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Ross JM, Greene C, Broshkevitch CJ, Dowdy DW, van Heerden A, Heitner J, Rao DW, Roberts DA, Shapiro AE, Zabinsky ZB, Barnabas RV. Preventing tuberculosis with community-based care in an HIV-endemic setting: a modelling analysis. J Int AIDS Soc 2024; 27:e26272. [PMID: 38861426 PMCID: PMC11166187 DOI: 10.1002/jia2.26272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 04/30/2024] [Indexed: 06/13/2024] Open
Abstract
INTRODUCTION Antiretroviral therapy (ART) and tuberculosis preventive treatment (TPT) both prevent tuberculosis (TB) disease and deaths among people living with HIV. Differentiated care models, including community-based care, can increase the uptake of ART and TPT to prevent TB in settings with a high burden of HIV-associated TB, particularly among men. METHODS We developed a gender-stratified dynamic model of TB and HIV transmission and disease progression among 100,000 adults ages 15-59 in KwaZulu-Natal, South Africa. We drew model parameters from a community-based ART initiation and resupply trial in sub-Saharan Africa (Delivery Optimization for Antiretroviral Therapy, DO ART) and other scientific literature. We simulated the impacts of community-based ART and TPT care programmes during 2018-2027, assuming that community-based ART and TPT care were scaled up to similar levels as in the DO ART trial (i.e. ART coverage increasing from 49% to 82% among men and from 69% to 83% among women) and sustained for 10 years. We projected the number of TB cases, deaths and disability-adjusted life years (DALYs) averted relative to standard, clinic-based care. We calculated programme costs and incremental cost-effectiveness ratios from the provider perspective. RESULTS If community-based ART care could be implemented with similar effectiveness to the DO ART trial, increased ART coverage could reduce TB incidence by 27.0% (range 21.3%-34.1%) and TB mortality by 34.6% (range 24.8%-42.2%) after 10 years. Increasing both ART and TPT uptake through community-based ART with TPT care could reduce TB incidence by 29.7% (range 23.9%-36.0%) and TB mortality by 36.0% (range 26.9%-43.8%). Community-based ART with TPT care reduced gender disparities in TB mortality rates, with a projected 54 more deaths annually among men than women (range 11-103) after 10 years of community-based care versus 109 (range 41-182) in standard care. Over 10 years, the mean cost per DALY averted by community-based ART with TPT care was $846 USD (range $709-$1012). CONCLUSIONS By substantially increasing coverage of ART and TPT, community-based care for people living with HIV could reduce TB incidence and mortality in settings with high burdens of HIV-associated TB and reduce TB gender disparities.
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Affiliation(s)
- Jennifer M. Ross
- Division of Allergy and Infectious DiseasesDepartment of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Chelsea Greene
- Department of Industrial and Systems EngineeringUniversity of WashingtonSeattleWashingtonUSA
| | - Cara J. Broshkevitch
- Department of EpidemiologyUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - David W. Dowdy
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Alastair van Heerden
- Centre for Community Based ResearchHuman Sciences Research CouncilPietermaritzburgSouth Africa
- SAMRC/Wits Developmental Pathways for Health Research UnitUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Jesse Heitner
- Division of Infectious DiseasesMassachusetts General HospitalBostonMassachusettsUSA
| | - Darcy W. Rao
- Bill & Melinda Gates FoundationSeattleWashingtonUSA
| | - D. Allen Roberts
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | - Adrienne E. Shapiro
- Division of Allergy and Infectious DiseasesDepartment of MedicineUniversity of WashingtonSeattleWashingtonUSA
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Zelda B. Zabinsky
- Department of Industrial and Systems EngineeringUniversity of WashingtonSeattleWashingtonUSA
| | - Ruanne V. Barnabas
- Division of Infectious DiseasesMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
