Screening Test Accuracy of Gynocular™, HR-HPV Testing, VIA for Detection of Cervical Neoplastic Lesions, in Women Living With HIV

Study Overview
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Brief Summary
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Cervical cancer in HIV-positive women is largely preventable through regular screening. The World Health Organization (WHO) recommends cervical screening for HIV-positive women every three years. Currently the least costly method for screening and the most viable option for many countries is visual inspection after application of acetic acid (VIA). Alternative testing methods are HPV testing and assessment with a portable magnification device. The investigators plan to assess and compare the screening test accuracy of these screening tests in women living with HIV. All women will receive histopathology reference standard.

Detailed Description
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The simplest and least costly method for cervical cancer screening is visual inspection after application of acetic acid (VIA). However, the ability of this screening method to correctly identify precancerous lesions (sensitivity) and women free from these lesions (specificity) is limited. The investigators aim to identify alternative screening methods which maximize sensitivity and specificity, particularly in HIV-infected women in receiving care in Southern Africa. The investigators will evaluate the screening test accuracy of a new portable magnification device , the Gynocular™ with Swede score assessment, in women who are HIV-positive and eligible for cervical cancer screening. The investigators will assess the accuracy of the device when used as a stand alone test, as well as when used subsequent to positive VIA or HPV tests. The investigators will make comparisons with current screening practices (VIA alone), as well as, recommended screening practices (HPV testing). The investigators will enrol 450 HIV-positive women receiving care for HIV/AIDS at the Centre for Infectious Disease Research in Zambia, in Lusaka, Zambia. Consenting women will be screened with VIA, HPV testing and visual assessment with Gynocular™. All women undergo biopsy (reference standard) and receive treatment as indicated and in accordance with national guidelines.

Official Title
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Screening Test Accuracy of a Gynocular™, HR-HPV Testing, and VIA for Detection of Cervical Intraepithelial Neoplasia, Grade Two and Above, in Women Living With HIV in Lusaka, Zambia

Conditions
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Uterine Cervical Neoplasms, HIV/AIDS

Intervention / Treatment
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* Diagnostic Test: Screening for CIN2+/HSIL


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: HIV-infected women confirmed through medical records Women residing within Lusaka district and plans to stay in this area for the next 6 months Women between 18 and 65 years of age (age bracket as per Zambian guidelines for cervical cancer screening) Able and willing to consent Willing to undergo a pelvic examination and cancer screening Has had sexual intercourse before Agrees to have follow-up appointment in 6 months Exclusion Criteria: Women with a history of cervical cancer or previous hysterectomy (where the cervix was also removed) Pregnant women or women who plan to get pregnant within the next 6 months Women who have been vaccinated against HR-HPV

