Results from Two HPV-Based Cervical Cancer Screening-Family Planning Integration Models in Malawi: A Cluster Randomized Trial

SIMPLE SUMMARY: Our study evaluated which of two HPV-based cervical cancer screening–family planning integration models would result in a higher proportion of eligible women ever being screened for cervical cancer in our targeted communities in Malawi. We found that the model that offered HPV self-collection in both the local health clinic and through community health workers resulted in a significantly higher proportion of eligible women ever being screened in that model’s targeted communities, when compared to the model that only offered HPV self-collection at the local health clinic. In addition, women in the clinic–community integration model were more likely to be using modern family planning services. Therefore, we recommend that countries and programs aiming to increase the proportion of eligible women ever screened for cervical cancer integrate HPV self-collection with family planning services in both clinic- and community-based settings to reach women that have never been screened for cervical cancer. ABSTRACT: We conducted a cluster randomized trial of two models for integrating HPV self-collection into family-planning (FP) services at 16 health facilities in Malawi between March 2020–December 2021. Model 1 involved providing only clinic-based HPV self-collection, whereas Model 2 included both clinic-based and community-based HPV self-collection. An endline household survey was performed in sampled villages and households between October-December 2021 in the catchment areas of the health facilities. We analyzed 7664 surveys from 400 villages. Participants from Model 2 areas were more likely to have ever undergone cervical cancer screening (CCS) than participants from Model 1 areas, after adjusting for district, facility location (urban versus rural), and facility size (hospital versus health center) (adjusted odds ratio = 1.73; 95% CI: 1.29, 2.33). Among participants who had ever undergone CCS, participants from Model 2 were more likely to report having undergone HPV self-collection than participants from Model 1 (50.5% versus 22.8%, p = 0.023). Participants from Model 2 were more likely to be using modern FP (adjusted odds ratio = 1.01; 95% CI: 1.41, 1.98) than Model 1 participants. The integration of FP and HPV self-collection in both the clinic and community increases CCS and modern FP uptake more than integration at the clinic-level alone.