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.
Treatment modalities
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).