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Principal Investigator: Prajakta Adsul
Organization: ALBERT EINSTEIN COLLEGE OF MEDICINE
Fiscal Year: 2024
Award: $629,068
Funding agency: National Cancer Institute
PROJECT ABSTRACT
Each year, more than 500,000 women are diagnosed with cervical cancer (CxCa), a preventable cancer
caused by human papillomavirus (HPV) that disproportionately burdens low- and middle-income countries
(LMICs). Women living with HIV (WLHIV) are up to six times more likely to develop CxCa, making them an
especially important target population for prevention and control efforts. In Ethiopia, a national CxCa
screening program was established in 2016 and screening guidelines for WLHIV have recently been updated
to shift from visual inspection with acetic acid (VIA) to human papillomavirus (HPV) DNA testing. There is
limited data on the provider or facility adherence to the “screen-triage-and treat” guidelines and algorithm for
HPV testing; Up to 30% of WLHIV screen positive for HPV and the proportions that are appropriately triaged
with VIA and treated if needed are currently unknown. Implementation challenges to CxCa screening, as
reported by health providers, include high variability in practices between screening sites, and insufficient
training and monitoring and evaluation. We seek to explore and address these challenges through an
implementation science study of point-of-care HPV self-sampling integrated with routine HIV care in
antiretroviral therapy (ART) clinics of hospitals, thereby leveraging established HIV care infrastructure for
improved cancer control of WLHIV. A mixed method situational analysis will be conducted to describe the
existing integration of CxCa screening with HIV care in hospitals, identify opportunities for optimization of the
integrated service, and assess facility readiness to improve the cascade of care. Project ECHO, a facilitated
virtual learner community of health professionals, will be used to promote experience sharing between five
hospitals of which two low-performing sites will receive intensive technical assistance to increase the
proportion of screen-positive individuals appropriately triaged and treated. Acceptability, appropriateness, and
feasibility (implementation outcomes) will be assessed as will ECHO (1) participation, (2) satisfaction, (3)
impact on knowledge, (4) impact on confidence, and (5) impact on professional practice. Finally, a costing aim
will evaluate the cost-benefit of Project ECHO and technical support to inform decision-making around the
sustainability of this approach to improved cancer control in people living with HIV. This study is consistent
with goals of the RFA-CA-23-033 FOA “Implementation Science for Cancer Control in People Living with HIV
in Low- and Middle-Income Countries” by identifying and addressing the unique public health needs of the
LMIC population through a situational analysis and by demonstrating potential for broader implementation of
integrated CxCa screening with patient-centered HPV self-sampling for WLHIV in LMICs and other low-
resource settings, considering scale-up and sustainability in terms of triage and treatment coverage,
implementation, and cost. By considering the entire screening cascade, this study will generate important
insights that go beyond screening uptake, to advance CxCa control for WLHIV in LMICs and to move the
needle on the elimination of an almost entirely preventable cancer that unjustly impacts sub-Saharan Africa.
Terms: <AIDS Virus><AIDS prevention><AIDS test><AIDS/HIV test><Acetic Acids><Acquired Immune Deficiency Syndrome Virus><Acquired Immunodeficiency Syndrome Virus><Active Follow-up><Address><Adherence><Advanced Cancer><Advanced Malignant Neoplasm><Affect><Africa South of the Sahara><Algorithms><Application Context><Awareness><Bilateral><Body Tissues><Cancer Burden><Cancer Control><Cancer Control Science><Cancers><Caring><Case Study><Cellular Expansion><Cellular Growth><Cervical><Cervical Cancer><Cervical Cancer Screening><Cervix Cancer><Cessation of life><Clinic><Clinics and Hospitals><Clinics or Hospitals><Communities><Community Health><Cost Analyses><Cost Analysis><Cost Effectiveness Analysis><Costs and Benefits><DNA><Data><Death><Decision Making><Deoxyribonucleic Acid><Early Diagnosis><Effectiveness of Interventions><Ethiopia><Ethiopian><Evaluation><Funding Opportunities><General Population><General Public><Goals><Guidelines><HIV><HIV Prevention><HIV test><HIV-1 test><HIV-2 test><HIV/AIDS prevention><HPV><HPV detection><HPV infection><HPV