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Broshkevitch CJ, Barnabas RV, Liu G, Palanee-Phillips T, Rao DW. Enhanced cervical cancer and HIV interventions reduce the disproportionate burden of cervical cancer cases among women living with HIV: A modeling analysis. PLoS One 2024; 19:e0301997. [PMID: 38781268 PMCID: PMC11115290 DOI: 10.1371/journal.pone.0301997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 03/26/2024] [Indexed: 05/25/2024] Open
Abstract
INTRODUCTION Women living with HIV experience heightened risk of cervical cancer, and over 50% of cases in Southern Africa are attributed to HIV co-infection. Cervical cancer interventions tailored by HIV status delivered with HIV antiretroviral therapy (ART) for treatment can decrease cancer incidence, but impact on HIV-related disparities remains understudied. METHODS Using a dynamic model calibrated to KwaZulu-Natal, South Africa, we projected HIV prevalence, cervical cancer incidence, and proportion of cancer cases among women living with HIV between 2021-2071. Relative to the status quo of moderate intervention coverage, we modeled three additive scenarios: 1) ART scale-up only; 2) expanded human papillomavirus (HPV) vaccination, screening, and treatment; and 3) catch-up HPV vaccination and enhanced screening for women living with HIV. RESULTS Under the status quo, HIV prevalence among women aged 15+ decreased from a median of 35% [Uncertainty Range (UR): 26-42%] in 2021 to 25% [19-34%] in 2071. The proportion of cervical cancer cases that were women living with HIV declined from 73% [63-86%] to 58% [47-74%], but incidence remained 4.3-fold [3.3-5.7] that of women without HIV. ART scale-up reduced HIV prevalence in 2071, but increased the incidence rate ratio to 5.2 [3.7-7.3]. Disparities remained after expanding cancer interventions for all women (incidence rate ratio: 4.8 [3.6-7.6]), while additional catch-up HPV vaccination and screening for women living with HIV decreased the incidence rate ratio to 2.7 [1.9-3.4] in 2071. CONCLUSIONS Tailored cervical cancer interventions for women living with HIV can counteract rising cancer incidence incurred by extended life expectancy on ART and reduce disparate cancer burden.
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Affiliation(s)
- Cara J. Broshkevitch
- Department of Epidemiology, University of North Carolina-Chapel Hill, Chapel Hill, NC, United States of America
| | - Ruanne V. Barnabas
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Gui Liu
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, United States of America
| | - Darcy White Rao
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, United States of America
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Tran J, Hathaway CL, Broshkevitch CJ, Palanee-Phillips T, Barnabas RV, Rao DW, Sharma M. Cost-effectiveness of single-visit cervical cancer screening in KwaZulu-Natal, South Africa: a model-based analysis accounting for the HIV epidemic. Front Oncol 2024; 14:1382599. [PMID: 38720798 PMCID: PMC11077327 DOI: 10.3389/fonc.2024.1382599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 03/27/2024] [Indexed: 05/12/2024] Open
Abstract
Introduction Women living with human immunodeficiency virus (WLHIV) face elevated risks of human papillomavirus (HPV) acquisition and cervical cancer (CC). Coverage of CC screening and treatment remains low in low-and-middle-income settings, reflecting resource challenges and loss to follow-up with current strategies. We estimated the health and economic impact of alternative scalable CC screening strategies in KwaZulu-Natal, South Africa, a region with high burden of CC and HIV. Methods We parameterized a dynamic compartmental model of HPV and HIV transmission and CC natural history to KwaZulu-Natal. Over 100 years, we simulated the status quo of a multi-visit screening and treatment strategy with cytology and colposcopy triage (South African standard of care) and six single-visit comparator scenarios with varying: 1) screening strategy (HPV DNA testing alone, with genotyping, or with automated visual evaluation triage, a new high-performance technology), 2) screening frequency (once-per-lifetime for all women, or repeated every 5 years for WLHIV and twice for women without HIV), and 3) loss to follow-up for treatment. Using the Ministry of Health perspective, we estimated costs associated