A mixed-methods preliminary evaluation of an innovative treatment for cervical precancer in El Salvador’s screen-and-treat program

Background: Cervical cancer remains a leading cause of cancer death for women worldwide. Screen-and-treat programs are a key strategy to reduce disease burden in low and middle-income countries (LMICs). Thermal ablation (TA) has emerged as a portable alternative to cryotherapy, the treatment typically used in screen-and-treat initiatives. Interest in TA is growing, but there is limited research on its implementation in public health settings. Here we present results from a preliminary evaluation of the barriers and facilitators of TA in El Salvador, one of the first countries to adopt a national HPV screen-and-treat program. Methods: This mixed-methods study took place between August 2022 to February 2023 across five clinics. The Practical, Robust Implementation and Sustainability Model (PRISM) was utilized to map findings to contextual factors that impact implementation and sustainability. Participants were frontline providers and women who presented for treatment after a positive HPV test. Providers took part in semi-structured interviews while women completed questionnaires. Additional data were collected from clinic records. Quantitative data were analyzed using inferential statistics and a rapid qualitative analysis approach was used for interviews. Results: Providers perceived TA as easier to use and more comfortable for patients, but cryotherapy was utilized 20% more frequently during the study period (cryotherapy treatments = 133 vs. TA treatments = 100). Although the two treatments have the same contraindications, a greater proportion of women were deemed eligible for treatment with TA vs. cryotherapy (95% vs. 79%, p <.001). There were discrepancies in provider and women’s perceptions of pain and side-effects. While > 80% of women received counseling during the screen-and-treat process, misconceptions regarding screenings results and treatment remained. Conclusions: The new treatment (TA) was highly acceptable to participants. However, there may be a need for additional provider training to support TA adoption and fidelity to program guidelines, while patients would benefit from more effective counseling. As LMICs strive to meet cervical cancer elimination targets set by the World Health Organization, it is expected that innovations will be quickly introduced to clinical practice. Thus, it is critical to understand the factors that impact their implementation and sustainability in these settings.