positive><HPV screening><HPV(+)><HPV+><HPV-High Risk><Health><Health Care Professional><Health Care Providers><Health Facilities><Health Personnel><Health Professional><Health care facility><Health system><Healthcare Facility><Healthcare Providers><Healthcare professional><Healthcare worker><High Risk Oncogenic HPV><High risk HPV><High risk Human Papillomavirus><High risk Human papilloma virus><Hospitals><Human Immunodeficiency Viruses><Human Papilloma Virus><Human Papilloma Virus detection><Human Papilloma Virus screening><Human Papillomavirus><Human immunodeficiency virus test><Human papilloma virus infection><Human papillomavirus infection><Incidence><Individual><Infectious Human Wart Virus><Infrastructure><International><Intervention><Intervention Strategies><Interview><Investigators><Knowledge><LAV-HTLV-III><LMIC><Lesion><Link><Low-resource area><Low-resource community><Low-resource environment><Low-resource region><Low-resource setting><Lymphadenopathy-Associated Virus><Malignant Cervical Neoplasm><Malignant Cervical Tumor><Malignant Neoplasm of the Cervix><Malignant Neoplasms><Malignant Tumor><Malignant Tumor of the Cervix><Malignant Tumor of the Cervix Uteri><Malignant Uterine Cervix Neoplasm><Malignant Uterine Cervix Tumor><Malignant neoplasm of cervix uteri><Measures><Methodology><Methods><Modeling><Monitor><National Cancer Burden><Needles><Notification><Outcome><Participant><Patients><Persons><Policies><Population><Preparedness><Prevalence><Preventable cancer cause><Prevention><Professional Practice><Provider><Public Health><Public Hospitals><Readiness><Reporting><Research Personnel><Researchers><Resource-constrained area><Resource-constrained community><Resource-constrained environment><Resource-constrained region><Resource-constrained setting><Resource-limited area><Resource-limited community><Resource-limited environment><Resource-limited region><Resource-limited setting><Resource-poor area><Resource-poor community><Resource-poor environment><Resource-poor region><Resource-poor setting><Sampling><Screening for cancer><Services><Site><Sub-Saharan Africa><Subsaharan Africa><Survey Instrument><Surveys><Target Populations><Test Result><Testing><Time><Tissues><Training><Triage><Update><Uterine Cervix Cancer><Virus-HIV><Visit><Visual><Woman><World Health Organization><active followup><antiretroviral therapy><antiretroviral treatment><assess cost><assess effectiveness><barriers to implementation><cancer prevention><care facilities><case report><cell growth><cervical cancer early detection><cervical screening><co-morbid><co-morbidity><community-based health><comorbidity><compare cost><contextual factors><cost><cost assessment><cost comparison><cost efficient analysis><cost evaluation><cost-effective analysis><cost-effectiveness evaluation><design><designing><determine effectiveness><diagnosis among females><diagnosis among women><diagnosis in females><diagnosis in women><diagnosis within females><diagnosis within women><early cancer detection><early detection><effectiveness assessment><effectiveness evaluation><effectiveness outcome><effectiveness-related outcomes><evaluate cost><evaluate cost-effectiveness><evaluate effectiveness><evidence base><examine cost><examine effectiveness><experience><female diagnosis><female outcomes><follow up><follow-up><followed up><followup><health care personnel><health care professional practice><health care worker><health provider><health workforce><healthcare personnel><healthcare professional practice><human papillomavirus +><human papillomavirus positive><implementation barriers><implementation challenges><implementation cost><implementation efforts><implementation investment><implementation outcomes><implementation science><implementation strategy><implementation study><improved><informant><insight><interventional strategy><learning community><low and middle-income countries><malignancy><medical personnel><microcosting><mortality><neoplasm/cancer><outcomes among females><outcomes among women><outcomes in females><outcomes in women><patient centered><patient oriented><peer learning><point of care><precancer><precancer cervical detection><precancerous><premalignant><presence of HPV><presence of human papillomavirus><prevent><preventing><recommended screening><satisfaction><scale up><screening><screening cancer patients><screening guidelines><screening program><screening recommendations><screening services><screenings><strategies for implementation><success><theories><tool><treatment provider><uptake><virtual><wart virus><women's diagnosis><women's outcomes>