Sub-Saharan Africa concentrates the largest burden of cervical cancer worldwide. The introduction of the HPV vaccination in this region is urgent and strategic to meet global health targets. This was a cross-sectional study conducted in Mozambique prior to the first round of the HPV vaccine demonstration programme. It targeted girls aged 10–19 years old identified from schools and households. Face-to-face structured interviews were conducted. A total of 1147 adolescents were enrolled in three selected districts of the country. Most girls [84% (967/1147)] had heard of cervical cancer, while 76% believed that cervical cancer could be prevented. However only 33% (373/1144) of girls recognized having ever heard of HPV. When girls were asked whether they would accept to be vaccinated if a vaccine was available in Mozambique, 91% (1025/1130) answered positively. Girls from the HPV demonstration districts showed higher awareness on HPV and cervical cancer, and willingness to be vaccinated. This study anticipates high acceptability of the HPV vaccine in Mozambique and high awareness about cervical cancer, despite low HPV knowledge. These results highlight that targeted health education programmes are critical for acceptance of new tools, and are encouraging for the reduction of cervical cancer related mortality and morbidity in Mozambique. •Cervical cancer incidence rates in Mozambique are among the highest in the world.•Introduction of HPV vaccination in Mozambique is an urgent and necessary strategy to meet global targets on women´s health.•The awareness on cervical cancer, and anticipated acceptance of HPV vaccination was assessed in Mozambican adolescent girls.•The study anticipates high acceptability of HPV vaccine and adequate awareness about cervical cancer.•These results are timely in the context towards the implementation of the HPV vaccine at a national scale in Mozambique. It is the most frequent cancer among women of all ages and the leading cause of female cancer-related mortality countrywide It is clear that the introduction of the HPV vaccination to prevent cervical cancer in low and middle-income countries is an urgent and strategic approach to meet global health targets on women´s health Political barriers and health systems weakness are pointed out as major limitations for the success and the sustainability of HPV vaccination programmes This study aimed to assess the awareness on cervical cancer and HPV infection, and anticipated acceptance of HPV vaccination for cervical cancer prevention among adolescent girls in three districts of Mozambique in the framework of an HPV vaccine demonstration programme. Since HPV vaccine strategies prioritize girls prior to sexual debut, it was also an objective to understand the pattern for initiation of sexual practices, perceived risk and self-reported protection against cervical cancer among Mozambican adolescent girls. This information will serve to understand the barriers and facilitators for effective HPV vaccine implementation, and it may be of relevance to other countries in sub-Saharan Africa and elsewhere with similar health problems and limited resources.22.1The study targeted adolescent girls aged 10–19 years old. This group was selected based on the study´s intention to document wider issues about prevention of HPV, as a sexually transmitted infection among adolescents The study was conducted between August 2013 and May 2014 in three geographically different areas of Mozambique, namely Ka-Mavota  and Manhiça  districts, both in Maputo province, in Southern Mozambique, and in Mocímboa da Praia district , in Cabo Delgado province, in Northern Mozambique  2.2This was a quantitative, cross-sectional study conducted prior to the first round of the HPV vaccination campaign in the context of the HPV vaccine demonstration programme in Mozambique, and concomitantly to the education and communication activities that preceded the HPV vaccination pilot programme. Two of the three districts where this study was conducted (Mocímboa da Praia and Manhiça), were target districts for the demonstration programme. Eligible participants were identified and selected randomly from schools and households within the selected study areas and invited to participate in the study. The reason for this mixed method of recruitment was to ensure that girls not enrolled in school were also captured. To capture this reality, a conservative assumption was made that 2/3 of the girls would be enrolled in school. In each district, 10 schools were randomly selected and served as the sampling frame. In each school, 30 girls were randomly selected and invited to participate in the study. In the community, the target sample was of at least 100 girls randomly selected per district, which were captured from 10 randomly selected neighbourhoods per district and identified either via the demographic surveillance platform (in Manhiça) or a list of known 10-year old girls by the neighbourhood secretaries.A total sample size of 1248 adolescent girls, with a minimum sample of 410–420 girls per site, was foreseen in order to fulfil the study objectives, based on a sample size calculation to detect 50% acceptance to vaccinate against HPV . Each participant was provided with a study information sheet written in the language in which the respondent was most comfortable . Most interviews were conducted in Portuguese and very few of them in the local language.A paper-based standardised questionnaire was administered to adolescent girls by trained female interviewers with experience conducting community-based questionnaires, assessing awareness on cervical cancer and HPV infection, perception of their own risks with regards to HPV transmission, acceptability and willingness of adolescent girls to be vaccinated against HPV, and perceived risks and benefits of HPV vaccination. For the assessment of sexual behaviour patterns and perception of risk of cervical cancer, due to the nature of the questions, only girls aged 15–19 were inquired.2.3Ethical approval for this study was granted by the Institutional Review Board of the Manhiça Health Research Centre (CIBS-CISM) [Reg. No. CIBS_CISM_09/13] and by the Ethics Review Committee of the Hospital Clinic of Barcelona, Spain (CEIC) [Reg. No. HCB/2013/0903]. The study was conducted in accordance with the Good Clinical Practice Guidelines set up by the WHO, and under the provisions of the Declaration of Helsinki, and local rules and regulations. Adolescent girls were enrolled after they gave written consent (if 18 years of age or older) and assent accompanied by parents´ or guardians´ written informed consent (if younger than 18 years of age).2.4chi-squared test or Fisher's exact test if the application conditions of the former were not met. For quantitative variables, the ANOVA test was used for group comparisons. Associations between outcome variables  and socio-demographic variables  were explored using logistic regression. Multivariable models were built using a stepwise procedure, where the variables study site and age category were forced to remain in the model. The significance level was set at p < 0.05. Missing values were coded as such and excluded from analysis. Adolescents were defined, according to WHO definition, as young people between the ages of 10 and 19 years A standardised system for data entry, data management, and statistical analysis was established. All data were double entered by two independent data clerks into form-specific databases (REDCap) 33.1A total of 1147 Mozambican adolescent girls from three selected districts , accepted to participate in the study, of which 85% (970/1141) were recruited at school and 15% (171/1141) at their households. Mean age of participants was 14.4 years [standard deviation (SD) 2.8], being 627 girls between 10 and 14 years of age, and 520 girls between 15 and 19 years of age. Baseline characteristics of study participants are shown in 3.2The majority, [84% (967/1147)] of girls had heard of cervical cancer, and 64% of them (725/1139) reported the uterus as the main organ affected by cervical cancer; however, only 33% of the participants (373/1144) recognized having ever heard of HPV infection; with higher knowledge on HPV in the districts where the HPV demonstration programme was being conducted  Seventy-one percent of adolescent girls (685/963) considered sexual transmission as the principal mode of acquisition of cervical cancer followed by history of cancer in the family (21%) See . Regardi3.3Seventy six per cent (866/1146) of study participants were aware that cervical cancer can be prevented see . When as3.4When girls were asked whether they would accept to be vaccinated if a vaccine was available in Mozambique, 91% (1025/1130) of girls answered positively. This high HPV vaccine acceptability was observed across all study sites see . Across 3.5Adolescent girls from Mocímboa da Praia, in Northern Mozambique, showed higher knowledge about what HPV infection and cervical cancer represent and its prevention, followed by girls from Manhiça district, in Southern Mozambique see . A betteNo differences were seen on the acceptability of the HPV vaccine across study sites (p = 0.118) or age groups (p = 0.323) see . Factors3.6Overall, 94% (481/514) of older adolescent girls interviewed had heard of sexually transmitted infections (STIs). Of them, 84% (405/480) reported that STIs could be prevented by using condoms, and 23% (109/480) by having only one sexual partner see . Sixty oOf those girls who had initiated sexual relations, 43% (132/307) reported one previous sexual partner, 39% (121/307) two sexual partners, and 18% (54/307) three or more sexual partners. Regarding use of condoms, 76% (237/313) reported to use them . Nearly 60% (257/451) of participants felt they were at risk of cervical cancer, being Mocímboa da Praia (70%) and Manhiça (57%) the districts where perception of such risk was higher.4To our knowledge, this is the first study conducted in Mozambique assessing the awareness of cervical cancer and willingness to be vaccinated against HPV among adolescent girls. This study was carried out in advance of the roll out of HPV vaccination countrywide. Overall, knowledge about cervical cancer and its prevention was high among girls, with 84% of them having heard of cervical cancer, while 76% believed that cervical cancer could be prevented, and recognising vaccination as the main strategy to prevent it. However, the level of awareness about HPV infection was low, with only a third of girls that recognized having heard about this infection. In addition, acceptability levels of the HPV vaccine was high across sites, with an overall 91% of the girls willing to be vaccinated should the vaccine be available in the country.Most studies in SSA on awareness about cervical cancer and HPV vaccine consistently reported that while levels of knowledge are generally low, willingness to vaccinate against HPV is high Several studies in SSA have shown high levels of awareness in the population and acceptability of the HPV vaccine following HPV vaccination campaigns Interestingly, the preferred place for vaccination was the health centre (61%) across sites and age groups, despite the limited routine contacts of adolescents with the health system and the