WHO recommendations on self-care interventions: human papillomavirus (HPV) self-sampling as part of cervical cancer screening

What is self care? What are self-care interventions? WHO’s definition of self care is the ability of individuals, families and communities to promote health, prevent disease, maintain health, and cope with illness and disability with or without the support of a health-care provider. • Worldwide, an estimated shortage of 18 million health workers is anticipated by 2030. • At least 400 million people worldwide lack access to the most essential health services. • During humanitarian emergencies, including pandemics, routine health services are disrupted and existing health systems can be over-stretched. For select health services, incorporating self care can be an innovative strategy to strengthen primary health care, increase universal health coverage (UHC) and help ensure continuity of health services which may otherwise be disrupted due to health emergencies. WHO published global normative guidance on self-care interventions, with the first volume focusing on sexual and reproductive health and rights (SRHR). Each recommendation is based on extensive consultations and a review of existing evidence. WHO consolidated guidelines on self-care interventions Self-care interventions are evidence-based, quality drugs, devices, diagnostics and/or digital products which can be provided fully or partially outside of formal health services and can be used with or without the direct supervision of health care personnel. Self care WHO recommendations on self-care interventions Human papillomavirus (HPV) self-sampling as part of cervical cancer screening • Cervical cancer is affected by socio-economic inequalities and health disparities across and within countries. While 81% of countries have cervical cancer screening policies and strategies, only 48% have an operational plan with funding. • In many countries, a majority of women do not have access to screening services. Women aged 30 and above need to be screened regularly, as pre-cancerous lesions can take many years to develop. For some groups, including women living with HIV, screening should be done earlier, as soon as they know their HIV status and have been sexually active. • When good services are available, women may not get screened regularly. Barriers include fear or shame, cultural or religious considerations, time in and distance to services. Self care Cervical cancer prevention and screening 85% of all cervical cancer-related deaths occurred in low- and middle-income countries, where it is the leading cause of cancer- related deaths for women. Current challenges to health systems to screen for cervical cancer • 99% of cervical cancer cases are linked to infection with ‘high-risk’ types of human papillomavirus (HPV), which is sexually transmitted. • Vaccination against specific high-risk strains of HPV is an important way to prevent cervical cancer; however, women in many countries are not able to access these. • Screening services and treatment for precancerous lesions are important secondary prevention. • WHO recommends three methods for cervical cancer screening: HPV testing from cervico- vaginal samples, visual inspection with acetic acid (VIA) and cytology. • When diagnosed early and managed effectively, cervical cancer is one of the most successfully treatable forms of cancer. Cervical cancer infographic https://www.who.int/ reproductivehealth/publications/self-care-infographics/en/ Comprehensive Cervical Cancer Control https://www.who.int/reproductivehealth/ publications/cancers/cervical-cancer-guide/en/ Learn more: Globally, cervical cancer is the fourth most common type of cancer among women. In 2018, an estimated: 570 000 women were diagnosed with cervical cancer worldwide About 311 000 women died from the disease. Self care Self-sampling involves an individual obtaining a kit and collecting one’s own vaginal sample. Collection can be done alone in private, in a health facility or another location. The individual (or a health worker) sends it to a laboratory for testing and the results of the test are returned to the individual. In the case of positive test result, the individual is linked to follow-up clinical assessments and treatment. How does HPV self-sampling as part of cervical cancer screening work? • The option to self-sample is generally associated with increased uptake of cervical cancer screening services: self-sampling nearly doubled use of cervical cancer screening services. • Self-sampling is seen as highly acceptable for its privacy, convenience, time and effort saved, cost- effectiveness, ease, comfort (including decreased embarrassment, pain and anxiety), speed, safety and user-friendliness. • Linkages to follow-up testing