Cervical cancer screening in rural Bhutan with the careHPV test on self-collected samples: an ongoing cross-sectional, population-based study (REACH-Bhutan)

OBJECTIVES: The Bhutanese Screening Programme recommends a Pap smear every 3 years for women aged 25–65 years, and coverage ranges from 20% to 60%, being especially challenging in rural settings. The ‘REACH-Bhutan’ study was conducted to assess the feasibility and outcomes of a novel approach to cervical cancer screening in rural Bhutan. DESIGN: Cross-sectional, population-based study of cervical cancer screening based on the careHPV test on self-collected samples. SETTING: Women were recruited in rural primary healthcare centres, that is, Basic Health Units (BHU), across Bhutan. PARTICIPANTS: Overall, 3648 women aged 30–60 were invited from 15 BHUs differing in accessibility, size and ethnic composition of the population. INTERVENTIONS: Participants provided a self-collected cervicovaginal sample and were interviewed. Samples were tested using careHPV in Thimphu (the Bhutanese capital) referral laboratory. MAIN OUTCOME MEASURES: Screening participation by geographic area, centre, age and travelling time. Previous screening history and careHPV positivity by selected characteristics of the participants. RESULTS: In April/May 2016, 2590 women (median age: 41) were enrolled. Study participation was 71% and significantly heterogeneous by BHU (range: 31%–96%). Participation decreased with increase in age (81% in women aged 30–39 years; 59% in ≥50 years) and travelling time (90% in women living <30 min from the BHU vs 62% among those >6 hours away). 50% of participants reported no previous screening, with the proportion of never-screened women varying significantly by BHU (range: 2%–72%). 265 women (10%; 95% CI 9% to 11%) were careHPV positive, with a significant variation by BHU (range: 5%–19%) and number of sexual partners (prevalence ratio for ≥3 vs 0–1, 1.55; 95% CI 1.05 to 2.27). CONCLUSIONS: Community-based cervical cancer screening by testing self-collected samples for human papillomavirus (HPV) can achieve high coverage in rural Bhutan. However, solutions to bring self-collection, HPV testing and precancer treatment closer to the remotest villages are needed.