Screening program characteristics and HPV positivity
A total of 44,635 women were screened with HPV tests across the three provinces in 2017 [Table 1]. The largest proportion of women screened (47.8%) was in the Chinandega province. The mean age of women across all three provinces was 40.8 years (standard error [SE]: 8.6) and nearly all women (99.1%) were within the target age range of 30 to 59 years. Nearly all women (96.6%) collected their own vaginal samples.
HPV positivity ranged among provinces from 14.2% (95% CI 13.7–14.7) in Chinandega to 16.2% (95% CI 15.5–16.9) in Chontales, with a value of 16.0% (95% CI 15.4–16.7) in Carazo. Chinandega had significantly lower HPV positivity compared to the other two provinces. HPV prevalence varied by age group; some differences were statistically significant (Table 1). Women aged 25 to 29 years had the highest HPV prevalence of 25.7% (95% CI 19.9–32.5), followed by a significant drop in the 30 to 34 year age group to 18.5% (95% CI 17.9–19.2). Prevalence generally declined through subsequent age groups to 12.5% among women aged 55 to 59 years (95% CI 11.4–13.5) and then increased significantly to 22.7% in women aged 60 years or older (95% CI 16.8–30.0). HPV prevalence was slightly lower in women with self-collected samples (15.3%, 95% CI 14.9–15.6) as compared to provider-collected samples (17.6%, 95% CI 14.8–20.7), but this difference did not reach statistical significance.
Triage of HPV positive women
Among the 6,776 HPV positive women, 3,656 (54.0%) had a triage test recorded [Table 2]; the remaining 3,120 (46.0%) were considered lost at the triage step. Overall, 2,784 (76.1%) of the HPV-positive women who were triaged received Pap while the remaining 872 (23.9%) received VIA. The proportion of VIA triage varied by province, with Chontales using VIA for the highest proportion (60.9%) and Chinandega the least (15.9%) (data not shown).
Triage and treatment among women managed with Pap, VIA
Among the women triaged with Pap, 513 women (21.7%) received a result of ASCUS or greater (ASCUS+), and 15.1% did not have Pap results recorded in our available data [Table 2]. Among women with a Pap result of ASCUS+, 117 had an ASCUS result (22.8%), 308 had a low-grade squamous intraepithelial lesion (LSIL) result (60.0%), 82 had a high-grade squamous intraepithelial lesion (HSIL) result (16.0%), and 6 had a result of cancer (1.2%) (data not shown); these results were not biopsy-confirmed in our available dataset. Among women triaged with Pap, 132 women were treated; this represents 25.7% of women with an ASCUS+ Pap result in triage. Considering only those women with an HSIL or cancer result (HSIL+) in Pap triage, 27 (30.7%) were treated; this percentage did not differ significantly from those women with an LSIL or ASCUS (LSIL-) result in Pap triage (p=0.243; data not shown).
Among women triaged with VIA, 402 (46.1%) received a VIA positive result and 28 (3.2%) had no VIA result recorded [Table 2]. Among women triaged with VIA, 361 were treated; this represents 89.9% of VIA-positive women in triage.
Time elapsed between screening, triage and treatment steps
The mean time elapsed between HPV sample collection and Pap collection for triage was 58.1 days (standard deviation [SD]: 37.7); mean time from Pap triage to treatment was 102 days (SD: 93.5) [Table 2]. Among HSIL+ women, the mean time elapsed between triage and treatment was 158.4 days (SD: 156.8). This was significantly longer than for those women with LSIL- of 83.6 days (SD: 63.9, p<0.001; data not shown). The mean time elapsed between HPV sample collection and VIA triage exam was 78.6 days (SD: 61.5); mean time from VIA triage to treatment was 13.2 days (SD: 45.1 days), while the median time to treatment was zero (same-day treatment). Among triaged women, 70.2% of women had a mean time elapsed between screening and triage recorded, and 51.3% of triage-positive women likewise had mean time elapsed between triage and treatment recorded. Data on time between HPV sample collection and delivery of test result were not available.
Among those with a record of treatment, 472 women were treated with cryotherapy (97.1%) and 14 (2.9%) received advanced procedures including 5 hysterectomies, 7 cold knife conizations, 1 chemotherapy and 1 radiotherapy (data not shown). All excision treatments occurred in the Chontales province.
Factors associated with triage, treatment completion
In adjusted analyses, both province and screening modality were significantly associated with a woman completing the triage step [Table 3]. After adjusting for age and screening modality, the odds of a woman completing triage were 2.78 times higher for women residing in Chontales (95% CI: 2.43–3.19, p<0.001) and 1.23 times higher for women residing in Chinandega (95% CI: 1.09–1.38, p<0.001) compared to women residing in Carazo. After adjusting for age and province, the odds of completing triage were 2.82 times higher for women who had a provider-collected sample compared to women who collected their own sample for HPV testing (95% CI: 1.82–4.39, p<0.001).
In adjusted analyses, both province and triage method were significantly associated with a woman receiving treatment [Table 4]. After adjusting for age and triage method, women residing in Chinandega were 66% less likely to receive treatment than women residing in Carazo (aOR: 0.34, 95% CI: 0.20–0.56, p<0.001). After adjusting for age, province, and screening modality, women who were triaged with Pap were 95% less likely to receive treatment than those who were triaged by VIA (aOR: 0.05, 95% CI: 0.04–0.08, p < 0.001). There were no statistically significant associations observed between age and receipt of triage or treatment, or between screening modality (self- versus provider-collected sampling) and receipt of treatment. There was also no statistically significant association between a HSIL+ Pap result in triage and receiving treatment (data not shown).