Megan J. Huchko, MD, MPH, is a Duke benign gynecology specialist whose clinical specialty in cervical cancer prevention led her to develop a prevention program for underserved women in Kenya in partnership with the country’s Ministry of Health. She and her colleagues in Duke’s OB-GYN department are actively engaged in clinical initiatives, research studies, and evolving technology aimed at increasing access to human papillomavirus (HPV) screening and facilitating timely treatment for women in the U.S. and globally.

Here, she discusses some of the challenges, barriers, opportunities, and initiatives associated with HPV vaccinations and screening.

Q: What are some of the challenges associated with access to the HPV vaccine and cervical cancer screening in general?

Huchko: In the U.S. there are many people who don’t seek vaccinations for themselves or their children, so I think more direct messaging and education is needed, like the effort the CDC is making to publicize the facts about HPV. Another challenge is setting up systems to identify eligible vaccine candidates, and ensuring they get the appropriate follow-up dosing. The full course of the vaccine is either two or three doses (depending on age) administered over separate office visits, so it’s challenging for clinicians to track where women are in the cycle and find ways to remind them to finish the full regimen. Another challenge is that in underserved populations in the U.S. and around the world, access to laboratory infrastructure and colposcopy equipment for screening and follow-up treatment is very limited.

Q: What initiatives has Duke implemented to improve screening and access to the vaccine?

Huchko: Duke has seen an increase in HPV vaccination rates in our clinics over the past few years as part of a quality improvement plan, which involves several initiatives:

• We’re working closely with the Department of Pediatrics to increase HPV vaccinations for children as young as age 9, so they’re protected years before they’re exposed to the virus. We find that most vaccinations occur during the “catchup years” of ages 13 to 26, but the vaccine is safe, effective, and recommended for younger children.
• We’re working to enhance the EHR so that patients’ HPV vaccination information and recommendations are available to providers during visits, in the same way that pap smear and mammography information is displayed. The long-term vision for the enhancement is for women to receive reminders to start or finish their HPV vaccine regimen, and for providers to see individualized, risk-based guidelines based on age, medications, and health complications to determine the next steps for follow-up or screening.
• In our Kenya settings, we’re doing door-to-door campaigns and community-based testing, offering HPV screening to women via self-collection, with no pelvic exam required. With these efforts, we’ve increased screening coverage from 5% to 70% in certain rural areas of Kenya. We’ve also developed a mobile app to support counseling and tracking. The Ministry of Health recently introduced government-sponsored vaccines, so we are working to expand our messaging to include families and girls eligible for vaccination.

Q: How does the pocket colposcope that Duke developed in 2017 work, and how is it being used?

Huchko: Dr. Nimmi Ramanujam, who is a professor of biomedical engineering and a faculty member in the Global Health Institute at Duke, developed this novel technology in her lab to increase access to cervical cancer screening in primary care settings. When women have a positive HPV test, they are normally referred to a facility with a full-sized colposcope for screening. The pocket device detects abnormal tissue in the cervix in the same way as the full-sized device—with equivalent imaging quality—but at a fraction of the cost. It can be used by non-physician clinicians and has the potential for women to self-insert it to perform their own exams. The device has been deployed in low-income areas around the world, and plans are underway to implement it in peripheral clinics in underserved regions of the U.S., with the ultimate goal of helping women with treatable disease get to the next steps for evaluation and treatment more quickly.