generally low attendance to adolescent-specific services in settings like this It is noteworthy to mention that while we found a perceived understanding by adolescent girls that sexually transmitted infections (STIs) were associated with increased risk of suffering from cervical cancer, there was a huge disparity between awareness of STIs in general and awareness of HPV infection . In addition, while willingness to be vaccinated to prevent cervical cancer was high, participants showed little understanding about best timing to be vaccinated and the link between the efficacy of the vaccine and sexual debut Mean age at first sexual intercourse was of 15 years across districts and nearly 25% of girls had initiated sexual relations before the age of 15. This finding are aligned with the rates of child marriage in Mozambique, being the highest in Northern provinces; 17.6% of girls in Cabo Delgado between the ages of 20 and 24 years were married before 15 years of age Despite the wide anticipated overall acceptance of the HPV vaccine observed across sites this study, we found differences on knowledge and perceived risk for cervical cancer. Adolescent girls from the district in the periphery of the capital, Ka-Mavota, showed the poorest knowledge about cervical cancer and the HPV vaccine. This may be explained because this area was not a target HPV vaccination demonstration site, reflecting the imbalance of information spread between targeted and non-targeted areas. When comparing the two targeted sites for HPV vaccine demonstration, baseline knowledge either on HPV and vaccines for prevention of cervical cancer was the highest in Mocímboa da Praia, a remote rural area in Northern Mozambique, compared to Manhiça, also a rural area, but relatively proximate to the capital city in the South. Moreover, in Mocímboa district a much higher proportion of adolescent girls reported feeling at risk of cervical cancer compared to the other sites in the south of the country. The results on higher awareness about HPV and cervical cancer among Mocímboa da Praia adolescents seem to contrast their reported riskier sexual behaviour, where the average age at sexual debut was lower compared to other districts 5In conclusion, our study anticipated high acceptability of HPV vaccine in Mozambique indicated by willingness to be vaccinated among adolescents across different settings of the country, as well as the adequate awareness about cervical cancer, prior to the roll out of vaccination against HPV. Specific aspects of knowledge of aetiology of cervical cancer need improvement. Our results highlight that relevant targeted health education programmes across the country, as those provided as part of the HPV vaccine demonstration programme, are critical for the acceptance of new tools to prevent cervical cancer, and that delivery strategies should address socio-cultural specificities across the country. The results coming from this study are encouraging and favourable to advance towards reduction in cervical cancer related mortality and morbidity in Mozambique.We declare no competing interests.Department for International Cooperation, Barcelona City Hall, Spain [Grant No. 12S05844]; the Aga Khan Foundation (AKF); and the Global Alliance for Vaccination and Immunization (GAVI) . The sponsors of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report, except for the Agha Kahn Foundation, which participated in the study design and data collection. The study was coordinated by the Centro de Investigação em Saúde de Manhiça (CISM), Mozambique, in collaboration with the Universidade Eduardo Mondlane, Faculdade de Medicina, Maputo, Mozambique, and the Barcelona Institute for Global Health /Barcelona Centre for International Health Research, Hospital Clínic-Universitat de Barcelona, Spain.This work was supported by the KM, CaM and ES designed the study. KM, CaM, OC and ES organised investigations at study districts, implemented and supervised the study. CaM, OC and KM enrolled study participants and data collection. AB, AC, OA, KM were responsible for data management. AB and AC prepared the analytical plan and analysed data. AB wrote the manuscript. CaM, OA, OC, AC, ESi, GM, EM, ES, CM and KM commented on the manuscript. All authors contributed to discussion and interpretation of results and review and have seen and approved the final version of the manuscript.


Increasing numbers of patients face the psychosocial challenge of a diagnosis of oropharyngeal squamous cell carcinoma (OSCC) caused by human papillomavirus (HPV). We explored the psychosocial impact of an HPV‐OSCC diagnosis for patients and their partners.n = 20) and a subset of their partners (n = 12), identified through medical records at two UK hospitals. Interviews were recorded, transcribed verbatim and analysed using thematic Framework Analysis.In‐depth interviews were conducted with patients (n = 3) described feelings of embarrassment and perceived stigma about HPV.Only 12/20 patients interviewed (and five partners) were aware of their HPV status and the main analysis focused on this sub‐sample. In discussing the cause of their cancer, patients and their partners talked about not wanting to know; whether they disclosed the cause of their cancer to others; their reactions to being diagnosed with HPV; the prognosis information they were given and the questions they had about HPV. Most concerns were cancer‐related rather than HPV‐related, but some patients (Some patients and partners who are told HPV is the cause of their OSCC have questions about HPV and seek further information. Concerns and uncertainties about the sexually transmitted nature of HPV need to be addressed by health professionals. All participants had to be able to communicate in English and be able to give informed consent. Ethical approval was granted by South East London NHS Research Ethics Committee (Reference: 15/LO/0803).2.2In‐depth interviews followed a topic guide developed using the existing literature on patient experiences of HNC  or by telephone (n = 3) and lasted 26–84 min. They were recorded and transcribed verbatim. Emerging themes from the transcripts were noted simultaneously with carrying out the interviews. Once no new themes had emerged from three consecutive interviews, this indicated that saturation had been achieved. Data collection ceased at this point  and developed codes independently. All coding was then discussed and disagreements were resolved before RD coded all of the transcripts. Once all the data had been coded in NVivo, it was summarised in a framework matrix with rows for participants and columns for themes. Framework Analysis  and partners (n = 12) were interviewed in September/October 2014 and between September and November 2015. Patients average time since diagnosis was 23 months (range 12–53 months). All were diagnosed with a primary tumour in the tonsil (n = 14) or base of tongue (n = 5) and all except one had late‐stage disease (stage IV A to C). Patients had received surgery alone (n = 1), surgery with chemoradiation (n = 5), surgery with radiation (n = 5) or radiation only (n = 8). The medical records for one patient were not obtainable. The majority of patients were male, white British, married or cohabiting, and either employed full‐time or retired . Patients  who were aware of the causal role played by HPV in their (or their partner's) cancer. These themes include: disclosing HPV to others, being diagnosed with HPV, prognosis, and questions and information about HPV.Twelve patients in the sample were aware of the cause of their cancer being HPV, whereas the rest were not. The first theme explores causal beliefs across the whole sample and includes discussion of the information patients received from health professionals about the cause of their cancer. Subsequent themes focus on the data from the sub‐sample of participants  or “by a virus” (n = 3). HPV was not always disclosed by a doctor as the cause of patients’ cancer, with a couple of patients finding out after being approached by a member of a clinical trials team asking them about taking part in research and others remained unaware of the cause. HPV was not always accepted as the cause of cancer, with one partner, after a conversation with her friend who was a nurse, dismissing HPV as the cause of her partner's cancer.Some patients were told by their doctor that their cancer was caused by HPV I would have loved, ‘Yeah, that’s what’s caused it.’ But to this day, I don’t know what it is. A number of patients who did not recall being told what the cause of their cancer was had searched for a causal attribution; some attributed it to smoking, related it to work or genetics. Some of these patients expressed the view that they wanted to know:3.3.3I don’t care how it was caused. It was just that it’s gone, we hope, you know. Nearly half of the patients said it did not matter what had caused their cancer, the most important thing was that they “got rid of it.” The cause was also seen as something that could not be changed, “I can't go back and say I'll not do that”  and that it did not affect the treatment. This partner expressed her relief that her husband's cancer was now gone:3.4A couple of patients gave examples of why they thought others did not ask them about the cause of their cancer, believing that “the cancer word's enough for most people”  and “they think well you get cancer and you just get it, it's one of those things that happens” . Some patients who knew that HPV was the cause of their cancer, felt uncomfortable talking about it with others: “It's not a conversation you really want to have with your daughter” . One patient described telling people “It's viral, in my throat, very treatable, a type of skin cancer, it comes from HPV” and that “you don't go around broadcasting that something's sexually transmitted” .When they told me it was because of HPV I don’t think I told him for ages … I think it was easier to tell other people why as opposed to him. One of the younger patients said she found it easier to tell other people than her partner:One partner described how everyone assumes HNC is caused by smoking and how people reacted when she and her partner told them about HPV. Most of their friends said they looked HPV up on the internet after they had explained, as they “didn't know that could happen or exist.”This is the most contagious virus in the world, 95% of people manage to disperse it through their immune system, 5% don’t and unfortunately, 5% of that 5% it turns to cancer and you’re unlucky. Reluctance to discuss HPV as a cause of their cancer with others was evident, not fully disclosing their diagnosis to others and viewing it as a “medical thing” so only felt comfortable talking about HPV with medical professionals. One patient explained how she felt there was “stigma attached to it [HPV],” due to experiencing negative reactions from other people and how this prevented her from disclosing the cause of her cancer. This patient felt more comfortable talking about HPV after her consultant had told her:Well, to start with probably I was quite open telling people that [name of patient]’s cancer was caused by HPV but, after that, a bit more reluctant to discuss it. Which is a shame, because I think that more people need to be aware of