and a narrative of a successful HPV POC test-and-treat program in a provincial hospital

Cervical cancer is the fourth most common cancer of women worldwide with an estimated 570,000 cases and 311,000 cancer-related deaths annually.¹ Papua New Guinea (PNG) has the highest cervical cancer incidence and mortality rates in the Asia-Pacific region, with an incidence that is five times that of Australia,¹ and contributes to 1500 preventable deaths annually in PNG. It is a disease of health inequity, with more than 85% of the global burden occurring among women in low and middle-income countries (LMIC), such as PNG, where the highly effective strategies of human papillomavirus (HPV) vaccination, HPV-based cervical screening, and treatment of pre-cancer and cancer are largely unavailable.¹

While there have been some emerging primary prevention strategies for cancers in general in some neighbouring Pacific Island countries,² cervical cancer prevention and control has not been considered a national priority in PNG. There are no effective cervical cancer treatment facilities, particularly radiotherapy, chemotherapy and supportive surgical oncology services and technical expertise. Effective public health primary prevention programs such as HPV vaccines are relatively expensive and not available in public health facilities. Over the years, there has been a lack of political will and inadequate public sector budget support, in part deriving from limited access to updated data on the burden of disease, competing health and development priorities, and limited access to the available tools and technology for prevention and control of cervical cancer. As a result, the personal and family impacts of untreated or locally advanced cervical cancer have been profound with non-availability of timely surgical intervention and radiotherapy, and lack of appropriate medication for pain relief and the absence of proper palliative services in PNG. These all lead to unacceptable suffering, incapacitation and isolation within the community, and lastly a terrible demise.

Historical perspectives of cervical cancer screening programs in Papua New Guinea

Until 2002 there were no effective national cervical cancer screening or prevention programs for PNG. As the disease burden continued to take the lives of women within the community, the government and national health authorities advocated and introduced the Pap smear screening as a possible national screening program from 2002 to 2012. It was piloted across 35 clinics in 15 provinces in PNG, funded by Meripath, a non-governmental organisation (NGO) from Australia. However, only 3.7% of the target population was reached and the majority of clients were lost to follow up.³ The reason for discontinuation was multifactorial. From 2011 to 2014, visual inspection with acetic acid (VIA) and cryotherapy was trialled in three provinces. However, overtreatment was associated with this method of screening, along with numerous technical and logistical challenges, so was therefore discontinued.³

More recently, the human papillomavirus point-of-care (HPV POC) testing and treatment from self-collected vaginal specimens has yielded results that promise to have wide coverage as a national screening program for cervical cancer. This strategy is widely being supported and recommended for LMIC by the World Health Organization (WHO) to accelerate access to cervical screening and treatment services.⁴ WHO has also recommended thermal ablation over cryotherapy for the treatment of cervical precancer lesions due to greater cure rates, a more favourable adverse events profile, and reduced logistical requirements.⁴

HPV POC test-and-treat project in Madang Province

Even though the HPV POC test-and-treat strategy has been an effective cervical cancer screening and treatment program, it has not been implemented in all health facilities and hospitals in PNG. With the overwhelming burden of cervical cancer incidence in the country and particularly in Madang (a province on the northern side of mainland PNG), the business communities of Madang and a few notable individuals who lost family members to cervical cancer initiated a series of fundraising drives. These included Islands Petroleum Colour Fun Run, barbecues, cycling and a few walkathons that also included climbing Mt Wilhelm, the tallest mountain in PNG, which is approximately 4500 meters above sea level (Figures 1 and 2).

Mt Wilhelm is located along the rugged terrains of the central Highlands Bismarck Range in Simbu Province. It takes two days of steep climbing through thick evergreen forests, savanna grassland, alpine forests and lastly the gruelling rocky mountains to reach the summit and enjoy a memorable and breathtaking scene of the country. Regular climbs are organised through Friends of Madang Provincial Hospital Group for fund raising events and anyone interested can contact the author for more information. Hearing of our plight, more of the sponsors assisted and notably the Cabrini Hospital in Melbourne, Victoria, donated funds through its outreach program. From all of the funds raised and donations, we were able to build the clinic infrastructure and purchase the Gene-Xpert Machines and consumables to start the first of what is now the Centre of Excellence in HPV POC test-and-treat centre in PNG. This clinic is now engaged in training and assisting in setting up of HPV POC test-and-treat centres for other provincial hospitals around the country and many corporate entity sites in PNG to screen and treat HPV infections. A further collaboration with the Kirby Institute (UNSW) has enabled this community project to partner and screen 4300 women (including Mt Hagen Hospital Clinic), the results of which have recently been published in the Lancet.⁵

