AFJOG

GUIDELINES living with HIV. There is a strong recommendation for screen-and-treat approaches in the general population; however, in people living with HIV the guidelines suggest a screen, triage, and treat approach. The South African HPV board used these guidelines as a departure point to refine a guideline document for use in our setting. Current SA policy, screening uptake The national cervical cancer prevention policy of 2017 allowed for three cervical cytology tests at ten-yearly intervals for low-risk women, commencing at the age of 30 years. 11 For women in the high-risk group, including WLWH, cervical cytology screening start at diagnosis and is repeated at shorter intervals. According to the present policy, HPV-based screening is to be phased in based on resource availability. Cervical screening uptake in South Africa however remains low in the public healthcare sector. 12,13,14 Data from the National Health Laboratory Network show that cervical cytology screening coverage in WLWH was well below 50%. 15 In the private health sector, opportunistic screening where the patient or her doctor takes initiative for regular screening visits, is common practice. Opportunistic screening can lead to some patients being overserviced while others remain inadequately screened. 16 Self-sampling The validity and feasibility of HPV testing on cervico-vaginal specimens collected by the patient has been accepted world-wide. 17,18 The WHO included self-sampling as part of cervical cancer screening in the latest guidelines. 10 Self- sampling has been shown to be preferable in terms of privacy, convenience, ease of use, physical and emotional comfort. 19 Self-sample specimens are stable, do not require a cold chain after collection, and can be effective in reaching under-screened populations. At the time of writing, there is no standardised way of managing the pre-analytical pathways and resulting of self-sampling and is therefore not widely used or recommended by most laboratory services. Moving towards self-collection in the near future is possible and may increase the uptake of screening significantly. 20 Alternative screening options Cytology is not an ideal screening tool in South Africa any longer due to the multistep process and relative lack of laboratory capacity. Turnaround times are problematic in the public sector. Sensitivity of a single cytology test is not adequate when infrequent screening opportunities exist. 21 Visual Inspection with Acetic acid (VIA) and other visual options are not sensitive or specific enough. Treatment options for cervical pre-cancer Treatment options for pre-cancer must be scalable in a country with huge healthcare disparities between urban and rural environments and should include ablative options like thermal ablation or cryotherapy. Limited data on the long-term cure rate in people living with HIV, especially following ablative therapies, is of concern. There is a need for prospective research to provide better evidence on which to base follow-up guidelines. Strengthening of policy, programs, treatment capacity and adequate training of healthcare workers are all integral to the success of secondary prevention of cervical cancer. Methodology for generating these guidelines The South African HPV Advisory Board was launched in 2010 in response to new diagnostic tests for HPV becoming available as a screening tool for cervical cancer, to provide guidance to clinicians and industry. The first clinical guidelines on screening and testing using HPV technology were published in 2010. 22 Soon after, HPV vaccines became available, and the Board was tasked to advise also on HPV vaccination as primary prevention tool. After its inception, leadership decided to become totally independent from individual industry sponsors and all guidelines have been developed based on the opinions of Board members only and not influenced by the pharmaceutical and diagnostic industries. Now renamed as the South African HPV Board to reflect the independent nature, membership includes clinicians and scientists working as gynecological oncologists, public health specialists, pathologists, virologists and program specialists. The Board and its working groups are multidisciplinary in nature, and works in collaboration with and supported by the South African Society of Obstetricians and Gynaecologists (SASOG) and the South African Society of Gynaecologic Oncology (SASGO). These guidelines were developed and workshopped during an in-person meeting where there was representation from the national Department of Health, SASOG and SASGO. Methods for screening and treatment of pre-cancer lesions have evolved rapidly over the last two decades and current global and local literature was reviewed. A comprehensive list of literature consulted is not included in this document; special attention was paid to the WHO 2021 updated guidelines 9 and recent evidence of disease prevalence and screening test performance among the South African population. 22,23,24 All members of the Board gave input into the final document, which is the fourth updated guideline from the group. 25,26,27 These guidelines should not be used as official policy document from the Department of Health, but rather as a simplified practice guide for clinicians in public and private sector healthcare environments, working in a middle-income country with high rates of HPV and HIV. Guidelines for screening Target population The age at initiation of screening is set at 25 years due to the high background risk of HIV infection, the resultant higher risk for oncogenic HPV infection and rapid progression to precancer in the South African population. In low-risk sub-populations first screening at age of 30 may be more appropriate and will reduce false positive screen results and overtreatment. Screening of women younger than 25 years is generally not recommended except for individuals with a particular risk, in which case cervical cytology is the preferred method for screening. Age at exit of screening depends on previous screening history. All unscreened women older than 25 years should be offered at least one screening test. If an individual had three negative screening tests, screening can be stopped at 50 years of age. In individuals with any previous abnormal results, screening should continue until 60 years of age. Primary screening test Screening guidelines for South Africa have promised the phasing in of HPV as primary screening test for more than a decade. Now, for the first time, cervical cytology is not African Journal of Obstetrics and Gynaecology | Volume 1 | Issue 1 | 2023 | 36