Delays and missed opportunities for timely treatment contribute significantly to disparities in cervical cancer mortality in low- and middle-income countries (LMICs) compared to high-income countries (HICs). Cervical cancer is one of the most common female cancers globally, with approximately 90% of cases and deaths occurring in LMICs, particularly those with high rates of HIV. This global disparity is partly driven by successful efforts in HICs to increase implementation and adoption of evidence-based cancer care. In Botswana, a LMIC with a particularly high prevalence of HIV (18.5%), and cervical cancer incidence (34.4 per 100,000) and mortality (20.1 per 100,000), we identified substantial delays in cervical cancer care from diagnosis to treatment in a cohort of nearly 1,000 patients, driven by myriad individual- and system-level barriers. While several implementation strategies appear effective for increasing cervical cancer screening in Botswana and other LMICs, no published studies have specifically targeted evidence-based care following diagnosis of HIV-associated malignancies. As such, there is a critical need to identify effective strategies to ensure timely care, and to understand contextual factors that shape the response to strategies. Without this fundamental knowledge, cervical cancer will remain a public health crisis in Botswana and other LMICs, particularly for people living with the added burden of HIV.

To help fill this critical gap, we will test the effectiveness of adaptive strategies on timely treatment adoption using a hybrid (type III) and pragmatic Sequential Multiple Assignment Randomized Trial (SMART) design, complemented by mixed-methods evaluation. The adaptive strategies are designed to target patient- and system-level determinants identified in our preliminary data, including delayed communication of results, individual and structural barriers to accessing treatment, and suboptimal care coordination between referring and cancer treatment clinics. The strategies draw upon key principles in behavioral economics and are supported by systematic evidence of the effectiveness of nudge strategies in preventive, HIV, and cancer care. The overarching rationale for the study is that enhancing coordination, communication, and navigation through centralized outreach and nudge strategies will increase timely treatment adoption and be scalable and sustainable in the long-term.