Cervical cancer prevention: safety, acceptability, and feasibility of a single-visit approach in Accra, Ghana

Modelling cervical cancer elimination using single-visit screening and treatment strategies in the context of high HIV prevalence: estimates for KwaZulu-Natal, South Africa

INTRODUCTION

In settings with high HIV prevalence, cervical cancer incidence rates are up to six-fold higher than the global average of 13.1 cases per 100,000 women-years. To inform strategies for global cervical cancer elimination, we used a dynamic transmission model to evaluate scalable screening and treatment strategies, accounting for HIV-associated cancer risks and weighing prevention gains against overtreatment.

METHODS

We developed a dynamic model of HIV-HPV co-infection and disease progression, which we calibrated to KwaZulu-Natal, South Africa. Our baseline scenario reflects the current practice of HPV vaccination with a multi-visit screening and treatment strategy involving cytology and colposcopy triage. We evaluated 13 comparator scenarios with increased vaccination coverage and one-time, two-time or repeat HIV-targeted cervical cancer screening with the following single-visit strategies: HPV DNA testing, HPV genotyping, automated visual evaluation (AVE) and HPV DNA with AVE triage. In all scenarios, HIV antiretroviral therapy, condom use and voluntary male medical circumcision continue at baseline levels. We simulated cancer incidence under each scenario from 2020 to 2120 using the 25 best-fitting parameter sets. We present the median and range of model output from these simulations to account for parameter uncertainty.

RESULTS

We estimate that cervical cancer incidence will decrease by 87% with the continuation of current cervical cancer and HIV prevention strategies, from an age-standardized rate per 100,000 women of 80.4 (range 58.2, 112.1) in 2020 to 10.7 (4.2, 29.9) in 2120. Scenarios scaling up vaccination and single-visit strategies resulted in near- and long-term gains. With repeat HIV-targeted screening, incidence rates were projected to be 29-34% lower in 2030 relative to the baseline scenario, and elimination (incidence <4/100,000) was achieved with HPV DNA testing in 2095 and with AVE in 2114. A strategy of HPV DNA with AVE triage optimized the tradeoff between cancer cases averted and overtreatment.

CONCLUSIONS

Single-visit screening strategies could avert a substantial burden of cervical cancer and accelerate progress towards elimination in settings with a high burden of HIV. Increasing the screening frequency among women with HIV and reducing loss-to-follow-up for treatment will be key components of a successful elimination strategy.

Implementation research on noncommunicable disease prevention and control interventions in low- and middle-income countries: A systematic review

BACKGROUND

While the evidence for the clinical effectiveness of most noncommunicable disease (NCD) prevention and treatment interventions is well established, care delivery models and means of scaling these up in a variety of resource-constrained health systems are not. The objective of this review was to synthesize evidence on the current state of implementation research on priority NCD prevention and control interventions provided by health systems in low- and middle-income countries (LMICs).

METHODS AND FINDINGS

On January 20, 2021, we searched MEDLINE and EMBASE databases from 1990 through 2020 to identify implementation research studies that focused on the World Health Organization (WHO) priority NCD prevention and control interventions targeting cardiovascular disease, cancer, diabetes, and chronic respiratory disease and provided within health systems in LMICs. Any empirical and peer-reviewed studies that focused on these interventions and reported implementation outcomes were eligible for inclusion. Given the focus on this review and the heterogeneity in aims and methodologies of included studies, risk of bias assessment to understand how effect size may have been compromised by bias is not applicable. We instead commented on the distribution of research designs and discussed about stronger/weaker designs. We synthesized extracted data using descriptive statistics and following the review protocol registered in PROSPERO (CRD42021252969). Of 9,683 potential studies and 7,419 unique records screened for inclusion, 222 eligible studies evaluated 265 priority NCD prevention and control interventions implemented in 62 countries (6% in low-income countries and 90% in middle-income countries). The number of studies published has been increasing over time. Nearly 40% of all the studies were on cervical cancer. With regards to intervention type, screening accounted for 49%, treatment for 39%, while prevention for 12% (with 80% of the latter focusing on prevention of the NCD behavior risk factors). Feasibility (38%) was the most studied implementation outcome followed by adoption (23%); few studies addressed sustainability. The implementation strategies were not specified well enough. Most studies used quantitative methods (86%). The weakest study design, preexperimental, and the strongest study design, experimental, were respectively employed in 25% and 24% of included studies. Approximately 72% of studies reported funding, with international funding being the predominant source. The majority of studies were proof of concept or pilot (88%) and targeted the micro level of health system (79%). Less than 5% of studies report using implementation research framework.

