Sexual and gender minority persons in low-income countries have very limited access to routine health services. This study evaluated the feasibility of using a self-sampled human papillomavirus (HPV) test to increase access to screening for cervical cancer among transgender men in El Salvador.
Methods:
We partnered with a local advocacy organization for recruitment. A total of 24 transgender men (men assigned female at birth) ages 19–55 were enrolled and provided consent. Questionnaires assessed sociodemographics, health and sexual histories, and knowledge about HPV and cervical cancer. Screening was performed with a self-sampled HPV test. Participants with a positive test were offered colposcopy and cryotherapy treatment, if appropriate. Those with a negative test were advised to return in 5 years for rescreening.
Results:
Out of 24 consenting participants, 23 (95.83%) agreed to conduct HPV self-sampling, and 22/23 (95.65%) expressed willingness to self-sample in the future. Among self-sampled individuals, 3/23 (13%) tested positive and accepted colposcopy and biopsy. Analyses of biopsied tissue revealed one case of cervical intraepithelial neoplasia grade 1.
Conclusion:
HPV self-sampling and subsequent procedures were accepted by the majority of participants. This screening method may be a viable alternative to cytology among transgender men in El Salvador.
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References
1.
FerlayJ, SoerjomataramI, DikshitR, et al.: Cancer incidence and mortality worldwide: Sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer, 2015; 136:E359–E386.
2.
OgilvieG, NakisigeC, HuhWK, et al.: Optimizing secondary prevention of cervical cancer: Recent advances and future challenges. Int J Gynaecol Obstet, 2017; 138(Suppl. 1):15–19.
3.
National Institute ofHealth, National Institute on Minority Health and HealthDisparities. Director's message: Sexual and gender minorities formally designated as a health disparity population for research purposes. 2016. Available at https://www.nimhd.nih.gov/about/directors-corner/messages/message_10-06-16.html Accessed May17, 2019.
4.
Obedin-MaliverJ: Time to change: Supporting sexual and gender minority people—An underserved, understudied cancer risk population. J Natl Compr Canc Netw, 2017; 15:1305–1308.
MayerKH, BradfordJB, MakadonHJ, et al.: Sexual and gender minority health: What we know and what needs to be done. Am J Public Health, 2008; 98:989–995.
7.
BradfordJ, ReisnerSL, HonnoldJA, XavierJ: Experiences of transgender-related discrimination and implications for health: Results from the Virginia Transgender Health Initiative Study. Am J Public Health, 2013; 103:1820–1829.
8.
JohnsonMJ, MuellerM, EliasonMJ, et al.: Quantitative and mixed analyses to identify factors that affect cervical cancer screening uptake among lesbian and bisexual women and transgender men. J Clin Nurs, 2016; 25:3628–3642.
9.
AgénorM, PeitzmeierSM, BernsteinIM, et al.: Perceptions of cervical cancer risk and screening among transmasculine individuals: Patient and provider perspectives. Cult Health Sex, 2016; 18:1192–1206.
10.
PeitzmeierSM, AgénorM, BernsteinIM, et al.: “It can promote an existential crisis”: Factors influencing Pap test acceptability and utilization among transmasculine individuals. Qual Health Res, 2017; 27:2138–2149.
11.
McDowellM, PardeeDJ, PeitzmeierS, et al.: Cervical cancer screening preferences among trans-masculine individuals: Patient-collected human papillomavirus vaginal swabs versus provider-administered Pap tests. LGBT Health, 2017; 4:252–259.
12.
CannerJK, HarfouchO, KodadekLM, et al.: Temporal trends in gender-affirming surgery among transgender patients in the United States. JAMA Surg, 2018; 153:609–616.
13.
Committee on Health Care for Underserved Women: Committee Opinion No. 512: Health care for transgender individuals. Obstet Gynecol, 2011; 118:1454–1458.
14.
PeitzmeierSM, KhullarK, ReisnerSL, PotterJ: Pap test use is lower among female-to-male patients than non-transgender women. Am J Prev Med, 2014; 47:808–812.
15.
TabaacAR, SutterME, WallCSJ, BakerKE: Gender identity disparities in cancer screening behaviors. Am J Prev Med, 2018; 54:385–393.
16.
MayrandMH, Duarte-FrancoE, RodriguesI, et al.: Human papillomavirus DNA versus Papanicolaou screening tests for cervical cancer. N Engl J Med, 2007; 357:1579–1588.
17.
ArrossiS, ThouyaretL, HerreroR, et al.: Effect of self-collection of HPV DNA offered by community health workers at home visits on uptake of screening for cervical cancer (the EMA study): A population-based cluster-randomised trial. Lancet Glob Health, 2015; 3:e85–e94.
18.
ArribaLN, EnersonCL, BelinsonS, et al.: Mexican Cervical Cancer Screening Study II: Acceptability of human papillomavirus self-sampler. Int J Gynecol Cancer, 2010; 20:1415–1423.
19.
RositchAF, GatugutaA, ChoiRY, et al.: Knowledge and acceptability of pap smears, self-sampling and HPV vaccination among adult women in Kenya. PLoS One, 2012; 7:e40766.
20.
Buchanan LunsfordN, RaganK, Lee SmithJ, et al.: Environmental and psychosocial barriers to and benefits of cervical cancer screening in Kenya. Oncologist, 2017; 22:173–181.
