Research Project 1

Cervical cancer is the leading cause of cancer-related deaths in South Africa where incidence and mortality rates are expected to rise, in part due to the largest global burden of HIV epidemic in women. Based on strong empirical evidence, WHO recommends Human Papillomavirus (HPV)-based testing followed by immediate treatment, an approach called screen-and-treat, as the optimal way to screen for cervical cancer in low- and middle-income countries (LMCIs) where fragmented care and inadequate infrastructure introduce delays in conventional multi- step screening process of referral, histological confirmation, and treatment (e.g., cytology-based screening). Our team’s decades-long international collaborative research has developed the evidence base and the capacity for implementing HPV-based screening in primary care and generated preliminary implementation data for a Point- of-Care HPV-based Screen-and-Treat (POC-SAT) approach that enables women to undergo, in a single visit, HPV testing, evaluation for, and, if indicated, treatment. To promote successful and equitable implementation of this evidence-based intervention, we propose to develop and assess contextually-informed and scalable strategies for integrating POC-SAT into public health primary care setting in Khayelitsha, an impoverished geographic area of predominantly Black residents in the Cape Town metropolitan area. Using stakeholder participatory processes and drawing on newly revised and LMIC-focused versions of Consolidated Framework for Implementation Research (CFIR) framework, we will undertake a systematic assessment of multilevel determinants of POC-SAT implementation within the local primary care context through a) key informant interviews and b) facility mapping (Aim 1). We will use this assessment to identify, prioritize and refine a package of tailored strategies for POC-SAT implementation through a) matching stakeholder and facility-level barriers to a range of implementation strategies listed in the Expert Recommendations for Implementing Change compilation, and b) seeking stakeholder and expert feedback and endorsement for prioritizing and packaging a set of implementation strategies using a modified Delphi process (Aim 2). Finally, we will conduct a mixed- methods evaluation of the POC-SAT implementation to assess the outcomes of a) adoption and reach of POC- SAT and tailored strategies, and impact on treatment completion (primary outcomes), and b) feasibility, acceptability and appropriateness among multiple stakeholder groups (secondary outcomes) (Aim 3). The Project activities synergize closely with the objectives of the Empilisweni Center Cores and Project 2, as well as with provincial Department of Health efforts to accelerate the integration, implementation and scale-up of equitable cervical cancer control among women in South Africa. Findings from this project will advance the current knowledge of optimal processes for the development and refinement of implementation strategies in LMICs, laying the groundwork to understand and tackle implementation challenges for achieving equitable global cervical cancer control.