with HPV vaccination, screening, and pre-cancer, CC, and HIV treatment. We quantified CC cases, deaths, and disability-adjusted life-years (DALYs) averted for each scenario. We discounted costs (2022 US dollars) and outcomes at 3% annually and calculated incremental cost-effectiveness ratios (ICERs). Results We projected 69,294 new CC cases and 43,950 CC-related deaths in the status quo scenario. HPV DNA testing achieved the greatest improvement in health outcomes, averting 9.4% of cases and 9.0% of deaths with one-time screening and 37.1% and 35.1%, respectively, with repeat screening. Compared to the cost of the status quo ($12.79 billion), repeat screening using HPV DNA genotyping had the greatest increase in costs. Repeat screening with HPV DNA testing was the most effective strategy below the willingness to pay threshold (ICER: $3,194/DALY averted). One-time screening with HPV DNA testing was also an efficient strategy (ICER: $1,398/DALY averted). Conclusions Repeat single-visit screening with HPV DNA testing was the optimal strategy simulated. Single-visit strategies with increased frequency for WLHIV may be cost-effective in KwaZulu-Natal and similar settings with high HIV and HPV prevalence.
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Affiliation(s)
- Jacinda Tran
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, WA, United States
| | - Christine Lee Hathaway
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, United States
| | - Cara Jill Broshkevitch
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Thesla Palanee-Phillips
- Faculty of Health Sciences, Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Ruanne Vanessa Barnabas
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, United States
- Division of Infectious Diseases, Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Darcy White Rao
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA, United States
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Davidović M, Asangbeh SL, Taghavi K, Dhokotera T, Jaquet A, Musick B, Van Schalkwyk C, Schwappach D, Rohner E, Murenzi G, Wools-Kaloustian K, Anastos K, Omenge OE, Boni SP, Duda SN, von Groote P, Bohlius J. Facility-Based Indicators to Manage and Scale Up Cervical Cancer Prevention and Care Services for Women Living With HIV in Sub-Saharan Africa: a Three-Round Online Delphi Consensus Method. J Acquir Immune Defic Syndr 2024; 95:170-178. [PMID: 38211958 PMCID: PMC10794028 DOI: 10.1097/qai.0000000000003343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 10/19/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Of women with cervical cancer (CC) and HIV, 85% live in sub-Saharan Africa, where 21% of all CC cases are attributable to HIV infection. We aimed to generate internationally acceptable facility-based indicators to monitor and guide scale up of CC prevention and care services offered on-site or off-site by HIV clinics. METHODS We reviewed the literature and extracted relevant indicators, grouping them into domains along the CC control continuum. From February 2021 to March 2022, we conducted a three-round, online Delphi process to reach consensus on indicators. We invited 106 experts to participate. Through an anonymous, iterative process, participants adapted the indicators to their context (round 1), then rated them for 5 criteria on a 5-point Likert-type scale (rounds 2 and 3) and then ranked their importance (round 3). RESULTS We reviewed 39 policies from 21 African countries and 7 from international organizations; 72 experts from 15 sub-Saharan Africa countries or international organizations participated in our Delphi process. Response rates were 34% in round 1, 40% in round 2, and 44% in round 3. Experts reached consensus for 17 indicators in the following domains: primary prevention (human papillomavirus prevention, n = 2), secondary prevention (screening, triage, treatment of precancerous lesions, n = 11), tertiary prevention (CC diagnosis and care, n = 2), and long-term impact of the program and linkage to HIV service (n = 2). CONCLUSION We recommend that HIV clinics that offer CC control services in sub-Saharan Africa implement the 17 indicators stepwise and adapt them to context to improve monitoring along the CC control cascade.
