Programmatic implementation of HPV self-collection in Jujuy, Argentina

ARROSSI S

Conferencia; International Meeting ?Investing in cervical cancer prevention?; 2015

In 2012-2014 we carried out the Jujuy Demonstration Project (JDP), tointroduced HPV testing as the primary screening Test in the province of Jujuy,in Northwest Argentina, for all women aged 30+ attending the public healthsystem (Arrossi et al, 2015). The JDP goal was to screening 56,000 women in three years (80% of womenattending the public health system). Jujuy publichealth system includes a main hospital and 270 primary health care centers. ThePrimary Health Care System (PHC) integrates approximately 700 paid full-time CHWswho twice yearly visit approximately 110.000 households for health-relatedtasks as immunization and promotion of maternal/child health. In 2012, we undertook the EMA project (nested in theJDP), to assess the effect on women´s screening uptake of HPVself-collection offered by community health workers (CHWs) (Arrossi et al, 2015).In order to do this, we undertook a cluster-randomizedtrial where 200 CHWs were randomly selected and assigned 1:1 to offer duringhome-visits HPV self-collection (intervention group, IG) or to promote clinician-collectedHPV-testing (control group, CG). Results showed that 94 and 97 CHWs in the IGand CG respectively enrolled 6013 women. In the IG 2618/3049 (85·9%) women hada self-collected or clinician-collected HPV-test, compared to 599/2964 (20·2%)HPV-tested women from the CG (Risk Ratio 4·02, 95%CI 3·44-4·71). CIN2+detection rates were 1·15% (29/2519) and 1·29% (9/698) among women withself-collected tests and clinician-collected tests respectively, difference notstatistically significant. We concluded that HPV self-collection offered byCHWs is highly effective to rapidly increase screening uptake and detection ofcancer precursors. Based on these results, we worked with Jujuy´s health authorities tointroduce HPV-self collection as a programmatic strategy, aimed at screeningunder-users. To do this, we matched the national system on screeninginformation (SITAM) with the PHC database to produce a list of screeningunder-users to be contacted by each of the 700 provincial CHWs. In 2014, xxwomen performed self-collection (results are under evaluation). Key components of the strategy were: Working closely with health authorities to establish cervical cancerprevention as a health priority.Incorporating research to the implementation project so strategies canbe evidence-based using local data. A key aspect of the research project wasthe fact that the Jujuy ministry of Health and PHC were core partners in itsdesign and implementation. This approach resulted in high involvement of thepublic health system with the strategy since its very beginning, includingconception and design. Later on this evidence was key to gain support fromlocal and national health professionals. Establishing a work alliance with PHC: self-collection was a projectdesigned and undertook both by cervical cancer prevention program and PHC.Also, regular meetings are held with PHC to monitor and evaluate projectperformance.Strong training component. Several training workshops were held withCHWs. These workshops included a motivational component that allowed us to gainCHWs´ support and commitment. At present, regular meetings are held once a yearto share results with CHWs, evaluate their performance in a participatorymanner, and discuss with them project strengthens and obstacles.Having an easy-to-use, accessible national information system (SITAM).This allowed us to have updated, ready-to-use data that is utilized to providepermanent feedback on project performance to health authorities and partnersinvolved in the project.     In 2015, the self-collection strategy was also introduced in theprovince of Tucuman.