Introduction Different approaches to screening and treatment of cervical precancer Anatomical considerations

Anatomical considerations Gross anatomy of female genital organs, External genitalia Internal genital organs Gross anatomy of the cervix Cervical epithelium Squamous epithelium Columnar epithelium Squamocolumnar junction (SCJ)

Physiological changes of the cervical epithelium

Ectropion Squamous metaplasia Transformation zone of the cervix Changes induced by pregnancy Atrophic changes Congenital transformation zone (CTZ)

Neoplastic changes of the cervical epithelium

Genesis of cervical cancer – Role of HPV HPV structure and types Genesis of precancerous lesions and cervical cancer Cervical intraepithelial neoplasia (CIN) Adenocarcinoma in situ (AIS) Cervical cancers

HPV tests – Variation between tests Instruments, consumables, and setup required

for collection of samples for HPV testing (provider-collected) for self-collection of samples for HPV testing

Procedure to collect samples for HPV testing

Sample collected by a health provider Counselling of a woman undergoing HPV testing History taking Preparation for sample collection for HPV testing Steps for inspection of the external genitalia Steps for insertion of the speculum and exposure of the cervix Steps for collection of cervical samples Steps for self-collection of samples Storage of the samples after collection, and transportation to the laboratory

Interpretation of HPV test results Management of women with a positive HPV test result

Management of women with a positive HPV test result The different strategies Triage with cytology Triage with VIA Triage with colposcopy

Treatment of cervical intraepithelial neoplasia – principles Steps to determine eligibility for ablative treatment

Criteria used to determine eligibility for ablative treatment Steps to determine eligibility for ablative treatment

Role of Lugol’s iodine in identifying the transformation zone for treatment

Role of Lugol’s iodine in identifying the transformation zone for treatment Steps for applying Lugol’s iodine to the cervix Pre-treatment assessment

Treatment by cryotherapy

Principles Cryosurgical unit Ancillary instruments and consumables Steps Side-effects and complications Post-treatment advice and follow-up Video

Treatment by thermal ablation

Principles The benchtop model The battery-operated model Complications Video

Using an HPV test as the test of cure in women treated for cervical abnormalities or cervical intraepithelial neoplasia (CIN) Infection prevention

Standard procedures for protection from infection Essential steps for infection prevention in a cervical cancer screening clinic Preparation of 0.5% chlorine solution

Case studies

VIA triage outcome (applicable in screen-and-treat setting only) – negative cases VIA triage outcome – positive cases VIA triage outcome – suspicious of cancer cases

Foreword Acknowledgement Authors Suggested citation Copyright

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Using HPV tests for cervical cancer screening and managing HPV-positive women – a practical online guide

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Introduction

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A test to detect human papillomavirus (HPV) in cervical samples was developed based on the evidence that persistent infection with certain HPV types was necessary for the development of nearly 95% of cervical cancers. There is now compelling evidence that HPV tests are superior to cervical cytology (Pap smear) or visual inspection of the cervix with acetic acid (VIA) in detecting cervical precancer and cancer; thus, they are the most suitable cervical screening test.

In November 2020, the World Health Organization (WHO) launched a global initiative to accelerate the elimination of cervical cancer as a public health problem worldwide. Elimination of this virus-induced cancer is feasible through vaccination against HPV, screening with HPV testing, and appropriate treatment of the screen-detected precancers and cancers. Prevention of cervical cancer will have a far-reaching global impact, given that more than 300 000 women per year still die from this cancer and that more than 80% of these deaths occur in low- and middle-income countries.

Modelling studies have shown that achievement of the following targets by all countries by 2030 will reduce cervical cancer incidence to fewer than 4 new cases per 100 000 women per year globally (from 13.3 new cases per 100 000 women in 2020) by 2100:

90% of girls are fully vaccinated with the HPV vaccine by the age of 15 years;
70% of women are screened using a high-performance test (e.g. HPV test) by the age of 35 years, and again by the age of 45 years;
90% of women diagnosed with cervical precancer or cancer receive appropriate treatment.

This practical guide to using HPV testing and managing HPV-positive women is based on the following guidelines published by WHO:

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