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Grants
- Central Africa, U01AI096299; East Africa, U01AI069911; Southern Africa, U01AI069924; West Africa, U01AI069919 NIDDK NIH HHS
- U01 AI096299 NIAID NIH HHS
- U01 AI069923 NIAID NIH HHS
- R24 AI124872 NIAID NIH HHS
- U01 AI069911 NIAID NIH HHS
- Central Africa, U01AI096299; East Africa, U01AI069911; Southern Africa, U01AI069924; West Africa, U01AI069919 FIC NIH HHS
- U01 AI069919 NIAID NIH HHS
- U01 AI069907 NIAID NIH HHS
- U01 AI069924 NIAID NIH HHS
- Central Africa, U01AI096299; East Africa, U01AI069911; Southern Africa, U01AI069924; West Africa, U01AI069919 NHLBI NIH HHS
- Central Africa, U01AI096299; East Africa, U01AI069911; Southern Africa, U01AI069924; West Africa, U01AI069919 NIMH NIH HHS
- Central Africa, U01AI096299; East Africa, U01AI069911; Southern Africa, U01AI069924; West Africa, U01AI069919 NIDA NIH HHS
- U01 AI069918 NIAID NIH HHS
- Central Africa, U01AI096299; East Africa, U01AI069911; Southern Africa, U01AI069924; West Africa, U01AI069919 NIAAA NIH HHS
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Affiliation(s)
- Maša Davidović
- Graduate School of Health Sciences, University of Bern, Bern, Switzerland
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Serra Lem Asangbeh
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
- Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland
| | - Katayoun Taghavi
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Tafadzwa Dhokotera
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
- Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland
| | - Antoine Jaquet
- University of Bordeaux, National Institute for Health and Medical Research (INSERM), UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Centre, Bordeaux, France
| | - Beverly Musick
- Department of Biostatistics and Health Data Science, School of Medicine, Indiana University, Indianapolis, IN
| | - Cari Van Schalkwyk
- The South African Department of Science and Innovation/National Research Foundation Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - David Schwappach
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Eliane Rohner
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Gad Murenzi
- Einstein-Rwanda Research and Capacity Building Program, Research for Development (RD Rwanda) and Rwanda Military Hospital, Kigali, Rwanda
| | | | - Kathryn Anastos
- Departments of Medicine and Epidemiology, Albert Einstein College of Medicine, Bronx, NY
| | | | - Simon Pierre Boni
- Programme PAC-CI, Abidjan, Côte d'Ivoire
- National Cancer Control Program, Côte d'Ivoire; and
| | - Stephany N Duda
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Per von Groote
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Julia Bohlius
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
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Ross JM, Greene C, Bayer CJ, Dowdy DW, van Heerden A, Heitner J, Rao DW, Roberts DA, Shapiro AE, Zabinsky ZB, Barnabas RV. Preventing tuberculosis with community-based care in an HIV-endemic setting: a modeling analysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.21.23294380. [PMID: 37662260 PMCID: PMC10473784 DOI: 10.1101/2023.08.21.23294380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Introduction Antiretroviral therapy (ART) and TB preventive treatment (TPT) both prevent tuberculosis (TB) disease and deaths among people living with HIV. Differentiated care models, including community-based care, can increase uptake of ART and TPT to prevent TB in settings with a high burden of HIV-associated TB, particularly among men. Methods We developed a gender-stratified dynamic model of TB and HIV transmission and disease progression among 100,000 adults ages 15-59 in KwaZulu-Natal, South Africa. We drew model parameters from a community-based ART initiation and resupply trial in sub-Saharan Africa (Delivery Optimization for Antiretroviral Therapy, DO ART) and other scientific literature. We simulated the impacts of community-based ART and TPT care programs during 2018-2027, assuming that community-based ART and TPT care were scaled up to similar levels as in the DO ART trial (i.e., ART coverage increasing from 49% to 82% among men and from 69% to 83% among women) and sustained for ten years. We projected the number of TB cases, deaths, and disability-adjusted life years (DALYs) averted relative to standard, clinic-based care. We calculated program costs and incremental cost-effectiveness ratios from the provider perspective. Results If community-based ART care could be implemented with similar effectiveness to the DO ART trial, increased ART coverage could reduce TB incidence by 27.0% (range 21.3% - 34.1%) and TB mortality by 36.0% (range 26.9% - 43.8%) after ten years. Increasing both ART and TPT uptake through community-based ART with TPT care could reduce TB incidence by 29.7% (range 23.9% - 36.0%) and TB mortality by 36.0% (range 26.9% - 43.8%). Community-based ART with TPT care reduced gender disparities in TB mortality rates by reducing TB mortality among men by a projected 39.8% (range 32.2% - 46.3%) and by 30.9% (range 25.3% - 36.5%) among women. Over ten years, the mean cost per DALY averted by community-based ART with TPT care was $846 USD (range $709 - $1,012). Conclusions By substantially increasing coverage of ART and TPT, community-based care for people living with HIV could reduce TB incidence and mortality in settings with high burdens of HIV-associated TB and reduce TB gender disparities.