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 65 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Portable magnification device (Gynocular™)<br>The Gynocular™ examination will be performed following the steps involved in colposcopy as described in the IARC colposcopy manual. These steps include: visualization of the vagina, vulva and cervix following insertion of a speculum, magnified assessment after application of normal saline, examination of cervical vessel patterns using the red-free mode (or green filter), application of 5% acetic acid for 1 minute and finally assessment following application with Lugol's iodine. The findings of the live examination will be documented using the parameters of the Swede score. Each parameter is scored between zero and two. Treatment will be based on the results found at histopathology, unless the woman is also VIA positive in which case, after biopsy she will undergo routine treatment as per local guidelines. The results will be used to determine the optimal threshold for treatment in WLHIV. | Diagnostic Test: Screening for CIN2+/HSIL<br>* The investigators will compare three different screening methods: visual assessment with portable magnification device , visual inspection after application of acetic acid, screening for high risk variants of HPV. All patients will receive cervical biopsies and histopathological examination.<br>|
| Testing for high risk HPV (HRHPV)<br>To reduce the number of examinations undergone by the study participant during the same day, HRHPV testing will be carried out at the time of the first gynecological examination by the VIA nurse (see next arm). Using specific single-use cervical cytobrush provided by GeneXpert, a specimen will be collected immediately prior to VIA examination. Cervical cytobrush specimens will be placed into ThinPrep PreservCyt (Cepheid, Sunnyvale, CA) immediately after collection. The HR-HPV testing of cervical specimens will be conducted by a GeneXpert™ machine (Cepheid, Sunnyvale, CA), which will be placed at the health facility and will be operated by a trained nurse in accordance with the manufacturer's instructions. Additionally, as part of the baseline clinical characteristics of the study participant, the study participant will undergo an STI test at the same time. The sample will be collected and tested using the same GeneXpertTM platform. | Diagnostic Test: Screening for CIN2+/HSIL<br>* The investigators will compare three different screening methods: visual assessment with portable magnification device , visual inspection after application of acetic acid, screening for high risk variants of HPV. All patients will receive cervical biopsies and histopathological examination.<br>|
| Visual inspection with acetic acid (VIA)<br>VIA, which is standard of care for cervical cancer screening in Zambia, will be carried out using the methodology described by IARC. This is summarized as follows: visualization of the vagina, vulva and cervix following insertion of a speculum; assessment with the naked eye after application of normal saline; and further assessment after application of 5% acetic acid for 1 minute. This will be recorded as normal or abnormal by the assessor. | Diagnostic Test: Screening for CIN2+/HSIL<br>* The investigators will compare three different screening methods: visual assessment with portable magnification device , visual inspection after application of acetic acid, screening for high risk variants of HPV. All patients will receive cervical biopsies and histopathological examination.<br>|
| Histopathological examination of tissue biopsies<br>All acetowhite lesions will be biopsied. When no lesion is seen, one biopsy is taken from each quadrant at the squamocolumnar junction. Biopsies will be sent and examined in a South African based lab. All histological slides will also be verified independently by an IARC trained pathologist at the end of the study. Histological endpoints are defined by the CIN classification system: CIN 1 affects only the lower third of the epithelium (mild dysplasia), CIN 2 involves two thirds of the epithelium and CIN 3 involves the full thickness (severe dysplasia and carcinoma in situ). These findings can be dichotomized by the Lower Anogenital Squamous Terminology into low-grade squamous intraepithelial lesions (LSIL) and high-grade squamous intraepithelial lesions (HSIL). All patients with CIN grade 2 that stained diffusely positive for p16 are considered as HSIL, all patients with CIN 3 are considered as HSIL. Expression of p16 will be visually assessed by immunohistochemistry. | Diagnostic Test: Screening for CIN2+/HSIL<br>* The investigators will compare three different screening methods: visual assessment with portable magnification device , visual inspection after application of acetic acid, screening for high risk variants of HPV. All patients will receive cervical biopsies and histopathological examination.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Test accuracy (sensitivity, specificity) of the Gynocular™ when used as stand-alone tests to detect CIN2+ | To estimate the sensitivity and specificity of the Gynocular when used as a standalone tests to detect CIN2+ among WLHIV. | 6 months | 