this, but it’s difficult. Some participants also brought up Michael Douglas  and viewed what he had said as “not helpful” and there was a “sensationalist aspect” surrounding the sexually transmitted nature of HPV. One partner described how she was happy telling people that her partner's cancer was caused by HPV before Michael Douglas said that “it's caused by oral sex.”3.5This theme describes reactions to being diagnosed with HPV and preferences for being told about HPV.3.5.1Patients’ reactions to news of their cancer being caused by HPV were embarrassment, confusion, surprise, disappointment, shock and feeling unlucky. One patient described how she had “got a little bit of an issue still with it” and how her husband had “said something that made me feel really dirty” .One patient explained how she was embarrassed about the HPV aspect of her cancer, but how it feels less relevant now, with the cancer being most important, not the cause. Transmission of HPV to their partner was a concern for some patients and one of the partners decided to get tested privately for HPV.3.5.2There were mixed opinions from patients about when would be the best time to have been told about HPV as the cause of their cancer. Patients recognised that the initial diagnosis stage might not be the best time, but other participants thought it would have been helpful and honest to know at the beginning, when they were first told their diagnosis.When I found out I had it because of HPV … how it just came out totally at random … to me, if you are gonna be told something like that, which psychologically becomes very relevant, it would have probably been better to have known in a proper way not just a chat. This patient also described how she was told about HPV and how this was not how she believes she should have been told:3.6Most of the patients given information about their prognosis were told that it was treatable, curable and they could expect to recover completely. The statistics given to patients ranged from 50% to 85% survival, with research showing higher survival rates for HPV‐related diagnoses. Patients were reassured by the better prognosis given to HPV‐related diagnoses and one patient described how he focused on the words “it's treatable” .She [radiographer] said, we’ve got 42 masks at the moment. And I’ll tell you what kicked in then, there’s eight of us not going to make it then. That is what was in my mind. One patient interpreted 80% survival as good, but then translated this into real life and how many do not survive, when he saw the radiotherapy masks lined up in the room.3.7The final theme related to information patients and their partners were given about HPV, their information demands and information seeking behaviours.3.7.1Participants were given different information about HPV. Most participants had never heard of HPV before they were diagnosed. Those that were already aware of HPV tended to be women who had heard about it in the context of cervical cancer. Patients described discussing HPV in relation to cervical cancer and that “the HPV virus is in all of us.”Some of the understanding about HPV that participants came away with following consultations were that it is “a virus,” is “sexually transmitted,” and “seems to affect anybody,” “you could have had it for years,” it is “the most contagious virus in the world,” “it's on the increase” and is “becoming more and more common in all ages.”Questions participants had about HPV included whether HPV is likely to travel around their body, “what's the chance of it coming back,” “where has this [HPV] come from,” “how's it taken so long to come through,” have they still got HPV, “is it only sexually transmitted,” how long have they been carrying HPV, what is the prognosis, will the treatment get rid of HPV and are their children more at risk of HPV.I mean surely if you can transmit the virus around, there’s going to be other ways of doing it as well, surely? It could be a cut on your hand, it could be a kiss, it could be anything, couldn’t it really? You just don’t know really. One patient was reassured by a friend who works in a hospital, that people's beliefs about HPV being down to oral sex, “is their naivety.” One patient believed that there were ways, other than oral sex, that HPV could be transmitted:No. I never look on the Internet for anything like that ... it’s no disrespect to anyone who put it on there, but they don’t know like the professionals. Although the internet was a popular source of information for participants, there was an understanding that searching the internet should be done with caution. A few did not want to look for any more information on the internet because they did not want to “panic” or read the wrong information:Some patients looking for more information found confirmation of what their doctor had told them. The internet was used to look for general information on HPV, information about the best treatment options, to research symptoms, causes, information about their doctor, explanations of tests and for further information about their particular cancer. One patient described how she “broke down” after looking up HPV on the internet as all the information said it was all because of oral sex.It seemed like the chances of recurrence were pretty low after the sort of standard treatment, which was what [name of patient] had had. So I was pretty reassured by that. For those that did further research into HPV, the level of research undertaken varied. One partner read research papers on HPV:Some participants felt the information currently available was not applicable to them. One patient noted that information about HPV seems to be “centred on teenagers” and was “either aimed at young people not contracting HPV or old people not getting cancer through HPV” . This particular patient felt like the information available about throat cancer was aimed at “that sort of age group—60 plus. And you are like, well, that's not me.” There were a number of participants who were satisfied with the amount of information they had been given.The importance of keeping the family informed about how the patient was, was recognised, but was described by one partner as “emotionally draining” . Some partners found keeping people up‐to‐date was tiring, having to answer people's texts and phone calls. One partner adopted a strategy of emailing everyone to keep them updated at once.3.7.2It was acknowledged that there was a need for more research about HPV‐OSCC and that this was expected in a few years’ time. Also, that further research may lead to different and “milder treatment” for HPV cancer, with this one partner hoping this would mean people “wouldn't have had to go through the dramatic treatment he did have to go through” .3.7.3Most of the patients and their partners were positive about the future, but fear of recurrence was common among patients and their partners. This was sometimes related to HPV, such as this patient wondering “is it [cancer] more likely to come back because of this [HPV]? Is it something that stays in your body?” .4This study explored the psychosocial impact of being diagnosed with HPV‐OSCC for patients and their partners. Although the medical records of all patients showed their tumour was HPV‐positive, not all patients were aware of this. This suggests a need for better information provision to ensure greater understanding of HPV in this patient group. Reactions were mixed among those who knew their cancer was caused by HPV. Some participants felt embarrassed and felt that there was a stigma associated with HPV. Other participants were not concerned about the cause of their cancer and were more interested in knowing that survival rates for a diagnosis of HPV‐OSCC were better than for non‐HPV HNCs, suggesting concerns were more cancer‐related than HPV‐related. Patients and partners who were told that HPV was the cause of their cancer had a number of questions about HPV and some sought further information. Psychosocial effects were similar to those described in previous qualitative research with HNC patients (Baxi et al., Participants’ reactions to finding out that their HNC was caused by HPV varied. In line with findings from the cervical cancer literature, some patients reported feelings of embarrassment, confusion and concerns of transmission to their partner (McCaffery et al., One key message about HPV suggested in a previous study of health professionals (Dodd et al., Previous research in the USA has confirmed that less than half of oncologists discuss HPV with their patients (Milbury et al., Previous research with a small sample of male HPV‐OSCC survivors also found that HPV was often overshadowed by the cancer itself and that patients were encouraged by the positive prognosis (Baxi et al., Partners were often the source of information for others, being the ones to keep the wider family informed about the patient. Partners also sought information about HPV and other aspects of their partners’ cancer, in the effort to be as prepared as they could be, supporting previous findings from a study in New Zealand with 73 caregivers that found caregivers requested information, in an effort to improve their understanding of the situation (Richardson et al., 4.1This study is the first in the UK to interview patients diagnosed with HPV‐OSCC, as well as their partners. Qualitative interviews give a greater depth of data than questionnaires to provide an understanding and description of people's personal experiences. By interviewing patients and partners separately, we enabled each to share experience from their own perspective without being influenced by their partner, although it is possible that patients and their partners may have discussed the interview before participating. Interviewing both patients and their partners also allowed HPV to be discussed, which may have been too sensitive to bring up in joint interviews. Our sample of patients who were aware of their HPV status was small, so HPV was not discussed in some interviews, thereby limiting their scope. The response rate of 30% may have also limited the responses and our participants may not be representative of all patients diagnosed with HPV‐OSCC due to their recruitment from two UK hospitals. However, these two hospitals enabled us to sample from areas of different socioeconomic status and education levels and so may provide a broader representation than two hospitals in the same area of the UK. Participants were probed about changes to their relationship, but not specifically about their sexual relationships, which on reflection would have been important to discuss with this sample.5This study suggests that HPV‐OSCC has a significant psychosocial impact on patients and their partners, but that most concerns are related to dysfunction following cancer treatment and not to their HPV status. However, there are concerns and uncertainties about the sexually transmitted nature of HPV which could easily be addressed in information from a trustworthy and reliable source such as the patient's doctor. Participants in this study were ill informed and unaware regarding HPV, therefore written information for patients and their partners is also likely to be a useful resource which could be discussed around the time of diagnosis.None.


