Implementation of Screen, Treat, and Triage for Women Living with HIV in La Romana (iSTAR)

PROJECT SUMMARY Cervical cancer is preventable, yet it remains one of the most common causes of cancer-related death in women in low- and middle-income countries (LMICs). Few diseases reflect global inequities as much as cervical cancer. as incidence and mortality rates are 2-3 times higher in LMICs compared to richer countries. Further, women living with HIV (WLH) are six times more likely to develop cervical cancer compared to women who are HIV-negative. Reaching WLH, who are at high risk of developing cervical cancer, requires integration of preventive screening and treatment services for both diseases (cervical cancer and HIV) to increase efficiencies and maximize impact. For more than two decades, researchers have investigated alternative approaches to cervical cancer screening to maximize their impact in LMICs, culminating in strong endorsement of human papilloma virus (HPV) testing for primary screening in the current World Health Organization (WHO) guidelines. Importantly, for WLH, among whom HPV co-infection is exceptionally high, approaches known as “Screen, Triage, and Treat” (iSTAR) have been demonstrated to be safe and effective. The Screen, Triage, and Treat approach is designed for implementation in a single visit to reduce attrition and to use health care personnel expertise optimally for maximal efficiency. In response to RFA-CA-23-033, our study seeks to identify, understand, and develop strategies to address barriers to the adoption, integration, and sustainability of evidence-based cancer control interventions among persons with HIV in LMICs. To that end, we propose to use a bundle of strategies (mHealth clinical decision support tool, practice facilitation, and patient education material) to implement the WHO-endorsed iSTAR approach for cervical cancer screening for WLH in La Romana, Dominican Republic (DR). The existing cervical cancer screening programs in the DR are inefficient and ineffective, resulting in one of the highest disease burdens in the world. In response to this need, the clinical team at Clínica de Familia approached experts in cervical cancer control, HIV, informatics, and implementation science at Columbia University to assemble a multidisciplinary team to overcome the current challenges in providing cervical cancer screening for the women attending their clinic. The overall goal of this project is to sustain implementation of the evidence-based iSTAR approach for cervical cancer screening in WLH and to generate new data to inform effective and equitable implementation on a wider scale.