPLANT) might help reduce its premature discontinuation. RESULTS: A total of 66 women were randomized in the ENG-IMPLANT group (26) and in the DSG + ENG-IMPLANT group (40), respectively, in the Geneva University Hospitals and Basel University Hospital, from August 15th, 2016 through September 30th, 2019. In the DSG + ENG-IMPLANT group, patients were given a 3 months' supply of 75 µg of DSG before the insertion of the ENG-IMPLANT. All women were seen after 3 months for bleeding and satisfaction evaluation, and at 12 months post ENG-IMPLANT insertion. Higher levels of satisfaction at 12-months were found in the ENG-IMPLANT group compared to the DSG + ENG-IMPLANT group (8.5 ± 1.7 vs. 6.6 ± 2.9, p = 0.012). There were no statistically significant differences regarding tolerance (7.8 ± 2.5 vs 6.8 ± 2.6, p = 0.191) and contraceptive continuation (80% vs 72.4%, p = 0.544) between groups. CONCLUSION: DSG prior to insertion of the ENG-IMPLANT did not improve its continuation rate neither its satisfaction at 1 year. Trial registration NCT05174195. Retrospectively registered, the 30th December 2021.

Harms and benefits of cervical cancer screening among non-attenders in Switzerland: The transition towards HPV-based screening.

Human papillomavirus (HPV) testing is replacing cytological screening for cervical cancer. Our aim was to assess the expected benefits and harms of different cervical screening strategies. This study is sub-analysis of a previous cost-effectiveness study with a target population of unscreened women without cervical cancer aged ≥ 25 years. A recursive decision-tree with one-year cycles was used to model the life-long natural HPV history. Markov cohort simulations were used to assess the expected outcomes from the model. The outcomes of three strategies were compared with the absence of screening: HPV-testing on self-collected vaginal samples (Self-HPV) followed by colposcopy (Self-HPV/colpo), Self-HPV and triage with cytology (Self-HPV/PAP), cytology and triage with HPV (PAP/HPV). All screening strategies resulted in reductions in cancer cases and deaths. Self-HPV strategies were associated with a lower cancer incidence and mortality life-long, not only when performed every 3 years but also when Self-HPV was performed every 5 years vs cytology every 3 years. The gain in life expectancy obtained was 82 days with Self-HPV/colpo, 81 days with Self-HPV/PAP and 75 days with PAP/HPV compared to no screening. The number of lifetime total visits was greater with PAP/HPV compared with the Self-HPV strategies (13.13 vs < 3). The number of conizations remained relatively stable with the change of screening frequency and strategy. Self-HPV may represent a reasonable balance of harms and benefits when performed every 5 years compared to cytology every 3 years. Self-HPV/PAP yielded the most efficient harm to benefit ratio when using colposcopy as a proxy for harms.

ABCD criteria to improve visual inspection with acetic acid (VIA) triage in HPV-positive women: a prospective study of diagnostic accuracy.

OBJECTIVES: A simple system for visual inspection with acetic acid assessment, named ABCD criteria, has been developed to increase accuracy for triaging of high-risk human papillomavirus (HPV)-positive women. This study aimed to determine the accuracy of ABCD criteria for the detection of histologically confirmed cervical intraepithelial neoplasia grade two or worse (CIN2+) in HPV-positive women living in a low-resource setting. DESIGN: Prospective study of diagnostic accuracy. SETTING: Cervical cancer screening programme based on a 3T-Approach (test, triage and treat) in the Health District of Dschang, West Cameroon. PARTICIPANTS: Asymptomatic non-pregnant women aged 30-49 years were eligible to participate. Exclusion criteria included history of CIN treatment, anogenital cancer or hysterectomy. A total of 1980 women were recruited (median age, 40 years; IQR 35-45 years), of whom 361 (18.4%) were HPV-positive and 340 (94.2%) completed the trial. INTERVENTIONS: HPV-positive women underwent a pelvic examination for visual assessment of the cervix according to ABCD criteria. The criteria comprised A for acetowhiteness, B for bleeding, C for colouring and D for diameter. The ABCD criteria results were codified as positive or negative and compared with histological analysis findings (reference standards). PRIMARY OUTCOME MEASURE: Diagnostic performance of ABCD criteria for CIN2+, defined as sensitivity, specificity, negative and positive predictive values. RESULTS: ABCD criteria had a sensitivity of 77.5% (95% CI 61.3% to 88.2%), specificity of 42.0% (95% CI 36.5% to 47.7%), positive predictive value of 15.1% (95% CI 10.8% to 20.8%), and negative predictive value of 93.3% (95% CI 87.6% to 96.5%) for detection of CIN2 +lesions. Most (86.7%) of the ABCD-positive women were treated on the same day. CONCLUSIONS: ABCD criteria can be used in the context of a single-visit approach and may be the preferred triage method for management of HPV-positive women in a low-income context. TRIAL REGISTRATION NUMBER: NCT03757299.

Remote self-assessment follow-up for medical termination of pregnancy at Geneva University Hospitals: an insight into its acceptability, success rate and costs.