To assess triage compliance and the effect of the time from screening to triage on follow-up among HPV-positive women.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).A total 1232 self-sampled HPV tests were performed in the study period . 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.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. Cervical cancer (CC) is the third most common cause of cancer mortality in lower-middle-income countries (LMIC) . WorldwiVisual inspection of the cervix with acetic acid (VIA) and Lugol’s iodine (VILI) is the nationally recommended approach for CC screening in Madagascar, as is the case in most LMIC. VIA/VILI has the advantages of being low-cost and providing immediate results, allowing screening and treatment during the same visit . A 2015 Human papillomavirus (HPV) infection is an important cause of CC. There are many subtypes of HPV, most of which do not cause CC, and a large majority (90%) of HPV infections do not persist beyond two years; however, 70% of cases of CC and precancerous cervical lesions are caused by the two highest-risk types of HPV (HPV-16 and HPV-18) . The incHPV tests generally require that samples be sent to distant reference laboratories for analysis, making the same-day screen-and-treat strategy impractical. A two-stage protocol including HPV testing and VIA/VILI triage with treatment (if needed) performed on different days requires a recall system and may result in a significant drop-out rate . It is aNewly available on-site rapid HPV tests may reduce the length of time between HPV testing and invitation for VIA/VILI triage ,17. ThesIn this study, our aim was to examine the compliance of HPV-positive women invited for triage with different time delays and to assess the influence of the delay period on the follow-up rate. Additionally, we aimed to identify factors that may influence adherence to triage.The study reported in this article was a secondary analysis of data from a larger study. The present study can be considered a cohort study nested within a randomized controlled trial. The main study aimed to evaluate whether smartphones can assist health-care workers and assess the diagnostic reliability and accuracy of cervical examination using smartphone photos for VIA, compared with conventional VIA, for women testing positive for HPV. In the course of analyzing the data collected for the main study, we realized that it would be interesting to investigate differences in triage compliance between women who were provided with immediate HPV results and those who received delayed results and consequently had delayed gynecological exams. For this secondary analysis, there was no assignment: Women participated in the screening program as part of their standard care, and whether they were in the “delayed invitation” or “prompt invitation” group was determined by real-life conditions rather than being assigned by the investigators. The authors confirm that all ongoing and related trials for this drug/intervention are registered.The CC screening campaign took place in the Saint Damien Healthcare Centre in Ambanja, Madagascar, and in five dispensaries in the surrounding rural areas from February to October 2015. Here, CC prevention is integrated with a range of reproductive and sexual health services  available at the center. Women aged 30–65 years living in Ambanja and its surroundings were invited to undergo CC screening. They were asked to collect a vaginal sample with a sterile swab  for HPV detection after providing signed informed consent form.In the first period (February to May 2015), The HPV samples were analyzed in Switzerland with the cobas 4800  test. It was necessary to wait for a colleague to take the tests to from Madagascar to Switzerland, where they were analyzed (a 1-day process). The results were then returned by email for management in Ambanja. In total, this took a minimum of 2 weeks from the administration of the test to the receipt of results, which required recalling all women to the health care facility for information about the results. HPV-positive women received a delayed invitation for a VIA/VILI triage. In the second period (May to October 2015), HPV tests were analyzed on-site with the Xpert assay , and HPV-positive women were invited either immediately (< 24 hours) or promptly (24–48 hours) to undergo triage with VIA/VILI, which was performed by trained local gynecologists.A lower threshold for VIA positivity than is usually recommended by the International Agency for Research on Cancer criteria  was applThe study took place from January 1, 2015, to October 31, 2015. The original study was registered (accepted by the ethics committee after corrections) in February 2015, before the first patient was enrolled in the study in the same month. The study was approved by the representative officer of the Malachi National Commission for the Ethics of Science and Technology in Ambanja and the Ethical Cantonal Board of Geneva, Switzerland (CER: 14–071). The authors confirm that all ongoing and related trials for this drug/intervention are registered.The cobas HPV Test uses amplification of target DNA by polymerase chain reaction and nucleic acid hybridization to detect the 14 high-risk HPV types in a single analysis. The cobas test individually identifies HPV-16 and HPV-18 and reports the other 12 high-risk types of HPV  as a combined result. The Xpert HPV assay consists of a real-time cartridge-based polymerase chain reaction that enables partial genotyping among 14 high-risk HPV types. . The results are available in 1 hour. In addition to reporting whether the test was positive or negative, we also report HPV co-positive test results, which indicate that the HPV test yielded “HPV-16 and HPV-18/45,” “HPV-16 and other high-risk HPV,” or “HPV-18/45 and other high-risk HPV” as a result.Time to triage invitation among HPV-positive women was evaluated as follows : Women wp < 0.20 in bivariate analyses. Statistical significance was defined as p-value < 0.05, and 95% confidence intervals (CI) were calculated for the results. Data were analyzed using a statistical analysis software package .To assess the associations between the HPV test used and the participants’ socio-demographic characteristics and pathological and screening test results, the results of Fisher’s exact tests are reported when at least one of the expected frequencies was less than three; otherwise, the results of chi-square tests are reported. Compliance with VIA/VILI triage among HPV-positive women was the main outcome variable in this study. Multiple logistic regression analysis was performed including all explanatory variables with p = 0.383). The mean ± SD age at first sexual intercourse was 16.6 ± 2.1 in Group I and 16.9 ± 2.1 years in Groups II/III (p = 0.083). Women whose highest educational achievement was elementary school made up 211/496 (42.5%) of Group I and 328/736 (44.9%) of Groups II/III. The participants’ socio-demographic characteristics are reported in p = 0.008), employment status (p < 0.001), and contraceptive method used (p = 0.050).The study design is illustrated in p = 0.034). Of women who had a biopsy, 9.8% (10/102) in Group I and 7.3% (10/136) in Groups II/III received a CIN2+ diagnosis. Among participants in Group I, 96/105 who underwent VIA/VILI had valid triage test result data. A total of 3/105 women who underwent VIA/VILI had missing test result data, and 6/105 had invalid test results. Among participants in Groups II/III, 168/181 who underwent VIA/VILI had valid test result data, 11/181 had missing VIA/VILI data, and 2/181 had invalid test result data. As shown in p = 0.292). There were 54/96 (56.3%) and 73/168 (43.5%) with a positive triage among women tested in the Group I and Groups II/III, respectively (p = 0.128).p = 0.043).Overall, the mean time between screening and VIA/VILI exam was 48.4 ± 56.8 days. In Group I, the mean was 103.5 ± 43.6 days between HPV self-testing and VIA/VILI triage. The proportion of non-adherers to triage over time is illustrated in Optimal benefit of CC screening can be achieved through appropriate follow-up of abnormal test results. To be effective, the follow-up strategy must be defined by organizational strategies including an appropriate sequence of steps leading to an optimal management of women with a positive screening test. Triage In the present study, a prompt or, especially, immediate invitation to triage resulted in much higher VIA/VILI triage uptake when compared with a delayed invitation. This finding highlights the potential impact of a screening strategy that minimizes the number of visits on triage attendance rate. Overall, 78% of HPV-positive women had VIA/VILI triage when they received a delayed invitation (Group I), whereas 86.2% of HPV-positive women attended VIA/VILI triage when they received a prompt or immediate invitation (Groups II/III). It should be emphasized that 95% of HPV-positive women in this study attended VIA/VILI triage when their HPV test results were available immediately after the screening (Group III).Among women in Groups II/III, supplementary analyses showed that those who received their results with a delay of less than 24 hours were four times more likely to adhere to VIA/VILI triage, compared with women who received their results from 24 to 48 hours after the screening (p = 0.005). This clearly shows the negative impact on follow-up adherence rate of even a one-day delay in providing the triage invitation. Previous studies have shown that loss to follow-up can be even greater—as high as 70%—when visits are scheduled more than 4 weeks after the initial visit , 26. TheOther than the time interval between HPV testing and triage with visual inspection, other factors were found to be associated with non-attendance. One significant factor was living in a rural setting. This illustrates one of the biggest challenges in CC screening participation in LMIC. The distance between women’s homes and health care centers is an obstacle to screening attendance because of the difficulty of accessing transportation, organizing child care, and obtaining permission to take the necessary time off work ,27,30,31The main strength of this study is its pragmatic design and the fact that it was conducted under “real life” conditions. Our study supports the importance of a same-day strategy as a key component of efforts to reduce loss to follow-up and to achieve efficient CC screening. Because a delay of even 48 hours can impact screening uptake, efforts should be directed toward implementing a single-day test-triage-and-treat strategy in developing countries. The limitations of the present study include the fact that, although the two groups in our study population came from the same setting and were similar in terms of socio-demographic and clinical characteristics, the non-randomized design of the study limits the generalization of our results to the general population. Future studies should also consider assessing the impact-level effect of different screening methods on the rate of CC, compared with the baseline rate in the unscreened population in this context. It would also be useful to identify specific population subgroups that are unscreened or under-screened to facilitate appropriate targeted interventions.In conclusion, compliance with VIA/VILI triage among HPV-positive women is higher when the invitation to triage is issued immediately or shortly after the administration of an HPV self-test. This indicates that a single-day test-triage-and-treat strategy is preferred for LMIC. Our findings underscore the importance of point-of-care CC screening to increase screening and treatment and to decrease loss to follow-up.S1 Checklist(PDF)Click here for additional data file.S1 Protocol(DOCX)Click here for additional data file.


