PROJECT SUMMARY / ABSTRACT Cervical cancer is the 4th most common female cancer and cause of cancer-related mortality worldwide, despite being preventable through HPV (human papillomavirus) vaccination and early detection and treatment of precancerous lesions. In high-income countries, cervical cancer incidence and mortality rates have been reduced through HPV vaccination and screening based on cytology and HPV testing. However, in low- and middle-income countries, especially in sub-Saharan Africa, the burden of cervical cancer remains high due to a lack of effective programs for vaccination and screening. While the World Health Organization (WHO) recommends cervical cancer screening using a nucleic acid test to detect high-risk HPV DNA, most low- and middle-income countries have difficulty implementing HPV testing due to the high cost of tests, the need for lab infrastructure and trained personnel, and long sample-to-answer times. There is an urgent need for novel, low-cost, accurate, and accessible approaches to improve screening. The goal of this project is to develop a point-of-care HPV DNA test that meets WHO goals for cervical cancer screening in low- and middle-income countries by adapting and integrating two innovations: 1) an extraction- free, multiplexed, isothermal nucleic acid amplification assay; and 2) a fully integrated nucleic acid amplification and lateral flow detection platform called NATFlow. The resulting NATFlow HPV test will be affordable, rapid, and simple to use at the point-of-care. We aim to: 1) adapt existing extraction-free, multiplexed, sample-to- answer Loop-Mediated Isothermal Amplification (LAMP) assays to detect eight high risk types of HPV on the NATFlow platform and demonstrate technical functionality with 140 provider-collected clinical specimens; (2) evaluate clinical performance of the NATFlow HPV test in Mozambique, first in 558 banked preserved samples and then prospectively in 1,890 women undergoing cervical cancer screening at Hospital Central de Maputo and surrounding community clinics; and (3) evaluate barriers/facilitators to cervical cancer screening using the NATFlow HPV test in Mozambique. We have assembled an interdisciplinary team based in the US, Mozambique, and Australia with extensive collective experience in developing, evaluating, commercializing, and scaling new technologies to prevent cervical cancer. We have a strong record of carrying out translational and implementation research in low- and middle-income countries including Mozambique. Our industrial team has expertise in developing and translating well-designed instrumentation and chemistries for point-of-care tests. Our team is ideally suited to adapt, validate, and prepare to scale the NATFlow HPV test to accelerate global efforts to prevent cervical cancer.

PROJECT NARRATIVE There is an urgent need to develop low-cost, accurate and accessible approaches to improve cervical cancer screening in low- and middle-income countries, which bear the greatest burden of disease. We will adapt advances in nucleic acid amplification technology developed for COVID surveillance to develop the NATFlow HPV assay, a low-cost, fully integrated, sample-to-answer nucleic acid test that meets the needs for cervical cancer screening in low-resource settings. We will use a community- and stakeholder-engaged process to evaluate the technical and clinical performance of the NATFlow HPV test in Mozambique, as well as barriers and facilitators to its future implementation, in Mozambique.