Uptake and safety of community-based ‘screen-and-treat’ with thermal ablation preventive therapy for cervical cancer prevention in rural Lilongwe, Malawi.

Malawi has the highest invasive cervical cancer (ICC) mortality rate worldwide, and ICC is the leading cause of cancer death among women. In 2004, Malawi adopted visual inspection with acetic acid (VIA) and ablative treatment with cryotherapy. However, screening coverage has remained low (<30%) and few women (<50%) who require ablative treatment receive it. Additional barriers include long distances to health facilities and challenges with maintaining gas supplies. Thermal ablation is a safe and effective alternative to cryotherapy. We assessed the safety and uptake of community-based ICC screening with VIA and same-day treatment using a Handheld Thermocoagulator (HTU) in rural Malawi. We held educational talks alongside community leaders and conducted VIA screening in non-clinic community settings to non-pregnant women aged 25-49 without history of hysterectomy or genital cancer/precancer. Eligible women received same-day thermal ablation and HIV testing/counseling. We collected cervical biopsies before treatment and followed-up women at weeks 6 and 12, with repeat biopsy at week 12. Between July and August 2017, 408 (88%) of 463 eligible women underwent VIA. Overall, 7% (n=30) of women had a positive VIA, of whom 93% (n=28) underwent same day thermal ablation. Among the 30 VIA-positive women, 5 had cervical intraepithelial neoplasia (CIN) 1, 4 had CIN 2/3, and 21 had benign histologic findings. Abnormal vaginal discharge (60%) and light vaginal bleeding (52%) were the most reported adverse events. There was high uptake of the community-based ICC screening in the study population and treatment was safe in this setting. Similar strategies which minimize false positive results are urgently needed in Malawi.