Background: The Veterans Health Administration (VHA) has pioneered the implementation of video to home (VTH) technology to increase access to mental health treatments for Veterans facing barriers to receiving in-person care, particularly for posttraumatic stress disorder (PTSD). Randomized controlled trials have established the noninferiority of evidence-based psychotherapies (EBPs) for PTSD delivered through VTH, compared to in-person delivery. Less is known about the use of VTH to deliver EBPs for PTSD in routine clinical practice.Objective: We examined the provision of EBPs for PTSD delivered via VTH at a large Southwestern VHA PTSD outpatient clinic.Methods: Data were obtained from chart review of the electronic medical records of Veterans receiving at least one session of Cognitive Processing Therapy or Prolonged Exposure via VTH in the VHA PTSD clinic during the study time frame.Results: Fourteen providers (including six psychology trainees) delivered EBPs for PTSD via VTH between 2016 and 2018. Providers treated 74 Veterans (33.8% women) from diverse sociocultural backgrounds who ranged in age from 25 to 79. Each provider treated about 3.08 (± 2.18) Veterans using VTH, not including one provider who saw more than 30. A hybrid approach, in which VTH-delivery was coupled with in-person delivery, was used with 70.3% of Veterans across treatment (including sessions completed before initiation and after termination of the EBP). This demonstrates the versatility of VTH for meeting individual patient needs. Most EBP sessions (85.4%) were conducted over VTH. Despite Veterans attending an average of 6.85 (± 4.88) EBP sessions, 50% terminated before session 7. This dropout rate is consistent with national and local EBP completion averages within the VHA. Veterans receiving Cognitive Processing Therapy via VTH were more likely to complete treatment than those receiving Prolonged Exposure. No other patient factors predicted attrition.Conclusions: This study highlights the use of VTH as “tool in the toolbox” that expands the scope of practice for providers and increases opportunities for Veterans to receive EBPs for PTSD. We describe other potential advantages of using VTH to deliver EBPs for PTSD. Evidence-based psychotherapies (EBPs), including Cognitive Processing Therapy and Prolonged Exposure, are considered first-line interventions for posttraumatic stress disorder (PTSD) and have strong support in Veteran samples –3. Despivia video to home (VTH) technology is one promising option for overcoming barriers to care and increasing access to and retention in EBPs for PTSD. VTH is a safe and convenient alternative to in-person care and offers patients the opportunity to receive PTSD treatment in the comfort of their home, work, or other private location. Delivery of EBPs via VTH allows patients and providers to synchronously connect for live, interactive therapy sessions using a secure web-based videoconferencing feature on a personal computer, laptop, tablet, or other device. The content of the VTH-delivered EBPs for PTSD is identical to traditional in-person delivery.The provision of EBPs via VTH compared to in-person treatment, though sample sizes were relatively small  describe demographic and clinical characteristics of Veterans receiving VTH-delivered EBPs for PTSD, 2) report the number of PTSD clinic providers delivering these EBPs via VTH during the study period, 3) report the average number of Veterans each provider treated via VTH, 4) report the percentage of Veterans who engaged in the EBP for PTSD exclusively via VTH vs. both VTH and in-person, and 5) report rates of VTH EBP for PTSD completion. We also examined known predictors of in-person EBP for PTSD completion including demographic characteristics , symptom severity, comorbid substance use disorder, service-connection for a disability, and military service era  and employed two to three psychology interns and fellows at a time (their cases are included here). VHA PTSD clinic staff and trainees treat Veterans with a primary diagnosis of PTSD or Other Trauma/Stressor-Related Disorder. Of note, a diagnosis of military-related PTSD is not required for enrollment and Veterans are not excluded for having comorbid psychiatric diagnoses. The VHA PTSD clinic routinely offers Cognitive Processing Therapy and Prolonged Exposure as first-line, gold standard EBPs for PTSD. The VHA PTSD clinic staff were introduced to and gradually trained in VTH starting in 2015 as part of on-going implementation efforts to increase adoption of this clinical innovation .via VTH between January 1, 2016, and December 31, 2018. The study protocol was reviewed and approved by the Institutional Review Board at Baylor College of Medicine and Affiliated Hospitals in addition to the Research and Development committee at the Houston Veterans Affairs Medical Center. Because this study involved a retrospective review of patient medical records, a waiver of informed consent/HIPAA authorization was required and granted. De-identified data (described below) were collected in a SPSS database securely stored behind a VHA firewall only accessible by the principal investigator and approved research staff. Identifiable information was only used to collect aggregate data from the medical records and no identifiable data was downloaded, copied, or printed.We reviewed the electronic medical records of all Veterans enrolled in the VHA PTSD clinic who completed at least one individual EBP for PTSD session Demographic data were age (in years), gender, race, ethnicity, marital status, academic status , employment, rural or urban residence, military service era, deployment status, and VHA service-connected disability status for PTSD. Veterans' residency zip codes were classified as rural or urban according to the Rural-Urban Commuting Area Codes . Informavia VTH. Key variables collected at both time intervals were: use of mental health services within this or other VHA clinics , medication management visits, use of emergency services , and inpatient hospitalizations. Veterans who received psychotherapy  in the VHA PTSD clinic prior to their most recent episode of care were distinguished from Veterans who were newly admitted or never received treatment after admission into the clinic.Veterans' treatment history was gathered from two time intervals—the year preceding admission into the VHA PTSD clinic and during the most recent episode of care. The most recent episode of care was defined as the period during which the Veteran completed at least one EBP for PTSD session DSM-5 severity scores , and nature of primary or index trauma were recorded. Other treatment variables were number of individual sessions (including sessions completed before initiation or completion of EBP), number of EBP sessions, number of missed and cancelled sessions, and notable VTH connectivity issues . We differentiated between sessions delivered in-person vs. those delivered through VTH. A 7-session benchmark was used to define EBP completion based on existing definitions of EBP for PTSD completion , 26–28. y scores  were colDeidentified chart review data were entered into a shared project database by two research assistants, who had experience conducting VHA chart review research and had obtained thorough training for the current study. The first author (D.B.) oversaw chart review and met regularly with the research assistants to resolve any emergent problems. For any issues, the first author reviewed the individual charts, and the group reached a consensus.p ≤ 0.25 process were included in the final model , EBP type, index trauma type, and prior treatment history. Due to concerns about adequate power, predictors for the logistic regression analysis were purposefully selected by first conducting a univariate analysis of each predictor to determine which variables should be included in the final multivariate model. Predictors that had a significant univariate test at al model .via VTH within the VHA PTSD clinic during the study time fame. Veteran demographic and clinical characteristics are described in M = 42.01 ± 11.71). Most Veterans were Caucasian or African American, non-Hispanic/Latino, married, employed, receiving VHA service connection for a PTSD disability, and living at an urban residence at the time of admission into the clinic. Most Veterans had been deployed to a combat zone with many serving during the Operation Iraqi Freedom/Operation Enduring Freedom, or Gulf War eras. Almost all Veterans (73 of 74) had co-occurring psychiatric diagnoses, most often depression (52.7%) or a substance/alcohol use disorder (24.3%). Fewer Veterans (23 of 74) had significant medical comorbidities. Overall, this sample had low Charlson Comorbidity Index scores indicating low overall disease burden and mortality risk. Combat (54.1%) was the most commonly identified index trauma, followed by MST (20.3%); other military, noncombat trauma ; and nonmilitary, civilian trauma (9.5%).A total of 74 Veterans  received an EBP for PTSD via VTH steadily increased from 2016 to 2018. In 2016, four clinic providers (including one trainee) used this treatment modality with at least one patient. Seven additional providers (including four trainees) delivered EBPs via VTH in 2017, followed by three more providers (including one trainees) in 2018. Altogether, 14 providers  administered EBPs for PTSD using VTH during the study period. On average, each provider delivered care to approximately 3.08 (± 2.18) Veterans via VTH, not including one provider who saw more than 30 Veterans. Between 24 and 26 Veterans were seen each year during the study time frame.The number of clinic providers delivering EBPs for PTSD n = 52), 67.8% of sessions were delivered via VTH. Fifty-seven of 74 (77%) Veterans missed or cancelled an average of 2.77 (±2.59) scheduled sessions. Technical difficulties associated with VTH ranged in severity from temporary audio or video loss to major broadband issues . Significant technical difficulties that disrupted the quality of sessions  or led to early termination of a session were experienced once or twice during treatment by 54.0% of the sample.Including sessions completed before initiation and after termination of an EBP for PTSD, Veterans were seen for 11.08 (±11.19) total sessions. A minority of Veterans (29.7%) completed individual sessions that were delivered exclusively through VTH. Most