The development of cervical cancer depends on high-risk human papillomavirus (HR-HPV) persistent infection in the uterine cervix [1]. The 2–10 year transformation process leading to invasive cancer provides ample opportunity to detect, prevent and cure true precursor lesions [1]. Although cervical cancer is widely preventable, it is the fourth most common cancer among women throughout the world, being a real public health issue, especially in developing countries, as 85% deaths occur in low and middle income countries [2]. The situation in Bolivia is particularly alarming as the incidence, being 47 per 100,000 women, is estimated to be the highest in Latin America with a mortality rate of 21 per 100,000 womenFootnote 1 (standardized incidence and mortality rates by age) [2].
Cervical cancer-related deaths have nevertheless declined significantly in developed countries because of extensive cytology screening. However, similar initiatives in developing countries have not been equally successful because of the complexity of the required elements, such as laboratory expertise, depending on high operating costs [3, 4]. It is now well known that the HR-HPV screening test has marked advantages over cytology screening test, with sensitivity of about 90% for detecting high-grade intraepithelial neoplasms and high negative predictive value [5, 6].
Prevention of cervical cancer in Bolivia is primarily based on Papanicolaou smear cytology test (Pap) and more recently on visual inspection under acetic acid (VIA) [7, 8]. Screening, offered by the first level of care, responsible for prevention, is available free of charge, for sexually active women until 64 years old [7]. Nevertheless, Pap smear coverage, from 2005 to 2016, do not exceed 16.6% and coverage of VIA in 2015 and 2016 does not exceed 19% [7, 8].
The health personnel estimated that 50 to 80% of Pap screened women were lost to follow-up, mainly because of delays in result delivery [3].
Bolivia’s Ministry of health has introduced the HPV vaccine in 2016 as an alternative to reduce the incidence of cervical cancer. In 2017, 80% of the target population (girls between 10 and 12 year old) were vaccinated with the first dose [9].
Bolivia is characterized by significant disparities between rural and urban areas, including education and access to basic health services as some of the variables contributing to this difference [10, 11]. Although these differences have been reduced in recent years, the inequalities still persist among the poorest population [12, 13]. Poor coverage of the Pap smear, Pap poor quality, low follow-up of Pap positive cases, lack of information on cervical cancer prevention, poor human resources in health and low credibility in the health system, besides economic, cultural, and social barriers have been identified as the main factors involved in the high cervical cancer incidence in Bolivia [3, 14]. Large coverage disparity has been observed when stratified by area of residence, being much lower in rural areas than in urban areas and increasing the risk of dying from cervical cancer up to three fold in dispersed rural areas. This is linked to various factors, including low educational, cultural and economic level and limited access to health services, diagnostic tests and treatment [15].
The screening coverage rate is a key component in cervical cancer prevention programs. Vaginal self-testing of HR-HPV could reduce screening barriers for those women and therefore increase their screening coverage [16,17,18]. Indeed, self-collection is easy to perform, provides privacy, is less embarrassing and more comfortable to patients compared to samples collected by health personnel [19, 20]. Furthermore, self-collected samples have been shown to have sensitivity similar to that of samples collected by physicians [21]. We previously reported that a simple, cheap and transport safe method based on the smearing of vaginal and cervical cells on a glass slide (dry samples) using cotton swab gave satisfactory results to detect HR-HPV DNA, providing similar HR-HPV detection results as the physician collected samples [22].
The objectives of this study were to obtain information among the Bolivian women about their level of knowledge on HPV and cervical cancer and to evaluate the degree of the vaginal self-sampling test acceptability and confidence in comparison to gynecologist sampling at urban, peri-urban and rural areas, in order to evaluate the need for an adapted strategy within each three geographical areas, potentially corresponding to a characteristic population. Furthermore, this study assessed the impact of the HR-HPV self-sampling test on screening coverage in a restricted Bolivian peri-urban area.