AIMS OF THE STUDY: Remote follow-up based on self-assessment plus a telephone call with a healthcare provider is a safe and reliable method for assessing the success of medical termination of pregnancy (mTOP) and can lead to an important reduction in costs. The aim of the study was to analyse its efficacy, acceptability and associated costs. METHODS: This was a retrospective comparative study analysing two follow-up protocols for home-based mTOP. A total of 201 women were included: 56 for a standard in-clinic follow-up and 145 for a remote follow-up based on self-assessment with a low-sensitivity urine pregnancy test and a questionnaire. The main outcome was the total number of outpatient consultations needed for each procedure and the associated costs (according to the Swiss tariff system); acceptability and satisfaction were assessed using questionnaires. RESULTS: Demand for home-based termination increased by 7.8% in the observation period. There was a reduction in diagnosis of retained products of conception, with a consequent decrease of follow-up consultations from 1.47 to 0.41 appointments per patient. A reduction of 38.9% in the average cost per patient (including supplementary follow-up appointments) was observed. Moreover, the remote alternative led to higher patient satisfaction (95.1% vs 55.0%) and acceptability (84.8%). The choice for long-acting reversible contraceptives was not affected by the removal of in-person consultation. CONCLUSION: A remote follow-up procedure is an acceptable and less costly alternative to hospital-based follow-up with a higher rate of acceptability and adherence by the studied population.

Prognostic factors and long-term outcomes of obstetric fistula care using the Tanguiéta model.

OBJECTIVES: To identify factors influencing the long-term prognosis after surgical repair of obstetric fistula, establish a prognosis-based classification system, and examine changes in quality of life after surgery. METHODS: A retrospective study of 308 women who underwent obstetric fistula repair at Saint Jean de Dieu Hospital, Tanguiéta, Benin, between 2008 and 2016, and were supported by a multidisciplinary management model. All participants were from rural areas of Burkina Faso. The women completed interviews before, immediately after, and 2, 4-6, and 12 months after surgery to assess their clinical state and socioeconomic and psychologic status. RESULTS: Overall, the fistulae of 230/274 (83.9%) women were considered to be repaired after 12 months. Factors associated with poor repair outcome included the presence of sclerotic tissue (odds ratio [OR], 0.25; 95% confidence interval [CI], 0.11-0.53) and intraoperative complications (OR, 0.16; 95% CI, 0.07-0.39). Women with successful surgery had a better quality of life as compared with women with an unrepaired fistula (Ditrovie score, 1.1 vs 3.9; P<0.001). CONCLUSION: The multidisciplinary Tanguiéta model for management of obstetric fistula allowed successful fistula closure, thereby facilitating the women's long-term social reintegration, and improved quality of life.

Implementing the 3T-approach for cervical cancer screening in Cameroon: Preliminary results on program performance.

Option recommended by World Health Organization (WHO) includes human papillomavirus (HPV) primary screening followed by visual inspection with acetic acid (VIA) triage. We implemented a program based on a 3T-approach (Test-Triage and Treat). Our objective was to verify the effectiveness of the program by defining a set of performance indices. A sensitization campaign was performed in Dschang (Cameroon) and women aged 30-49 years were invited to participate for screening based on the 3T-approach. Participants performed HPV self-sampling (Self-HPV), analyzed with the point-of-care Xpert HPV assay followed by VIA/VILI triage and treatment if required. Key performance indicators (KPIs) for screening, diagnosis, treatment and follow-up were defined, and achievable targets were described for which the approach is likely to be running optimally. A total of 840 women with a mean age of 39.4±5.9 years participated. The KPIs included (i) the screening rate (8.4% at 7 months, target =20% at 12 months), (ii) HPV positivity rate (19.8%, expected range 18-25%), (iii) compliance to referral to VIA/VILI and complete test (100%, target >90%), (iv) compliance to referral to thermal ablation (100%, target >90%), (v) VIA/VILI positivity rate (50.6%, expected range 45-55%), (vi) a single visit from diagnostic to treatment (79.8%, target >80%), (vii) compliance to follow-up at 1 month (96.4%, target >80%) and (viii) at 6 months (70.6%, target >80%). Program performance based on the single-visit 3T-approach corresponded to defined targets and preliminary results support adequateness of KPIs for periodic monitoring.

HPV self-testing for primary cervical cancer screening in Madagascar: VIA/VILI triage compliance in HPV-positive women.

OBJECTIVE: To assess triage compliance and the effect of the time from screening to triage on follow-up among HPV-positive women. METHODS: We recruited 1232 women in a screening campaign in Madagascar from February to October 2015. In the first period (February-May), HPV tests were performed remotely using the cobas test. In the second period (May-October), testing was performed on-site using the Xpert HPV assay. HPV-positive women were invited for triage with visual inspection with acetic acid (VIA) and Lugol's iodine (VILI). Systematic biopsy and endocervical brushing were performed on all HPV-positive women for quality control. Three groups were defined according to time from HPV testing to triage invitation for HPV-positive women-Group I: delayed (> 3 months), Group II: prompt (24-48 hours), and Group III: immediate (< 24 hours). RESULTS: A total 1232 self-sampled HPV tests were performed in the study period (496 in Group I, 512 in Group II, and 224 in Group III). Participants' mean age was 43.2 ± 9.3 years. Mean time from screening to VIA/VILI testing was 103.5 ± 43.6 days. Overall HPV prevalence was 28.0%. HPV prevalence was 27.2% in Group I (cobas test), 29.2% in Group 2 (Xpert test), and 26,7% in Group III (Xpert test). The VIA/VILI compliance rate was 77.8% for Group I, 82.7% for Group II, and 95.0% for Group III. Of women undergoing VIA/VILI, 56.3% in Group I and 43.5% in Groups II/III had positive results. Prevalence of cervical intraepithelial neoplasia grade 2 or worse among HPV-positive women was 9.8% for Group I and 6.8% for Groups II/III. Non-adherence was higher among rural women, uneducated women, and women in Group I. CONCLUSION: HPV-positive women with immediate VIA/VILI triage invitation had the best triage compliance. A single-day test and triage strategy is preferred for low-resource settings.