often, a hybrid approach in which VTH-delivery was coupled with in-person delivery was used. Of those receiving this hybrid approach (n = 18), Prolonged Exposure and Cognitive Processing Therapy were examined together for the remaining analyses. Veterans attended an average of 6.85 (±4.88) EBP for PTSD sessions, with 85.4% of these sessions conducted over VTH. Thirty-seven (50%) Veterans completed treatment .Cognitive Processing Therapy was administered more often than Prolonged Exposure . Due to the small number of Veterans receiving Prolonged Exposure  offered VTH as one delivery option, rather than designating a smaller number of providers who exclusively offered telehealth services . The incThe Houston VHA PTSD clinic, as part of a multisite implementation project , 33, recAttrition in this study (50%) was on par with local and national in-person EBP completion averages for Veterans with PTSD , 28, 38.Despite attrition rates comparable with in-person EBP delivery, VTH resolves many major deterrents  that dissuade Veterans with PTSD from initiating EBPs . Put difA relative strength of this study is that it provides a longitudinal view of VTH utilization for EBPs in a single setting from 2016 to 2018. Nevertheless, our findings should be interpreted in light of study limitations. First, our data were derived from a single VHA PTSD clinic within a large VHA medical center and may not generalize to other VHA settings, such as smaller or more rural facilities. Of note, our sample size was relatively small, but mirrors the slow growth of VTH use within VHA nationally . Second,Home-based telemental health services, such as VTH, are revolutionizing mental healthcare delivery. VTH affords a high degree of flexibility that optimizes patient choice and eliminates major disruptions in care due to practical or logistical issues. With VTH, providers can remotely connect with a broad range of patients to deliver patient-centered, evidence-based care that might have otherwise been inaccessible. Despite these advantages, widescale adoption of VTH into clinical practice remains slow . More reAs VTH becomes more integrated into routine clinical practice, it will be important to gain a richer understanding of issues related to patient engagement and EBP completion. Our study indicated a potential dose advantage for VTH, although attrition rates were comparable to in-person delivery of EBPs. Future studies should consider mixed method research designs to better understand factors related to EBP engagement, especially factors that are unique to VTH administration. Knowing this information will inform best practice standards for VTH-delivery of EBPs and enhance the quality of care delivered through this modality.The datasets for this study will not be made publicly available because the dataset contains Veteran personal health information. Privacy laws prevent us from sharing personal health information outside the VHA. The Michael E. DeBakey Veterans Affairs Medical Center will not provide unrestricted, open public access to large scale health related datasets because of re-identification concerns and the obligation to protect Veterans' private information.The study protocol was reviewed and approved by the Institutional Review Board at Baylor College of Medicine and Affiliated Hospitals in addition to the Research and Development committee at the Houston Veterans Affairs Medical Center. Because this study involved a retrospective review of patient medical records, a waiver of informed consent/HIPAA authorization was required and granted. De-identified data were collected in a SPSS database securely stored behind a VHA firewall only accessible by the principal investigator and approved research staff. Identifiable information was only used to collect aggregate data from the medical records and no identifiable data was downloaded, copied, or printed.All authors contributed to conception of the study. TF, DB, JL, and FK designed the study. DB and FK organized the database. DB completed data collection and performed statistical analyses. DB, FK, and TF wrote sections of the manuscript. All authors contributed to manuscript revision, read and approved the submitted version.This work was partly supported by the use of facilities and resources of the Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety (CIn13-413), the Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, and the VA South Central Mental Illness Research, Education and Clinical Center. The opinions expressed are those of the authors and not necessarily those of the Department of Veterans Affairs, the U.S. government, or Baylor College of Medicine. None of these bodies played a role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Low- and middle-income countries have high incidences of cervical cancer linked to human papillomavirus (HPV), and without resources for cancer screenings these countries bear 85% of all cervical cancer cases. To address some of these needs, brigade-style screening combined with sensitive polymerase chain reaction–based HPV testing to detect common high-risk HPV genotypes may be necessary.We deployed an inexpensive DNA extraction technique and a real-time polymerase chain reaction–based HPV genotyping assay, as well as Papanicolaou testing, in a factory in San Pedro Sula, Honduras, where 1,732 women were screened for cervical cancer.We found that 28% of participants were positive for high-risk HPV, with 26% of HPV-positive participants having more than one HPV infection. Moreover, the most common HPV genotypes detected were different than those routinely found in the United States.This work demonstrates a deployable protocol for HPV screening in low- and middle-income countries with limited resources to perform cytopathology assessment of Pap smears. A lack of funding, trained cytopathologists to review Papanicolaou test slides, and other health care providers for follow-up care that comprise the needed infrastructure does not allow for routine cervical cancer screening. To alleviate some of these burdens associated with cervical cancer screening, we developed and validated a process with which to screen women using a simple, high-risk human papillomavirus (hrHPV) DNA test.4 We demonstrate that DNA testing for hrHPV using crude cell lysates and real-time polymerase chain reaction (PCR) with lyophilized reagents was feasible to perform in a mobile system so that women in various regions of Honduras could be tested.5Cervical cancer in low- and middle-income countries (LMICs) accounts for 85% of an estimated 528,000 new cases globally and 266,000 deaths annually.Key ObjectiveCould high-risk HPV genotyping be implemented in a low- and middle-income country setting for screening purposes?Knowledge GeneratedUsing modified DNA extraction methods and lyophilized reagents for real-time polymerase chain reaction, we were implemented screening of more than 1,000 participants. The prevalence of high-risk human papillomavirus types was different than that observed in high-income countries.RelevanceThis approach can help to alleviate the limitations associated with cervical cancer screening in low- and middle-income countries.11 Several low-cost HPV screening tests have been developed specifically for use in LMICs. Two of these tests, however, cannot distinguish between HPV types or resolve coinfections known to have higher rates of cervical disease, whereas a third less-sensitive immunologic test only detects HPV types 16, 18, and 45.15 Cervical cancer screening guidelines have recently been published that recommend DNA testing for the detection of hrHPV in a liquid cytology sample as a sole test or in conjunction with Papanicolaou test.16 Use of instrumentation and assays that are US Food and Drug Administration approved in the United States is not feasible, nor sustainable, in Honduras as a result of cost and facility logistics. We therefore developed a low-cost, simple DNA testing method for hrHPV using a crude cell lysate and real-time PCR instrument.5 In several studies, we showed that hrHPV type distributions were more reflective of those found in Asia than in North America.17 This geographically unexpected distribution underscores the need for HPV genotype surveillance to effectively triage hrHPV-positive participants for follow-up care and to strategize the implementation of successful vaccination programs.18As the causative agent for cervical cancer, detection of hrHPV types, which is less subjective, has the potential to improve outcomes relative to less-sensitive visual or cytologic tests.In the current study, we determine the hrHPV type frequency in women working in a manufacturing facility in San Pedro Sula, Honduras.This study was approved by the Dartmouth Committee for the Protection of Human Subjects and the Universidad de Catolica in San Pedro Sula, Honduras. Cervical samples were collected using cervical brushes on 1,732 participants who were employees at a manufacturing site in San Pedro Sula, Honduras, for Papanicolaou test and hrHPV testing. Samples were collected by trained physicians and medical students. Participants with a positive hrHPV result underwent a follow-up examination at a local cancer center.4 In brief, dried cervical brushes were cut and placed inside individual tubes that contained 400 µL of cell lysis buffer consisting of 50 mM NaOH and 0.2 μM EDTA in nuclease-free water  in addition to an internal human DNA sequence control. This is accomplished through a multiplexed PCR with end point melt-curve analysis that resolves type-specific melting temperatures for four distinct probes labeled with ROX , CY5 , FAM , and HEX for the internal control . Sample Of 1,732 samples, 480 (28%) were positive for high-risk HPV, and 1,199 samples (69%) had no detectable HPV. Fifty-three samples (3%) failed to amplify either the internal control or an HPV target and were deemed to be invalid and subsequently unable to type . HPVs 58Among 480 HPV-positive samples, 126 (26%) were positive for two or more HPV genotypes. There were five participants with HPV 58/HPV 16 coinfections and a single participant with an HPV 58/HPV 35 coinfection. No HPV 16/HPV 35 or HPV 16/HPV 18 coinfections were identified. Individual results of the identified HPV infections are shown in 20 but can also be performed by nontechnical staff. Moreover, higher negative predictive values with PCR-based HPV tests offer