Feasibility of HPV-based cervical cancer screening in rural areas of developing countries with the example of the North Tongu District, Ghana

Cervical cancer gains increasing recognition as a preventable threat to women’s health, as expressed by WHO Director General Dr. Ghebreyesus in his recent call for its elimination. Developing countries carry the global burden and despite existing recommendations for secondary prevention screening programs their implementation remains a barrier. This doctoral thesis aims to evaluate the feasibility of an HPV-based cervical cancer screening approach in the North Tongu District, Ghana.
Methods This work studied (i) the methodological validity of self-sampling specimens from cervical cancer patients for HPV oncoprotein testing before its use in a screening population, (ii) the HPV prevalence among 2002 women, 18-65 years of age, in the general population of the North Tongu Disctrict, Ghana, through a cross-sectional population-based study with self-sampling collection in rural communities, and (iii) the natural history of HPV infection by longitudinal comparison of HPV type-specific persistence and clearance for 104 women over a four years’ time period. Results Using self-sampling cervicovaginal lavage specimens for HPV oncoprotein detection was methodologically feasible with 95% sensitivity for HPV16/18 positive cervical cancer. However self-sampling cervicovaginal scraping specimens did not reveal reliable HPV oncoprotein test results during the cross-sectional assessment. The high-risk HPV prevalence found among women living in the North Tongu District, Ghana was 32.3% and 27.3% among women in the WHO-recommended screening age range of 30-49 years. Sample collection in the rural communities was successful. Infection associated risk factors were (i) increasing age, (ii) increasing number of sexual partners and (iii) marital status, in particular not being married. Over the four years’ time period 6.7% of the women observed had persistent high-risk HPV infection, while 93.3% cleared their initial infection and 21.2% acquired new infections.
Discussion The high-risk HPV prevalence found among the general population and women 30-49 years is high and therefore requires careful planning and good infrastructure to triage high-risk HPV positive women and reduce the number of women needing treatment. Using HPV oncoprotein triage from the same self-collected specimen is not reliable at this point, stratification by sociodemographic factors risks stigmatization and retesting for HPV persistence necessitates a well-functioning recall system and HPV genotyping.
Conclusion The high HPV prevalence found demands substantial governmental support and investment to build well-functioning screening infrastructure that offers necessary triage and treatment options for women high-risk HPV positive with increased risk for cervical cancer. Integrating local infrastructure and capacity is promising but requires regional assessment rather than one-size-fit-all approaches.