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 people are diagnosed with cervical cancer (CxCa), a preventable cancer caused by human papillomavirus (HPV). Vaccination against HPV, screening for early detection of HPV and cervical dysplasia, and appropriate treatment for pre-cancers and cancers, if implemented well, could eliminate CxCa as a public health problem. While screening with pap smears has reduced CxCa incidence and mortality in the U.S. since the 1970’s, approximately one fourth of eligible women remain underscreened. Following FDA approval, HPV self-collection will surely shift the paradigm for screening in the coming decades. Project TICHILALECH, an implementation of HPV self-collection (HPV-SC) among people living with HIV (PLHIV) in Ethiopia, leverages a U.S. originated, provider-directed implementation strategy (Project ECHO) for telementoring and peer learning among healthcare providers, generating insights of U.S. and global significance for introduction and scaling of this new screening approach. Ethiopia is a country with a high burden of CxCa (up to 30% of PLHIV screen positive for HPV) where HPV-SC was first introduced in 2021. Implementation challenges to CxCa screening 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 HPV-SC integrated with routine HIV care in hospitals. A mixed method situational analysis describes the existing landscape and integration, identifies opportunities for optimization of services, and assesses facility readiness to improve the cascade of care. Then, 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. This study addresses goals of RFA-CA-23-033 “Implementation Science for Cancer Control in People Living with HIV in Low- and Middle-Income Countries” by describing the unique context of the LMIC setting through a situational assessment and by demonstrating potential for broader implementation of integrated CxCa screening with HPV-SC in other 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 and to move the needle on the elimination of an almost entirely preventable cancer that remains one of the leading causes of cancer-related death globally.