| Test accuracy (sensitivity, specificity) of HR-HPV when used as stand-alone tests to detect CIN2+ | To estimate the sensitivity and specificity of HR-HPV when used as a standalone tests to detect CIN2+ among WLHIV. | 6 months | 
| Test accuracy (sensitivity, specificity) of VIA when used as stand-alone tests to detect CIN2+ | To estimate the sensitivity and specificity of VIA when used as a standalone tests to detect CIN2+ among WLHIV. | 6 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Diagnostic test accuracy of the Gynocular™to detect CIN2+/HSIL: other estimates, stand alone | To determine other estimates of test accuracy of the Gynocular™ (including positive and negative predictive values, positive and negative likelihood ratios, false positive rate, false negative rate, number needed to screen and area under the ROC curve (AUC). | 6 months | 
| Diagnostic test accuracy of HR-HPV testing to detect CIN2+/HSIL: other estimates, stand alone | To determine other estimates of HR-HPV testing test accuracy (including positive and negative predictive values, positive and negative likelihood ratios, false positive rate, false negative rate, number needed to screen and area under the ROC curve (AUC). | 6 months | 
| Diagnostic test accuracy of VIA to detect CIN2+/HSIL: other estimates, stand alone | To determine other estimates of VIA test accuracy (including positive and negative predictive values, positive and negative likelihood ratios, false positive rate, false negative rate, number needed to screen and area under the ROC curve (AUC). | 6 months | 
| Diagnostic test accuracy of HR-HPV testing followed by Gynocular™ to detect CIN2+/HSIL: test combination | To determine estimates of test accuracy for combinations of screening tests, i.e. HR-HPV followed by Gynocular™ | 6 months | 
| Diagnostic test accuracy of HR-HPV testing followed by Gynocular™ to detect CIN2+/HSIL: test combination - subgroup analyses | To investigate the effects of age, menopause, parity, ART status, HIV RNA, education, contraception, CD4 cell count, previous treatment for precancerous disease and sexually transmitted infections (STIs) on test accuracy of test combination in subgroup analyses | 6 months | 
| Diagnostic test accuracy of the Gynocular™ followed by HR-HPV testing to detect CIN2+/HSIL: test combination | To determine estimates of test accuracy for combinations of screening tests, i.e. Gynocular™ followed by HR-HPV | 6 months | 
| Diagnostic test accuracy of the Gynocular™ followed by HR-HPV testing to detect CIN2+/HSIL: test combination subgroup analyses | To investigate the effects of age, menopause, parity, ART status, HIV RNA, education, contraception, CD4 cell count, previous treatment for precancerous disease and sexually transmitted infections (STIs) on test accuracy of test combination in subgroup analyses | 6 months | 
| Diagnostic test accuracy VIA followed by Gynocular™ to detect CIN2+/HSIL: test combination | To determine estimates of test accuracy for combinations of screening tests, i.e. VIA followed by Gynocular™ | 6 months | 
| Diagnostic test accuracy VIA followed by Gynocular™ to detect CIN2+/HSIL: test combination - subgroup analyses | To investigate the effects of age, menopause, parity, ART status, HIV RNA, education, contraception, CD4 cell count, previous treatment for precancerous disease and sexually transmitted infections (STIs) on test accuracy of test combination in subgroup analyses | 6 months | 
| Diagnostic test accuracy of the Gynocular™ followed by VIA to detect CIN2+/HSIL: test combination | To determine estimates of test accuracy for combinations of screening tests, i.e. Gynocular™ followed by VIA | 6 months | 
| Diagnostic test accuracy of the Gynocular™ followed by VIA to detect CIN2+/HSIL: test combination - subgroup analyses | To investigate the effects of age, menopause, parity, ART status, HIV RNA, education, contraception, CD4 cell count, previous treatment for precancerous disease and sexually transmitted infections (STIs) on test accuracy of test combination in subgroup analyses | 6 months | 
| Diagnostic test accuracy of the HR-HPV followed by VIA to detect CIN2+/HSIL: test combination | To determine estimates of test accuracy for combinations of screening tests: HR-HPV followed by VIA. | 6 months | 