longer reassurance to patients that they are not at substantial risk of developing cervical cancer.23 In this context, DNA-based HPV screening methods are less subjective, more robust, and have been shown to have higher sensitivity23 and the ability to distinguish between many coinfections that increase the risk of cervical disease.15Cervical cancer screening strategies, including cytologic and HPV screens designed for higher-income countries with widespread health care access and reliable follow-up care, are difficult to implement in LMICs where those resources are scarce. Cytologic examination in LMICs is costly and the number of cytologists available is not sufficient to perform the analyses, especially in countries in which gaps in health care access are prevalent. Resolving these problems requires a paradigm shift. Low-cost HPV screening techniques offer a potential solution as there is now strong evidence to show that HPV-based screening assays are not only a more sensitive means with which to detect underlying cervical abnormalities compared with conventional cytology,24 However, continued and diligent HPV screening is critical for sustained impact and effectiveness of cervical cancer prevention.26 High-risk HPV screening should include data on vaccinations and genotypic information for both infection prevalence and HPV-related cancers.19 Such screening programs already have documented suppression of HPVs 16 and 18 in response to the bivalent vaccine.27 In other studies, particularly those in areas with prevaccine HPV genotype distributions that are known to include genotypes not included in vaccines, such as HPV 58, controversial active surveillance is underway to closely monitor for the potential of type replacement after widespread use of the bivalent vaccine.29For the 480 participants (28%) we identified with HPV infection, the benefits of screening will, we hope, translate into earlier interventions and a reduction in overall cervical cancer rates upon referral for cytologic examination and follow-up. For the remaining 1,202 HPV-negative participants (69%), there is strong confidence that they are relatively safe from developing cervical cancer for the next 5 years.30 In this study of factory workers in San Pedro Sula, Honduras, our results show a prevalence of HPV 58 and HPV 35 infections, with 90 (19%) and 64 (13%) of 480 infections, respectively (31In the current study, we found no HPV 16 and HPV 18 coinfections and relatively few single HPV 16 or HPV 18 infections; therefore, direct coverage provided by the bivalent vaccine against infection and possible progression to cervical cancer would equate to approximately 14% among those that are HPV positive in this study. When considering the nonavalent vaccine that covers HPVs 6,11, 16, 18, 31, 33, 45, 52, and 58, approximately 47% of those that are HPV positive in this study could receive some amount of protection from either single or coinfections and possible progression to cervical cancer among those genotypes. However, approximately 53% of participants in the current study would not have benefited from the nonavalent vaccine on the basis of genotype prevalence alone . There mectively . Neither5 HPV 52 was also found in neoplastic lesions at a prevalence that was higher than expected in Mexico.32 Similarly, HPV 52 and 58 are known to have a higher distribution in Asia relative to other regions.33 Not surprisingly, subsequent studies found that HPV 58 accounts for a larger proportion of cervical cancer burden in Asia than elsewhere.35Global HPV genotype distribution is broadly known to have geographic differences that must be considered for cervical cancer prevention and surveillance strategies. Our previous work found a high prevalence of HPV 52 in an isolated Honduran community located in the largest wilderness tract in Central America.31 Triaging patients on the basis of positive HPV status within these guidelines not only allows for the most effective use of the limited number of pathologists, but the HPV genotypic information provides critical information for both patient care and to support vaccination strategies adopted in those countries.27 A limitation of the current study is in the convenience sampling with respect to women working in a single factory in one Honduran city as well as the age of participants being limited to a working group.The HPV distribution identified in this participant population and limited number of in-country pathologists makes the use of primary HPV testing, as described here, both critical and effective, especially given the interim clinical guidance for the use of such testing for cervical cancer screening.4; and the combination of lyophilized reagents, crude lysate, and HPV genotyping performed by the instrument makes for an easy-to-perform operation that is suitable for testing in locations without highly trained personnel. These features allow for near-patient care diagnosis that is of critical importance for combining screening and treatment strategies in LMICs.Last, the low-cost DNA lysate and sensitive HPV assay described here allowed us to process 94 samples in less than 2.5 hours and return rapid genotype-specific results. This approach offers the following benefits: in contrast to other PCR-based assays that use hydrolysis probes, the equipment can be run off of a generator or variable power sources, as the system returns results despite power interruptions ; the PCR


Human papillomavirus (HPV) is a small double-stranded DNA virus with tropism for epithelial cells. To this date, over 150 genotypes are known and are classified into two major groups, low-risk and high-risk strains, depending on the ability of the virus to induce malignant transformation. The host's immunity plays a central role in the course of the infection; therefore, it may not be clinically manifest or may produce various benign or malignant lesions. The pathogenic mechanisms are complex and incompletely elucidated. Recent research suggests the role of chronic inflammation and oxidative stress (OS) in the pathogenesis of HPV infection and the associated carcinogenic processes. Chronic inflammation induces OS, which in turn promotes the perpetuation of the inflammatory process resulting in the release of numerous molecules which cause cell damage. Reactive oxygen species exert a harmful effect on proteins, lipids, and nucleic acids. Viral oncogenes E5, E6, and E7 are involved in the development of chronic inflammation through various mechanisms. In addition, HPV may interfere with redox homeostasis of host cells, inducing OS which may be involved in the persistence of the infection and play a certain role in viral integration and promotion of carcinogenesis. Knowledge regarding the interplay between chronic inflammation and OS in the pathogenesis of HPV infection and HPV-induced carcinogenesis has important consequences on the development of new therapeutic strategies. Numerous reports have pointed out the close link between chronic inflammation, oxidative stress (OS), and carcinogenesis . A factoOS is defined as the imbalance between oxidants and antioxidants in favour of the former, a condition that can lead to the alteration of various cell components and cellular signalling mechanisms . It is iSeveral studies have suggested that in human papillomavirus (HPV) infection and the associated carcinogenic processes, chronic inflammation and OS are important cofactors, a fact which may confer new perspectives on its pathogenesis and therapeutic approach .HPV is a nonenveloped and double-stranded DNA virus with tropism for epithelial cells . Its genα6-integrin and laminin-5, has a pivotal role. The virus is internalized into the cell through clathrin- or caveolae-mediated endocytosis and penetrates the nucleus where the replication process is initiated [HPV penetrates the epithelial tissues through small injuries, and its life cycle is closely related to the keratinocyte differentiation process. As keratinocytes progress to the spinous layer, amplification of gene expression accompanied by viral DNA replication occurs. The expression of viral genes was only evidenced in keratinocytes , but thenitiated , 15.After the infection of basal cells, including stem cells, with a high rate of division, the expression of viral genes is activated, generating up to 100 extrachromosomal copies of HPV DNA per cell. E1 and E2 proteins bear an important role in this stage. These two proteins form a complex that binds to the viral replication origin participate in the recruitment of cellular polymerases and accessory proteins and modulate the DNA replication. Regarding the role of E4 and E5 proteins, further studies are required, but it seems that they modulate the late viral functions. In addition, E6 and E7 proteins exert a stimulatory effect on viral proliferation. After penetrating into the suprabasal layers, the expression of the late viral genes is initiated, resulting in a spontaneously self-assemble into an icosahedral capsid. Therefore, the virions are assembled to be released and infect new cells , 16, 17.HPV is involved in a variety of cutaneous or mucous and benign or malignant lesions . To thisEarly onset of sexual life and multiple sexual partners facilitate the contraction of HPV; most sexually active women becoming infected. In 90% of cases, the clearance of the infection occurs in the first 2 years, but in the other 10%, the infection becomes persistent and may progress to malignant lesions , 22.Cervical intraepithelial neoplasia (CIN) is a precancerous lesion, the precursor of cervical cancer. CIN is classified as CIN 1, CIN 2, and CIN 3, depending on the degree of dysplasia, namely, mild, moderate, or severe. Clinically, the lesion is asymptomatic and may regress spontaneously or progress to invasive cancer over a certain period of time .Cervical cancer is an important cause of death among women worldwide. Most cases, over 80%, are noticed in developing countries where the screening programs are not correctly implemented. HPV infection is the leading cause of cervical cancer. HPV 16 and 18 are the main types involved, being identified in over 70% of cases , 25. OthThe most important players involved in the malignant transformation of HPV-related lesions are E6 and E7 proteins. They have the ability to interfere with cell proliferation and differentiation. These proteins are found both in low-risk