21.
MazaM, MelendezM, MaschR et al.: Acceptability of self-sampling and human papillomavirus testing among non-attenders of cervical cancer screening programs in El Salvador. Prev Med, 2018; 114:149–155.
22.
ReesHD, LombardoAR, TangorenCG, et al.: Knowledge and beliefs regarding cervical cancer screening and HPV vaccination among urban and rural women in León, Nicaragua. PeerJ, 2017; 5:e3871.
23.
ReisnerSL, DeutschMB, PeitzmeierSM, et al.: Test performance and acceptability of self- versus provider-collected swabs for high-risk HPV DNA testing in female-to-male trans masculine patients. PLoS One, 2018; 13:e0190172.
24.
SnijdersPJ, VerhoefVM, ArbynM., et al.: High-risk HPV testing on self-sampled versus clinician-collected specimens: A review on the clinical accuracy and impact on population attendance in cervical cancer screening. Int J Cancer, 2013; 132:2223–2236.
25.
MezeiAK, ArmstrongHL, PedersenHN, et al.: Cost-effectiveness of cervical cancer screening methods in low-and middle-income countries: A systematic review. Int J Cancer, 2017; 141:437–446.
26.
El Salvador Ministry ofHealth, Vice-Ministry of Health Policies: Technical guidelines for the prevention and control of cervico-uterine and breast cancer, 1st ed. San Salvador, El Salvador: Diseãrte SA de CV (Ministerio de Salud de El Salvador, Viceministerio de Politicas de Salud: Lineamientos técnicos para la prevención y control del cáncer cérvico uterino y de mama. 1o Edición. San Salvador, El Salvador: Diseñarte SA de CV), 2015. Available at asp.salud.gob.sv/regulacion/pdf/lineamientos/lineamientos_prevencion_cancer_cervico_uterino_y_de_mama_v3.pdf Accessed July3, 2019.
27.
BruniL, AlberoG, SerranoB, et al.: Human Papillomavirus and Related Diseases in El Salvador. Summary Report. ICO/IARC Information Centre on HPV and Cancer (HPV Information Centre). 2019. Available at: https://hpvcentre.net/statistics/reports/SLV.pdf Accessed February26, 2020.
28.
MurilloR, AlmonteM, PereiraA, et al.: Cervical cancer screening programs in Latin America and the Caribbean. Vaccine, 2008; 26(Suppl. 11):L37–L48.
29.
AndrinopoulosK, HemblingJ: Utilization of Health Services by Men Who Have Sex with Men and Transgender Women, San Salvador 2011-2012 (Utilización de los servicios de salud entre los hombres que tienen sexo con hombres y mujeres transgénero, San Salvador 2011–2012). MEASURE Evaluation, Chapel Hill, North Carolina, USA, 2013.
30.
International Human Rights Law Clinic: Sexual Diversity in El Salvador: A Report on the Human Rights Situation of the LGBT Community. Berkeley, CA: University of California, Berkeley, School of Law, 2012. Available at https://www.law.berkeley.edu/files/IHRLC/LGBT_Report_English_Final_120705.pdf Accessed February26, 2020.
CoorevitsL, TraenA, BingéL, et al.: Are vaginal swabs comparable to cervical smears for human papillomavirus DNA testing?. J Gynecol Oncol, 2018; 29:e8.
33.
KellyH, MayaudP, SegondyM, et al.: A systematic review and meta-analysis of studies evaluating the performance of point-of-care tests for human papillomavirus screening. Sex Transm Infect, 2017; 93:S36–S45.
34.
LaskowB, FigueroaR, AlfaroKM, et al.: A pilot study of community-based self-sampling for HPV testing among non-attenders of cervical cancer screening programs in El Salvador. Int J Gynaecol Obstet, 2017; 138:194–200.
MazaM, AlfaroK, GaraiJ, et al.: Cervical cancer prevention in El Salvador (CAPE)-An HPV testing-based demonstration project: Changing the secondary prevention paradigm in a lower middle-income country. Gynecol Oncol Rep, 2017; 20:58–61.
37.
HarrisPA, TaylorR, ThielkeR, et al.: Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform, 2009; 42:377–381.
38.
HarrisPA, TaylorR, MinorBL, et al.: The REDCap consortium: Building an international community of software partners. J Biomed Inform, 2019; 95:103208.
39.
StataCorp. Stata Statistical Software: Release 14. College Station, TX: StataCorp LP, 2015.
CremerM, MazaM, AlfaroK, et al.: Scale-up of an human papillomavirus testing implementation program in El Salvador. J Low Genital Tract Dis, 2017; 21:26–32.
42.
PeacockE, AndrinopoulosK, HemblingJ: Binge drinking among men who have sex with men and transgender women in San Salvador: Correlates and sexual health implications. J Urban Health, 2015; 92:701–716.
43.
PeitzmeierSM, ReisnerSL, HarigopalP, PotterJ: Female-to-male patients have high prevalence of unsatisfactory Paps compared to non-transgender females: Implications for cervical cancer screening. J Gen Intern Med, 2014; 29:778–784.
44.
ReisnerSL, PoteatT, KeatleyJ, et al.: Global health burden and needs of transgender populations: A review. Lancet, 2016; 388:412–436.
