In Mozambique, cervical cancer is the leading cause of cancer and cancer-related deaths in women, with 5,325 new cases and 3,850 related deaths in 2020.1 The national screening program implemented in 2009 targets women aged 30-55 years, is opportunistic and uses visual inspection with acetic acid (VIA) followed by cryotherapy when indicated.2 The national coverage rate of screening has been estimated to be approximately 3%.2 In addition, the referral system and resources to treat women who require excisional treatment are very limited. Women with high-grade cervical abnormalities who are not eligible for cryotherapy often do not receive appropriate treatment.

## Training of laboratory and clinical personnel

The laboratory technicians at Mavalane Hospital had no prior experience with molecular testing and were trained to perform the careHPV test by laboratory experts from Brazil and Qiagen. Technical support personnel from Qiagen provided training for one laboratory technician using the careHPV test training panel. Two additional technicians underwent one to four one-week training sessions conducted by laboratory specialists from Brazil using the cervical specimens collected for the study.

There was variability in the learning curve between the three laboratory technicians. The technicians received training and mentoring from Brazilian laboratory experts. For those laboratory technicians that experienced difficulties in pipetting techniques, multiple practice sessions of pipetting water in a 96 well plate were held.

Hands-on training sessions were also held for the clinical providers (nurses and doctors) to learn how to collect cervical samples for HPV testing and how to perform VIA, cryotherapy, colposcopy, and LEEP. Furthermore, regular didactic sessions were held for both the laboratory and clinical staff and covered topics such as an overview of the different HPV tests available and different aspects of cervical cancer screening and treatment.

# Recommendations

Based on our experiences, several aspects should be considered before implementing HPV testing. First, in a program comprising both local and external participants, the local leadership and staff must be committed to ensuring the project needs are met and have sufficient support to meet the goals.

It is crucial to understand the local regulations and procurement procedures during the study design process to avoid delays. Moreover, it is essential to assess the lab to ensure safe and adequate infrastructure before delivering any HPV testing equipment for a cervical cancer screening program.6 The budget should include funds to cover high shipment costs and importation fees. In addition, budgets should include funding to implement and support required site improvements, especially in the laboratory infrastructure. Funds are also needed to acquire individual protection equipment (IPEs), computers and internet access.

It is vital to assess the laboratory technicians experience and abilities prior to project implementation. Appropriate training sessions and ongoing mentoring and support can then be provided. Regular communication is needed, particularly if there is limited local expertise in the country and external support is needed. In our project, weekly meetings were held by Zoom between Mozambique, Brazil, and the US teams. Furthermore, regular training sessions may be required to avoid loss of skills, particularly when project activities are paused.

## Funding

The authors would like to thank Qiagen for providing the careHPV system for the study. This study was supported in part by the National Institutes of Health through MD Anderson’s Cancer Center Support Grant P30CA016672; The Anadarko Petroleum Corporation; The Prevent Cancer Foundation; The Dunaway Family Fund; The Joe Family Fund; and The Giles-O’Malley Foundation.

## Authorship contributions

EB, MPS, JHTGF, KMS, RRRK and CL were involved in the conceptualisation, project administration and supervision. CMO, EB, KMS and MPS were involved in writing the original draft, formal analysis and investigation. NP, EM, AM, MCV, RAMJ, KK, CS, VA and JC were involved in the methodology and investigation. VA were also involved in data curation and validation. All authors reviewed, edited, and approved the final manuscript.

## Competing interests

The authors completed the Unified Competing Interest form at http://www.icmje.org/disclosure-of-interest/ (available upon request from the corresponding author), and declare no conflicts of interest.

## Correspondence to:

Cristina Mendes de Oliveira, PhD.
Av. Juruá, 548 - Dasa laboratories, Barueri, Brazil. Phone:
+55 11 26302770.
[email protected]