and high-risk types. E6 of the high-risk types has been found in the nucleus and cytoplasm and can be associated with 12 proteins, such as paxillin, p300/CBP, etc. . E6 has E7 is mainly found in the nucleus and has the ability to bind to retinoblastoma (Rb) protein, inactivating its function . The Rb Inflammation is the first step of host immune defence against various harmful stimuli; it is a mechanism of innate immunity, with an important role in immunosurveillance . The proThe persistence of a certain type of cytokines can promote chronic inflammation . In thos2− (superoxide anion), H2O2 (hydrogen peroxide), and OH●  [●), which is formed by the conversion of L-arginine to citrulline, a reaction catalyzed by NO synthase. NO● can react with O2− resulting in the formation of peroxide nitrite (ONOO−), a product with toxic effect [Free radicals  are moladicals) , 45. Theadicals) . Seven madicals) . The maiadicals) , 47. Regc effect .Antioxidants are the most important weapons against OS damage. The main enzymes with antioxidant activity are superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GPx). Other molecules involved in the antioxidant defence are glutathione, tocopherols, carotenes, and ascorbic acid –51.When an inflammatory process is triggered by a certain stimulus, numerous cells are recruited and release various mediators including proinflammatory cytokines that will promote OS, which is part of the first line mechanisms of host defence . Thus, a● attack, resulting in modified proteins, which by overcoming proteolysis mechanisms accumulate in cells and lead to alteration of cell function. The protein degradation increases up to 11 times more when the cells are exposed to ROS. Oxidation occurs directly through ROS damage or indirectly by the attack of the molecules derived from lipid peroxidation [Protein oxidation is mainly the consequence of OHxidation , 54. Thexidation . Membranxidation . The lipxidation , 59. Thexidation , 58.Since many cases of HPV infection regress spontaneously, it has been hypothesized that cofactors are needed for virus persistence and development of a malignant process . CarcinoExposure of a tissue to chronic inflammation will induce mutations in susceptible cell populations. Cytokines and growth factors, released during inflammation, may be involved in genetic alteration , 64. ChrHistopathological analysis of severe HPV-induced lesions exhibited an increased inflammatory infiltrate . Of noteViral oncogenes E5, E6, and E7 are involved in the development of chronic inflammation associated with cervical cancer. These oncogenes lead to the increase in cyclooxygenase- (COX-) 2 expression and, consequently, to a high amount of prostaglandins with unfavourable effects on cervical tissue . The relThe study by Castle et al., including women infected with high-risk HPV types, revealed an association between cervical inflammation and the presence of high-grade cervical lesions, drawing attention to the role of inflammation as a risk factor for the progression of HPV infection to carcinogenesis . In lineTaking into consideration the hypothesis that inflammation is involved in HPV-induced malignancies, Hiraku et al. evaluated whether 8-nitroguanine, a by-product of inflammation, is involved in carcinogenesis. They included patients with CIN 1, 2, and 3 and condylomata acuminata, in all cases the diagnosis being histopathologically confirmed. Immunohistochemical studies have determined the presence of 8-nitroguanine, 8-oxo-7,8-dihydro-2′-deoxyguanosine (8-oxodG), and p16 in the studied samples. The expression of 8-nitroguanine was higher in CIN samples than in condylomata acuminata. Moreover, 8-oxodG and 8-nitroguanine positively correlated with the CIN grade. Regarding p16, there were no differences between the studied groups. Thus, it seems that 8-nitroguanine is a better marker to predict the risk of carcinogenesis related to inflammation than p16 in HPV-infected patients .It has been found that patients with high-grade squamous intraepithelial lesions or invasive lesions have higher levels of nitrite/nitrate in plasma and elevated expression of inducible NO synthase compared to normal subjects . NO can There is growing evidence suggesting that the decrease in expression of COX-2 prevents tumour growth, in particular, by inducing apoptosis and inhibiting angiogenesis. Based on this data, several studies have been conducted in order to assess the efficacy of nonsteroidal anti-inflammatory drugs (NAISDs) in various malignancies, including cervical cancer .The study by Friel et al. revealed that frequent use of aspirin (≥7 tablets/week) could reduce the risk of developing cervical cancer . In contThe study by Ferrandina et al. has suggested that celecoxib, a COX-2 inhibitor, can be a useful agent in both prevention and therapy of cervical cancer. There was a decrease in tumour expression of COX-2 and markers of proliferation and angiogenesis such as Ki 67 and microvessel density, respectively, in samples collected from cervical cancer patients after 10 days of celecoxib treatment (400 mg twice daily) . The stuAnother recent study investigated the effect of both nonselective (ibuprofen) and selective (celecoxib) agents on immortalized cervical cells. Both drugs decreased growth cell and induced apoptosis. The study concluded that NSAIDs are promising drugs in cervical cancer and to avoid adverse reactions that might occur during systemic administration, topical therapies could be useful . FurtherNonetheless, the Cochrane review published in 2014 and its updated version published in 2018 investigated the ability of NAISDs to induce regression and prevent progression of CIN and have shown that there is still insufficient evidence to support that fact , 87.There are numerous studies attesting an increased OS in malignant cells –91. ThisInterestingly, HPV has the ability to adapt to OS conditions by increasing the activity of protective mechanisms such as SOD and CAT in the infected cells , 95. TheThe study by de Marco et al. has shown increased OS in samples from women with cervical dysplastic or neoplastic lesions. In the case of dysplastic samples, OS-induced alterations have been observed in the structure of some proteins such as cytoskeletal keratin 6, actin, cornulin, retinal dehydrogenase, and glyceraldehyde 3-phosphate dehydrogenase, which are involved in cell morphology and differentiation. Conversely, in cancer samples, a better control of OS was observed, demonstrating that OS participates in the formation of a favourable environment for malignant transformation .The microenvironment of malignant cells is characterized by a high level of OS biomarkers. Romano et al. revealed a higher level of 8-hydroxy-2′-deoxyguanosine in dysplastic cells as compared to normal cells, attributing an important role to OS in carcinogenesis . The stuSiegel et al. have postulated the interesting hypothesis that markers of OS could reflect the immune host response to HPV infection. They investigated the link between the oxidant load and the clearance of the infection on a sample of 444 HPV-positive women. Anti-5-hydroxymethyl-2′-deoxyuridine autoantibody (anti-HMdU Ab) and MDA levels were measured. They observed elevated levels of the two biomarkers, which have been associated with a faster clearance of oncogenic HPV types . In addiIt seems that the deficiency of certain antioxidants might influence the course of the infection . AntioxiThe study by Manju et al., which included patients with cervical cancer, revealed low levels of the main antioxidant enzymes, GPx, glutathione S transferase (GST), and SOD as well as vitamin C and E. That could be the consequence of both the consumption at the site of the reaction and sequestration by the tumour cells . Anotherδ-aminolevulinate dehydratase (δ-ALA-D). Moreover, they concluded that erythrocyte TBARS and vitamin C levels might be used as OS markers in early stages of cervical cancer. Vitamin C may be valuable in the treatment of these patients, but this topic remains debatable [Gonçalves et al. conducted a study on women with untreated cervical cancer and premalignant cervical lesions and revealed low levels of vitamin C, an important antioxidant, and increased levels of erythrocyte thiobarbituric acid reactive substances (TBARS) and ebatable . Naidu eebatable .Antioxidant vitamins have the ability to neutralize free radicals capable of DNA damage, which makes cells become more vulnerable to HPV infection. The meta-analysis by Myung et al., which included 10,073 patients from 22 case-control studies, concluded that the intake of vitamin B12, vitamin E and beta-carotene was associated with a preventative effect on cervical cancer . SimilarCurcuma longa, has been shown to have numerous effects that interfere with HPV-related carcinogenesis, including the stimulation of apoptosis and inhibition of the expression of HPV oncoproteins [The role of curcumin has been studied in several cancers with promising results. Among antioxidants, the role of polyphenols has been evaluated in several studies . Curcumiproteins . In addiproteins .The study by Sedjo et al. showed that lutein and lycopene can reduce the incidence of cervical cancer due to their antioxidant properties . In addiIt is worth noting that treatments such as chemotherapy and radiotherapy induce free radical release and toxicity, thus antioxidant supplements may be adjuvant treatments associated with a better quality of life of these patients .HPV infection still represents an important public health issue, affecting a considerable number of individuals, being responsible for benign and malignant lesions. The variety of the lesions and the different outcomes of the infection, from self-limiting to invasive, make difficult to understand the HPV mechanism of action. Recent research suggests the role of chronic inflammation and OS as important players involved in virus pathogenesis and promotion of carcinogenesis. The interplay between chronic inflammation and OS induces various tissue alterations facilitating HPV integration, which is a key event in the multistep process of malignant transformation. The expression of viral oncogenes produces genetic abnormalities that promote the malignant transformation. In this context, anti-inflammatory drugs and antioxidants could be a promising therapy. However, current data are scarce and further studies are needed.