The van bringing HPV testing to rural Kenya

On a dusty rural road in western Kenya, what looked like an unremarkable van was pulled to the side of the road. Its back end was plastered with bumper stickers, including one of a lion in a tracksuit throwing a javelin. On the side was a sticker from a safari company — a reminder of the van’s role in a past life.

But this was no ordinary van. Inside a lab technician hovered over test tubes, furiously processing samples of vaginal fluid, checking for the human papillomavirus. The women who provided the samples sat under a tree nearby waiting for results. A solar panel propped on the roof fueled the lab machinery inside. The driver’s seat was crammed with cardboard boxes, making room for the lab in the back.

This is a mobile clinic providing on-site test results for HPV with a portable lab brought to the field. It was launched last month by the non-profits CureCervicalCancer, LVCT Health, as well as Kisumu county, using new technology developed by Atila Biosystems that makes running these tests more portable and cost-effective.

Women, recruited by community health volunteers, are trained to self-sample in a one-person sized pop-up tent. They then wait, receiving health education on cervical cancer prevention.

If positive, they enter a tent where a nurse, adorned with a headlamp, inserts a speculum, and sprays the cervix with vinegar to identify lesions — which will appear as shades of white. Women with HPV are treated with thermal ablation therapy — using a gun-like device that destroys pre-cancerous cells. If they have advanced cancer, they are referred to a hospital.

Of the 162 women tested that day, about 50% tested positive for high-risk types of HPV. Despite heavy rains that afternoon, which ended the event, the organization was able to have all of the women come back in the following days for treatment.

Early detection

HPV, the most common sexually transmitted infection, is linked to 99% of cervical cancer cases. In most cases the immune system fights off the virus, but it can cause changes in the cervix that lead to cancer. Women can have chronic HPV infections with no signs or symptoms for years. Those with HIV are at a higher risk of cervical cancer. About 30% of the women tested that day were HIV positive.

Each day, at least 9 women die from cervical cancer in Kenya, but one study published in 2018 found that only 16% of eligible women had been screened. It's the second leading type of cancer in Kenya, following breast cancer, and the leading cause of cancer deaths. East Africa has the highest incidence and mortality rates of cervical cancer in the world.

If diagnosed early and managed effectively, cervical cancer is “one of the most successfully treatable forms of cancer,” according to the World Health Organization. In the early stages, a woman can receive a hysterectomy, but when advanced, it can require extensive surgery, chemotherapy, and radiation, said Dr. Patricia Gordon, founding director of CureCervicalCancer.

“This is the exact reason that we're here — to catch these early,” she said. “It's a completely unnecessary death. It's a painful death. It's an undignified death.”

CureCervicalCancer’s work up until now has focused on the vinegar spray method, followed by treatment. But HPV testing is the best way to identify women who have the risk of developing cervical cancer.

With mobile testing, the organization aims to reach women who would otherwise travel long distances to reach the sub-county hospital, which is costly and time-consuming. Women might not prioritize getting an HPV test — or might not return for treatment, said Rebecca Lepsik, executive director at CureCervicalCancer. A study in western Kenya found 60% of women didn’t return for treatment after a positive result during community health campaigns. Also, HPV testing is not widely available in Kenya, and if it is, it can be expensive in a private facility.

The cost of the tests and the reagent used in the pilot is around $7, but this does not include other costs of running the clinics, such as staffing costs, and the lab machinery, which cost around $20,000, Lepsik said. But the tests are free for the women.

Doing this in a rural setting is challenging, Lepsik said. They need a clean space for the lab — many of the other HPV testing systems are large — and they need uninterrupted electricity.

On-site education regarding treatment is crucial because women might say they need their husband’s permission. “Those women don't tend to come back,” Gordon said. “We have to keep them here so that we don't lose women. Because if we lose a woman, we may lose a life.” Women express concerns the treatment could impact fertility — which it doesn’t. They also have concerns about telling their husbands they need to temporarily abstain from sex.

Prohibitive costs

“Hats off to the CureCervicalCancer team because it is an exciting model,” said Heather White, executive director at TogetHER for Health, which focuses on ending cervical cancer deaths. “The question perennially will be: How do you maintain all of the costs of running mobile screening and treating?”

This pilot builds off of similar efforts to have both HPV screening and treatment in one day. MSI Reproductive Choices led a pilot in rural Tanzania in 2017, with a consortium of partners, funded by the Bill & Melinda Gates Foundation. But, instead of a lab in a van, women came to a remote health clinic where the lab was set up.

The older version of the lab machinery required “batch testing” — meaning they had to test around 90 samples at a time, otherwise they would lose money. Because of this, they had to wait until enough women arrived and it took three to four hours to process. With the new technology, CureCervicalCancer’s lab can process the samples in smaller batches, without wasting money, and processing only takes about one and a half hours. In Tanzania, they also used an older version of treatment that is more time-consuming.

The shorter turnaround time in CureCervicalCancer’s pilot is “really good news,” White said.

The MSI teams in Tanzania worked about 12-hour days. “It was physically very, very tough,” said Raveena Chowdhury, head of integrated service delivery at MSI Reproductive Choices. It cost about $5 per test, but the overall costs were about $85 per woman, she said. Her organization ultimately recommended that the Gates Foundation not fund the model because the costs were prohibitive, the procurement of the supplies was difficult, and there was a need for highly experienced lab technicians.

“In reality, health budgets are really low and choices need to be made,” she said.

While CureCervicalCancer hopes its pilot will prove cost-effective, Chowdhury expressed concern about the cost of the tests alone. “I think if it's anything above $3, we will struggle to take it to scale at national levels.”

She said there is a consensus in the global health community that HPV tests should gradually replace older technologies, such as using only the vinegar screening method as a way to identify lesions without the HPV tests. But the challenge is ensuring the HPV tests are user friendly and widely available.

“In the absence of this, we will not be able to make progress towards the WHO's cervical cancer elimination goals," she said.

Lepsik said the vinegar test used alone is far too subjective. It's also not possible to scale, because it’s labor-intensive and there are not enough health care workers in resource-limited settings.

And even with a price point of about $7, the test only needs to be taken every 5 years, and the price will reduce if governments adopt this model and purchase tests en masse, she said. And ultimately, countries will see savings in health costs because fewer women will develop cervical cancer.

“If you can focus on preventative care, the cost savings are unquestionable and enormous,” she said. 

CureCervicalCancer facilitated Devex’s travel to Kisumu. Devex retains full editorial control of all content.

Update, Nov. 4, 2021: This article has been updated to reflect that efforts similar to the HPV testing model deployed in Kenya have been implemented elsewhere, following reader feedback about such work in Thailand.