| Diagnostic test accuracy of the HR-HPV followed by VIA to detect CIN2+/HSIL: test combination - subgroup analyses | To investigate the effects of age, menopause, parity, ART status, HIV RNA, education, contraception, CD4 cell count, previous treatment for precancerous disease and sexually transmitted infections (STIs) on test accuracy of test combination in subgroup analyses | 6 months | 
| Diagnostic test accuracy of the VIA followed by HR-HPV to detect CIN2+/HSIL: test combination | To determine estimates of test accuracy for combinations of screening tests: VIA followed by HR-HPV. | 6 months | 
| Diagnostic test accuracy of the VIA followed by HR-HPV to detect CIN2+/HSIL: test combination subgroup analyses | To investigate the effects of age, menopause, parity, ART status, HIV RNA, education, contraception, CD4 cell count, previous treatment for precancerous disease and sexually transmitted infections (STIs) on test accuracy of test combination in subgroup analyses | 6 months | 
| Subgroup analyses for the diagnostic test accuracy of Gynocular™: stand alone test | To investigate the effects of a age, menopause, parity, ART status, HIV RNA, education, contraception, CD4 cell count, previous treatment for precancerous disease and sexually transmitted infections (STIs) on test accuracy of test combination in subgroup analyses. | 6 months | 
| Subgroup analyses for the diagnostic test accuracy of VIA: stand alone test | To investigate the effects of age, menopause, parity, ART status, HIV RNA, education, contraception, CD4 cell count, previous treatment for precancerous disease and sexually transmitted infections (STIs) on test accuracy of test combination in subgroup analyses. | 6 months | 
| Subgroup analyses for the diagnostic test accuracy of HR-HPV testing: stand alone test | To investigate the effects of age, menopause, parity, ART status, HIV RNA, education, contraception, CD4 cell count, previous treatment for precancerous disease and sexually transmitted infections (STIs) on test accuracy of test combination in subgroup analyses | 6 months | 
| Subgroup analyses for the diagnostic test accuracy of VIA, HR-HPV testing and Gynocular™: Combined tests | To investigate the effects of age, menopause, parity, ART status, HIV RNA, education, contraception, CD4 cell count, previous treatment for precancerous disease and sexually transmitted infections (STIs) on test accuracy of test combination in subgroup analyses | 6 months | 
| Investigation of Swede Score in WLHIV | Area under the receiver operating characteristic (ROC) curve for Swede score determined by Gynocular™ in WLHIV | 6 months | 
| Investigation of co-infections of premalignant and malignant disease (STIs/HR-HPV) | Descriptive analysis of the STI and HR-HPV type distribution associated with each stage of CIN, and when there is persistent disease in WLHIV. | 6 months | 
| Investigation of Trichomonas vaginalis prevalence and persistence in association with menstrual hygiene practices | Descriptive analysis of the prevalence and persistence of Trichomonas vaginalis in association with vaginal and menstrual hygiene practices. | 6 months | 
| Investigations to inform telemedicine capacity: Comparison of image quality | Description of image quality from static assessors, in terms of the assessors' ability to adequately evaluate the images. | 6 months | 
| Investigations to inform telemedicine capacity: use of static images | Proportion of correctly diagnosed CIN2+ through static images obtained by the Gynocular™. | 6 months | 
| Investigations to inform telemedicine capacity: ROC curve for Swede score | Area under the ROC for static image Swede score obtained by Gynocular™ in WLHIV. | 6 months | 
| Investigations to inform telemedicine capacity: Live versus static assessors | Cohen's kappa coefficient to assess agreement between live and static assessors. | 6 months | 
| Artificial Intelligence (AI) for improving the detection of precancerous cervical lesions: testing AI algorithm | Test accuracies of AI deep learning tool retrospectively using coded images obtained in the study through the Gynocular™ and smartphone. | 6 months | 
| Artificial Intelligence for improving the detection of precancerous cervical lesions: improve AI algorithm | Inform and improve AI deep learning tools to detect HSIL by using images or GIFs obtained in the study through the Gynocular™ and smartphone. | 6 months | 
| Diagnostic test accuracy of AI tool to detect CIN2+/HSIL: other estimates, stand alone | To estimate the sensitivity and specificity of HR-HPV when used as a standalone tests to detect CIN2+/HSIL among WLHIV. | 6 months | 
| Diagnostic test accuracy of HR-HPV testing followed by AI tool to detect CIN2+/HSIL: test combination | To determine estimates of test accuracy for combinations of screening tests, i.e. HR-HPV followed by AI tool | 6 months |