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Affiliation(s)
- Jennifer M. Ross
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, USA
| | - Chelsea Greene
- Department of Industrial and Systems Engineering, University of Washington, Seattle, USA
| | - Cara J. Bayer
- Department of Epidemiology, University of North Carolina, Chapel Hill, USA
| | - David W. Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Alastair van Heerden
- Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg, South Africa
- SAMRC/Wits Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Jesse Heitner
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, USA
| | | | - D. Allen Roberts
- Department of Epidemiology, University of Washington, Seattle, USA
| | - Adrienne E. Shapiro
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, USA
- Department of Global Health, University of Washington, Seattle, USA
| | - Zelda B. Zabinsky
- Department of Industrial and Systems Engineering, University of Washington, Seattle, USA
| | - Ruanne V. Barnabas
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, USA
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Bolon J, Samson A, Irwin N, Murray L, Mbodi L, Stacey S, Aikman N, Moonsamy L, Zamparini J. An audit of adherence to cervical cancer screening guidelines in a tertiary-level HIV clinic. South Afr J HIV Med 2023; 24:1490. [PMID: 37293604 PMCID: PMC10244942 DOI: 10.4102/sajhivmed.v24i1.1490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 04/11/2023] [Indexed: 06/10/2023] Open
Abstract
Background Cervical cancer is the most common malignancy affecting South African women aged 15-44 years, with a higher prevalence among women living with HIV (WLWH). Despite recommendations for a screening target of 70%, the reported rate of cervical cancer screening in South Africa is 19.3%. Objectives To investigate the adherence of healthcare workers to cervical cancer screening guidelines in a tertiary-level HIV clinic. Method A retrospective cross-sectional record audit of women attending the Charlotte Maxeke Johannesburg Academic Hospital HIV Clinic over a 1-month period. Results Out of 403 WLWH who attended the clinic, 180 (44.7%) were screened for cervical cancer in the 3 years prior to the index consultation. Only 115 (51.6%) of those women with no record of prior screening were subsequently referred for screening. Women who had undergone screening in the previous 3 years were significantly older (47 years vs 44 years, P = 0.046) and had a longer time since diagnosis of their HIV (12 years vs 10 years, P = 0.001) compared to women who had not undergone screening. There was no significant difference in CD4 count or viral suppression between women who had and had not undergone screening. Conclusion The rate of cervical cancer screening in our institution is below that recommended by the World Health Organization and the South African National Department of Health.
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Affiliation(s)
- Jeffrey Bolon
- Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Amy Samson
- Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Natalie Irwin
- Division of Medical Oncology, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Medical Oncology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Lyle Murray
- Division of Infectious Diseases, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Infectious Diseases, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Langanani Mbodi
- Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Sarah Stacey
- Division of Infectious Diseases, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Infectious Diseases, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Nicholas Aikman
- Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Louell Moonsamy
- Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Jarrod Zamparini
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Obstetric Internal Medicine Unit, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital, South Africa
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