and treatment after self-sampling and after regular screening remains limited. There are now kits which allow people to collect their own samples to be tested. These methods include: a single-use swab or cervical brush with a tube containing collection/ transport medium. WHO recommends that HPV self-sampling should be made available as an additional approach to sampling in cervical cancer screening services, for women aged 30-60 years. Effective and acceptable - what the evidence tells us so far Where HPV tests are available as part of the national programme, HPV self- sampling offers an additional option to improve cervical cancer screening coverage. Self-sampling can help reach a global target of 70% coverage of screening by 2030. Women may feel more comfortable taking their own samples, rather than going to see a health worker for cervical cancer screening. 1. 2. 4. 5. 3. Self-collection of a sample for cervical cancer screening by swabbing the vagina1 1 The self-collection process may vary by product, but generally follows these steps. Diagram adapted from the WHO technical guidance and specifications of medical devices for screening and treatment of precancerous lesions in the prevention of cervical cancer https://apps.who.int/iris/bitstream/hand le/10665/331698/9789240002630-eng.pdf The swab or brush is removed and transferred to a provided collection tube The shaft of the swab or brush is broken off and discarded Tube is sealed and labelled Sample is sent to the laboratory The swab or brush is inserted into the vagina and gently rotated for 10-30 seconds References: • Information – Individuals must be provided with clear information on how to correctly take a sample, and what should be done with the sample. • Linkage to follow-up care – Whether samples are collected by health workers or individuals themselves, many people with a positive result do not return for clinical assessment and treatment of cervical lesions. • Quality products – Relevant regulatory agencies should ensure that appropriate, quality products are available in adequate quantities. Specifically, regulatory agencies and kit manufacturers should ensure that self-sampling kits are validated for the HPV laboratory tests available. • Policy and regulatory frameworks – Existing national cervical cancer screening policies and strategies should be adapted, developed and/or harmonized to consider HPV self-sampling. • Monitoring implementation – The incorporation of self-sampling into cervical cancer screening systems should be monitored for uptake, use as intended, cost incurred by users, and to identify any related social harm. Where HPV tests are available, programmes should consider whether the inclusion of HPV self-sampling as a complementary option within their existing approaches to screening could address gaps in current coverage. Countries should consider including HPV testing into their the national guidelines for cervical cancer prevention, and ensuring that appropriate laboratory infrastructure is in place to process tests. Requests for HPV self-sampling kits can be made by health workers or individuals themselves. Enabling access to the HPV self- sampling kits Considerations for success for HPV self-sampling WHO Consolidated Guideline on Self-Care Interventions for Health Sexual and Reproductive Health and Rights https://apps.who.int/iris/bitstream/hand le/10665/325480/9789241550550-eng.pdf?ua=1 Self-sampling for human papillomavirus (HPV) testing: A systematic review and meta-analysis https://gh.bmj.com/content/bmjgh/4/3/e001351.full.pdf Human papillomavirus (HPV) and cervical cancer Key Facts – WHO website https://www.who.int/news-room/fact-sheets/detail/human- papillomavirus-(hpv)-and-cervical-cancer Cervical cancer overview – WHO website https://www.who.int/health-topics/cervical-cancer Fact sheet: Self-care health interventions https://www.who.int/news-room/fact-sheets/detail/self-care-health- interventions WHO infographic on self-sampling for cervical cancer screening https://www.who.int/reproductivehealth/publications/self-care5-2. jpg?ua=1 A global strategy for elimination of cervical cancer https://www.who.int/activities/a-global-strategy-for-elimination-of- cervical-cancer Learn more: SELF-CARE INTERVENTIONS FOR HEALTH: SEXUAL & REPRODUCTIVE HEALTH AND RIGHTS Communications Toolkit 01 03 02 04 Introduction to this toolkit Technical resources on self-care interventions Overview: Background to self-care interventions and key messages Communications resources on self-care interventions Click to view the toolkit Self care Self-care interventions communications toolkit https://www.who.int/ reproductivehealth/self-care-interventions/ WHO-Self-Care-SRHR-Comms_Kit.pdf WHO/SRH/20.12 © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Self care