Leveraging Project ECHO for improved cervical cancer screening in Ethiopia: An implementation study of integrated HPV selfsampling in HIV care centers

PROJECT ABSTRACT Each year, more than 500,000 women are diagnosed with cervical cancer (CxCa), a preventable cancer caused by human papillomavirus (HPV) that disproportionately burdens low- and middle-income countries (LMICs). Women living with HIV (WLHIV) are up to six times more likely to develop CxCa, making them an especially important target population for prevention and control efforts. In Ethiopia, a national CxCa screening program was established in 2016 and screening guidelines for WLHIV have recently been updated to shift from visual inspection with acetic acid (VIA) to human papillomavirus (HPV) DNA testing. There is limited data on the provider or facility adherence to the “screen-triage-and treat” guidelines and algorithm for HPV testing; Up to 30% of WLHIV screen positive for HPV and the proportions that are appropriately triaged with VIA and treated if needed are currently unknown. Implementation challenges to CxCa screening, as reported by health providers, include high variability in practices between screening sites, and insufficient training and monitoring and evaluation. We seek to explore and address these challenges through an implementation science study of point-of-care HPV self-sampling integrated with routine HIV care in antiretroviral therapy (ART) clinics of hospitals, thereby leveraging established HIV care infrastructure for improved cancer control of WLHIV. A mixed method situational analysis will be conducted to describe the existing integration of CxCa screening with HIV care in hospitals, identify opportunities for optimization of the integrated service, and assess facility readiness to improve the cascade of care. Project ECHO, a facilitated virtual learner community of health professionals, will be used to promote experience sharing between five hospitals of which two low-performing sites will receive intensive technical assistance to increase the proportion of screen-positive individuals appropriately triaged and treated. Acceptability, appropriateness, and feasibility (implementation outcomes) will be assessed as will ECHO (1) participation, (2) satisfaction, (3) impact on knowledge, (4) impact on confidence, and (5) impact on professional practice. Finally, a costing aim will evaluate the cost-benefit of Project ECHO and technical support to inform decision-making around the sustainability of this approach to improved cancer control in people living with HIV. This study is consistent with goals of the RFA-CA-23-033 FOA “Implementation Science for Cancer Control in People Living with HIV in Low- and Middle-Income Countries” by identifying and addressing the unique public health needs of the LMIC population through a situational analysis and by demonstrating potential for broader implementation of integrated CxCa screening with patient-centered HPV self-sampling for WLHIV in LMICs and other low- resource settings, considering scale-up and sustainability in terms of triage and treatment coverage, implementation, and cost. By considering the entire screening cascade, this study will generate important insights that go beyond screening uptake, to advance CxCa control for WLHIV in LMICs and to move the needle on the elimination of an almost entirely preventable cancer that unjustly impacts sub-Saharan Africa.