Urine-based HR-HPV screening and CC prevention in Eswatini: preliminary epidemiological analysis

Abstract Background In Eswatini, cervical cancer (CC) incidence and mortality rates (95.9 and 64.3 per 100,000 women/year) are 5-6 times higher than globally. Following WHO recommendations, the feasibility of urine-based HPV DNA testing as a primary screening was evaluated in a Eswatini's rural primary healthcare center. We aim to describe epidemiological and sociodemographic characteristics of women who participated in the pilot phase of the urine-based HPV DNA screening program launched in January 2023. A second phase is underway to include 2,000 women. Methods Women 12-49 who independently presented at St. Philip's Clinic (Lubombo region) were invited to provide a urine sample. Samples were tested using Xpert HPV for 14 High-Risk types. HR-HPV positive women underwent VIA (visual inspection with acetic acid) and treatment if needed. Data on age, health status, sexual activity and HIV status were collected via REDCap and analyzed with summary, inferential statistics and epidemiological measures. Results Among 508 participants, 472 provided valid test results. Median age was 30 years (range 13-49). HR-HPV positivity was 42% (199/472); 37% were HIV positive. Of HR-HPV positive women, 45% underwent their first screening, 8% were pregnant and 45% were also HIV positive. A high risk genotype strain common and frequently detected in the sample (HPV-35) is not currently targeted by the vaccines. VIA was performed on 93 HR-HPV positive women (49%), identifying 5 cases with precancerous lesions or CC. The rest were lost to follow-up or deferred due to pregnancy. Conclusions The pilot revealed high rates of HR-HPV and HIV. Urine-based HR-HPV testing in rural Eswatini is feasible and well accepted, with potential to improve screening and CC prevention. Challenges include test failures, follow-up loss, access to treatment. The ongoing phase aims to evaluate long-term sustainability, improve care pathways and validate HR strains distribution. Vaccination strategy must be reviewed. Key messages • The Urine-based HR-HPV screening program is well accepted by Swati women and may be the key strategy for extending to younger girls and achieving high screening adherence rates. • Tailored interventions for 21-35y women, positive to HIV or STI diseases could impact HPV and CC prevention and control. Vaccination strategy must be reviewed, considering HR-HPV strains distribution.