PROJECT SUMMARY/ABSTRACT An estimated 90% of cervical cancer related deaths take place in low- and middle-income countries (LMICs), where the burden of disease is highest and there is limited access to effective screening and diagnosis [1]. In July 2021, the World Health Organization updated their recommended approach for cervical cancer screening to focus on human papillomavirus (HPV) DNA testing. However, it remains difficult for many women to access HPV DNA testing due to the necessary costs, high level of infrastructure, and requirement for trained personnel. Compared to expensive commercial platforms, a variety of promising point-of-care (POC) strategies have proposed isothermal amplification of DNA as an affordable avenue for testing [2]–[6]; however, there are important gaps to fully incorporate integrated sample-to-answer platforms that eliminate the risk of workspace contamination and subsequent false positive results. The objective of this project is to develop a low-cost (<$3/test, $500/instrument) fully integrated, quantitative HPV DNA test platform that is simple to use for effective HPV screening at the POC. The Richards-Kortum lab has shown that isothermal amplification with Recombinase Polymerase Amplification can be performed in paper membranes [7]. More recently, the Posner group demonstrated the capability to detect discrete fluorescent amplification nucleation sites using a paper membrane to quantify HIV-1 DNA using a mobile phone-based imager [8]. This proposal builds upon recent advances to design a two-dimensional paper microfluidic device and low-cost imaging platform for detection of high risk HPV types, HPV16 and HPV18, the primary causes of cervical cancer. This proposal will accomplish these goals by pursuing the following three specific aims: 1) Designing a test to accept and process cervical cytology specimens with pre-loaded lyophilized reagents for amplification of HPV 16/HPV 18 DNA, 2) Developing a low-cost instrument, including a heater and fluorimeter, to monitor multiplexed real-time isothermal nucleic acid amplification reactions, and 3) Conducting a proof-of-principle study to assess usability and efficacy of the test and instrument designed, using banked clinical samples in Houston and within a low resource setting in Mozambique, Africa. Sensitivity, specificity, and limit of detection analysis will be used to determine comparability to gold standard technologies. Completing these aims will improve cervical cancer screening and reduce morbidity and mortality in underserved areas of the world. This project benefits greatly from co-mentorship from Dr. Rebecca Richards-Kortum and her colleague Kathleen Schmeler, who both have extensive experience in evaluating new technologies for cervical cancer prevention and translating them to low-resource settings. The training plan and environment have been specifically tailored, focusing on multi- disciplinary, hands-on coursework, lab work, and teaching, and translational research aims with deployment within an LMIC to ensure project success and scalability.

PROJECT NARRATIVE Cervical cancer is a life-threatening pathology highly associated with human papilloma virus (HPV) infection that disproportionally affects low- and middle- income countries. A major barrier in implementing and sustaining screening programs for cervical cancer in low-resource countries is the lack of an affordable and effective screening test that can provide HPV results at the point-of-care. This proposal will develop and evaluate a novel DNA-based approach that combines isothermal recombinase polymerase amplification with fluorescent quantification in an accurate and low-cost test, which could improve access to cervical cancer screening and significantly decrease mortality due to the disease.