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The Capulana study: a prospective evaluation of cervical cancer screening using human papillomavirus testing in Mozambique
  1. Mila P Salcedo1,2,
  2. Cristina Oliveira3,4,
  3. Viviane Andrade5,
  4. Arlete A N Mariano6,
  5. Dércia Changule6,
  6. Ricardina Rangeiro6,
  7. Eliane C S Monteiro6,
  8. Ellen Baker2,
  9. Natacha Phoolcharoen2,7,
  10. Melissa L Varon2,
  11. Joseph P Thomas8,
  12. Philip E Castle9,
  13. Jose Humberto T G Fregnani10,
  14. Kathleen M Schmeler2 and
  15. Cesaltina Lorenzoni11,12
  1. 1The Department of Obstetrics and Gynecology, Federal University of Health Science of Porto Alegre/Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil
  2. 2Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
  3. 3Life and Health Siences Research Institute (ICVS), University of Minho, Braga, Portugal
  4. 4Molecular Oncology Research Center, Hospital de Cancer de Barretos, Barretos, São Paulo, Brazil
  5. 5Research Support Center of Teaching and Research Institute, Hospital de Cancer de Barretos, Barretos, São Paulo, Brazil
  6. 6Hospital Geral e Centro de Saúde de Mavalane, Maputo, Mozambique
  7. 7Department of Obstetrics and Gynecology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
  8. 8Department of Oncology Care and Research Information Systems, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
  9. 9Department of Epidemiology and Population Health, Albert Einstein College of Medicine, New York, New York, USA
  10. 10Teaching and Research Institute, AC Camargo Cancer Center, Sao Paulo, São Paulo, Brazil
  11. 11Ministério da Saúde de Moçambique (MISAU), Maputo, Mozambique
  12. 12Pathology Department, Hospital Central de Maputo, Maputo, Mozambique
  1. Correspondence to Dr Kathleen M Schmeler, Gynecologic Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; KSchmele{at}


Background Cervical cancer is the leading cause of cancer and related deaths among women in Mozambique. There is limited access to screening and few trained personnel to manage women with abnormal results. Our objective was to implement cervical cancer screening with human papillomavirus (HPV) testing, with navigation of women with abnormal results to appropriate diagnostic and treatment services.

Methods We prospectively enrolled women aged 30–49 years living in Maputo, Mozambique, from April 2018 to September 2019. All participants underwent a pelvic examination by a nurse, and a cervical sample was collected and tested for HPV using the careHPV test (Qiagen, Gaithersburg, Maryland, USA). HPV positive women were referred for cryotherapy or, if ineligible for cryotherapy, a loop electrosurgical excision procedure. Women with findings concerning for cancer were referred to the gynecologic oncology service.

Results Participants (n=898) had a median age of 38 years and 20.3% were women living with the human immunodeficiency virus. HPV positivity was 23.7% (95% confidence interval 21.0% to 26.6%); women living with human immunodeficiency virus were twice as likely to test positive for HPV as human immunodeficiency virus negative women (39.2% vs 19.9%, p<0.001). Most HPV positive women (194 of 213, 91.1%) completed all steps of their diagnostic work-up and treatment. Treatment included cryotherapy (n=158, 77.5%), loop electrosurgical excision procedure (n=30, 14.7%), or referral to a gynecologist or gynecologic oncologist (n=5, 2.5%). Of eight invasive cervical cancers, 5 (2.8%) were diagnosed in women living with human immunodeficiency virus and 3 (0.4%) in human immunodeficiency virus negative women (p=0.01).

Conclusion Cervical cancer screening with HPV testing, including appropriate follow-up and treatment, was feasible in our study cohort in Mozambique. Women living with human immunodeficiency virus appear to be at a significantly higher risk for HPV infection and the development of invasive cervical cancer than human immunodeficiency virus negative women.

  • cervix uteri

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  • Presented at This study was presented in part at the Annual Meeting of the International Gynecologic Cancer Society (IGCS), Rio de Janeiro, Brazil, September 2019.

  • Contributors Conception and design: MPS, PC, JHTGF, CL, and KMS. Administrative support: MPS, EB, CL, and KMS. Provision of study material or patients: DC, RR, and AANM. Collection and assembly of data: MPS, CO, VA, and KMS. Data analysis and interpretation: MPS, CO, VA, JPT, PC, and KMS. Manuscript writing: all authors. Final approval of the manuscript: all authors. Accountable for all aspects of the work: all authors.

  • Funding This research was supported in part by the National Institutes of Health (NIH) through MD Anderson’s Cancer Center Support grant P30CA016672; the Anadarko Petroleum Corporation; the Prevent Cancer Foundation; the Dunaway Family Fund; the Joe Family Fund; the Giles-O’Malley Foundation; as well as by the support of the American people through the United States Agency for International Development (USAID) and was prepared under the Cooperative Agreement AID-OAA-A-11-00012, Partnerships for Enhanced Engagement in Research (PEER) Program.

  • Competing interests PC reports he has received human papillomavirus tests and assays for research at a reduced or no cost from Roche, Becton Dickinson, Cepheid, and Arbor Vita Corporation but none of his conflicts are related to this study. The remaining authors do not have any conflicts of interest to disclose.

  • Patient consent for publication Not required.

  • Ethics approval Institutional review board approval (protocol 2017–1043) was obtained from all participating institutions.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information. In accordance with the journal’s guidelines, we will provide our data for the reproducibility of this study in other centers if such is requested.