According to International Agency for Cancer Research (IARC), in 2018, 569,847 new cases of cervical cancer and 311,365  associated  deaths were reported in women worldwide (Bray et al., 2018).  In Côte d’Ivoire, cervical cancer is the second most common cancer among females  with age-standardized (World) incidence rates of 28.6 per 100,000 women. Of the 1,789 women diagnosed in 2018, 1,448 deaths occurred making cervical cancer the leading cause of cancer related death in this country (Bray et al., 2018). This malignancy can be prevented through systematic screening for adult women and HPV immunization for adolescent females prior to sexual initiation (World Health Organization, 2014). To overcome financial and human resources challenges raised during the implementation of screening programs using pap smear, low and middle income countries (LMICs) endorsed visual inspection with acetic acid (VIA) as an alternative screening method, as recommended by the WHO (2013). Following a pilot phase of screening, the VIA-based program scaled up across sub-Saharan African countries (Shiferaw et al., 2016; Blumenthal et al., 2007; Parham et al., 2015; Boni et al., 2019; Ouedraogo et al., 2018).

This study provides the first data on factors affecting a follow-up after cryotherapy uptake in Côte d'Ivoire. Being HIV positive and attending an HIV clinic were significantly associated with attendance to the follow-up visit. In addition, proximity with a cervical cancer screening facility and access to screening and cryotherapy after the year 2013 also showed a significant link with one-year follow-up visit.

This study suggests a higher one-year post cryotherapy attendance rate among HIV positive women followed up in HIV clinics. This higher rate among HIV positive women could be the positive impact of the “retention to care” package implemented in HIV clinics. These includes SMS reminders and phone calls for antiretroviral drug pick up, as well as transport reimbursement and food supply during psychosocial support groups (Project Djidja Brief (2020). These retention strategies led to more frequent contacts with the health facility among HIV positive women, increasing the possibility for health care workers to remind participants of the post cryotherapy follow-up visit, as well as for women to attend the integrated cervical cancer unit at the time of this visit. In addition, the improved patients file management and existence of HIV client’s databases in almost all HIV clinics facilitates  the  follow-up  of  HIV  positive  women receiving cervical cancer screening services. Leveraging on the HIV clinics experience, the cervical cancer prevention programs in Sub-Saharan Africa could identify innovative and sustainable interventions to maintain frequent contact (mainly virtual) with women attending cervical cancer screening units. Strategies for introducing mobile health interventions such as SMS reminders, mobile apps calendars, and phones calls have been shown to be acceptable and feasible for cervical cancer screening in previous studies from South Africa and Australia respectively (Moodley et al., 2019; Downer et al., 2006).

In our study, women attending cervical cancer units for screening and cryotherapy between 2013 and 2014 were more likely to attend the cervical cancer screening unit for their one-year post cryotherapy follow-up visit. The analysis of NCCP activity reports 2010-2015 retrieved that the implementation of the cervical cancer prevention program was done in two phases. It commenced by pilot phases that focused on HIV clinics from 2009 to 2012 and was followed by a scale-up phase characterized by integration of cervical cancer screening activities in public and private non-HIV health facilities (Boni et al., 2019). Thus, there is a strong association between scaling up and integrating cervical cancer screening services in all health facilities and the attendance to the one-year post cryotherapy follow-up. This reinforces the WHO recommendation to provide cervical cancer screening services for the general population by integrating these services in reproductive health activities or in maternal and child health units of all the health facilities (World Health Organization, 2014).

Implementing this integration strategy will help overcome some challenges to the cervical cancer screening and the post treatment follow-up visit such as geographic accessibility (Lim and Ojo, 2017). This idea is reinforced by the positive association between the proximity of the cervical cancer screening unit to the living place of the women and the attendance to the one-year post cryotherapy follow-up visit, found in our study and also was reported in a systematic review in sub-Saharan Africa (Lim and Ojo, 2017). Thus, the decentralization of cervical cancer screening and treatment services through their integration into all public and private health facilities is a game changer for the cervical cancer prevention, and should be strengthened at a national level to achieve and sustain the appropriate follow-up of women and avoid recurrence of cervical abnormalities leading to cervical cancer.

This study did not assess some of the demographic and socioeconomic factors encompassing marital status and personal income that could help explore patient-related barriers to attending post cryotherapy follow-up visits. However, this study is among the first to explore the correlates of attendance to follow-up visit after cryotherapy in West Africa. Findings from this study could implementing partners, in designing or adopting innovative and sustainable interventions to effectively prevent cervical cancers in Sub-Saharan African countries. However, further studies are needed to better understand the determinants of follow-up after cryotherapy or thermo-coagulation in developing countries, and assess the effectiveness of some promising approaches.