The HPV POC intervention is a ‘one-stop shop’, where a woman will attend a clinic, self-collect her vaginal specimen, have it tested on the same day, receive her result on the same day and receive treatment on the same day if found to be positive. This cuts back on all the logistic, technical, transportation and patient follow-up requirements that we frequently encounter when using other forms of interventions, such as the Pap smear test, where results are not available on the same day. An additional benefit of the HPV POC intervention is that the self-collection method of sample collection is associated with less stigma and is more appropriate, particularly in our Melanesian Society where there is a lot of shame barriers associated with examination of a female private part. This remains a significant cultural taboo, which often results in many women presenting late and prematurely dying from late-stage cervical cancer.⁶ The HPV POC screening and treatment program for cervical cancer is tailored to our needs, has been trialled and found to be highly sensitive, cost-effective and acceptable in our setting,5,7,8 and is highly recommended by the WHO.⁴

Papua New Guinea’s contribution to global literature

The first field trials anywhere in the world to demonstrate the effectiveness, safety, acceptability, scalability and cost-effectiveness of HPV screen-and-treat programs were carried out in PNG, (2014–21) and involved more than 5000 women in Eastern Highlands, Madang, and Western Highlands Provinces.2,6–12 The innovative screening model pioneered in PNG comprises point-of-care Gene-Xpert HPV-DNA testing of self-collected vaginal specimens, followed by same-day thermal ablation for women who test positive for HPV. This strategy enables more than 90% of all cervical pre-cancers to be detected and treated on the same day, is highly acceptable among women, their families and health workers, can be delivered by trained nursing staff in routine primary health facilities, and it is highly cost-effective and efficient compared with the earlier Pap test or VIA-based screening.

From our recent publication in the Lancet Global Health of work done in Madang and Mt Hagen, 4300 women were recruited through this pilot project – HPV POC test and same-day treatment. The HPV positivity rate was 15% (645 women), and 93% of these women received treatment on the same day, with only 7% referred to a gynaecologist for further management. It was very effective, highly acceptable, cost-effective and feasible.⁵

Furthermore, the recent study by Nguyen et al.⁸ with economic modelling evaluation work showed that the HPV POC test is cost-effective and can easily be sustained with limited funding, particularly in resource-limited settings like PNG.

WHO global elimination strategy and scaling up in Papua New Guinea

In May 2018, the Director-General of the WHO announced a global call to action towards achieving the elimination of cervical cancer as a public health problem. In November 2020, WHO launched the global elimination strategy13 that included the ‘90–70–90’ coverage targets to be met by 2030:

• 90% of girls fully vaccinated with the HPV vaccine by age 15 years
• 70% of women screened with a high-precision HPV test by age 35 years, and again by age 45 years
• 90% of women with cervical precancer treated, and 90% of women with invasive cancer managed and treated appropriately

Achieving the triple-intervention targets in the next decade would put countries on the path to achieving elimination in the next century, reducing cervical cancer mortality by 99% and saving the lives of more than 62 million women over the next century.14

Moreover, with the unavailability of HPV vaccines in most LMICs, it is still possible to accelerate and expedite elimination of cervical cancer with HPV POC test-and-treat alone.15

Following the findings from the PNG field trials and the endorsement of HPV screen and treat for primary screening by the WHO in 2021, the PNG National Technical Working Group on Cervical Cancer recommended the introduction and scale-up of HPV screen and treat in December 2021. At present there is ongoing advocacy done by the Obstetrics and Gynaecology Society of PNG through different platforms and meetings.

Few philanthropic groups, industry partners and fundraisers strengthen the expansion of HPV screen and treat in PNG, and significant new investment is required from government and donor agencies to advance nationwide scale-up to ensure no woman in PNG is left behind as the global elimination agenda advances.

Conclusion

The HPV POC test-and-treat approach is by far the most acceptable, highly effective, scalable and cost-effective strategy available to optimise the early detection and treatment of cervical cancer. A ‘one-stop shop’ that involves self-collection of vaginal specimens, same-day test, same-day result, and treatment instituted on the same day. We have all the local data and evidence to advocate for implementation. Moreover, it needs political will and support from all stakeholders and donor agencies in implementing this program across the country in order to achieve the WHO elimination targets by 2030 and reduce the burden of cervical cancer in PNG.