CONCLUSIONS

Despite growth in implementation research on NCDs in LMICs, we found major gaps in the science. Future studies should prioritize implementation at scale, target higher levels health systems (meso and macro levels), and test sustainability of NCD programs. They should employ designs with stronger internal validity, be more conceptually driven, and use mixed methods to understand mechanisms. To maximize impact of the research under limited resources, adding implementation science outcomes to effectiveness research and regional collaborations are promising.

Developing a culturally tailored short message service (SMS) intervention for improving the uptake of cervical cancer screening among Ghanaian women in urban communities

Background

There has been extensive research across the globe to understand the barriers and facilitators of cervical cancer (CC) screening. However, few studies have focused on how such information has been used to develop text messages for mHealth screening programs, especially in resource-poor countries. This study elicited information on barriers and facilitators, the preferences of women regarding the modalities for delivery of health SMS messages on screening for cervical cancer, and demonstrates how this information was used to create a health screening program among women in the Greater Accra Region of Ghana.

Methods

Four main activities were carried out, including (1) a total of five focus group discussions, (2) a baseline survey involving 62 female bankers and 68 women from the communities, (3) a stakeholder meeting involving experts in cervical cancer research and clinical care, and (4) pilot testing of the text messages. Focus group discussions and the baseline survey data were collected concurrently between February and May 2017 and the results were used to develop 5 specific communication objectives during the stakeholder engagements held in June 2017.

Results

In all, 32 text messages were developed and pretested in July 2017(13 addressed knowledge on CC; 6 highlighted the importance of early detection; 5 allayed fear as a barrier to CC screening; 5 encouraged women to have time for their health, and 3 messages contained information on where to go for screening and the cost involved). Although awareness about the disease was high, knowledge of CC screening was low. For two-thirds of respondents (22/33), perceived lack of time, high cost, and fear (of cc, screening procedure, and potential for negative outcome) accounted for the reasons why respondents will not go for screening, while education on CC, especially from health workers and the mass media enabled uptake of CC screening.

Conclusion

Several factors prevent women from accessing screening services for CC, however, barriers such as low levels of education on CC, lack of time, and fear can be targeted in SMS messaging programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01719-9.

Communities' perceptions towards cervical cancer and its screening in Wolaita zone, southern Ethiopia: A qualitative study

Background

Cervical cancer is a malignant neoplasm from cells originating in the cervix uteri. Any woman who is sexually active is at risk of getting HPV. Women in sub-Saharan Africa region have higher chance of developing the disease. There are nearly 26 million Ethiopian women who are over the age of 15 and believed to be at risk of getting HPV. Regrettably, Ethiopian women typically present for cervical cancer care at a late stage in the disease, where treatment is most ineffective.

Objectives

To explore communities’ perceptions of cervical cancer and screening among women in Wolaita zone, southern Ethiopia.

Methods

A qualitative research using focused group discussions and in-depth interviews was used to explore communities’ perceptions of cervical cancer and screening among women in Wolaita zone, southern Ethiopia from March 2018-November 2019. The study participants were men, women and communities who were residents of the study settings and were not health professionals. All focused group discussions (FGDs) and key informant interviews were transcribed and entered into Microsoft Word and thematic content analysis was done.

Results

A total of fifty-nine participants participated in both FGD (three with men and six with women) and in-depth interviews (IDIs). Most participants have not heard about cervical cancer but know cancer in general. Participants mentioned that the disease usually relates to many births and unprotected sexual intercourse but none mentioned HPV infection. Most of the participants perceive that cervical cancer is incurable and assume that it could be prevented but they think they are not vulnerable to the disease and screening is not necessary.

Conclusion

This study indicates that rural communities in the zone had limited knowledge about cervical cancer and even less about risk factors, screening, treatment and prevention. There is a great need for cancer education and prevention in Ethiopia.

Cervical Cancer Prevention in Low- and Middle-Income Countries

Cervical cancer is one of the commonest cancers afflicting women in low and middle income countries, however, both primary prevention with human papillomavirus vaccination, and secondary prevention with screening programs and treatment of preinvasive disease are possible. A coordinated approach to eliminating cervical cancer, as has been called for by the World Health Organization, requires a complex series of steps at all levels of a health system. This article outlines the current state of cervical cancer prevention in low and middle income countries, the innovations being employed to improve outcomes, and consideration of the next steps needed as we move towards global elimination.

Knowledge on cervical cancer screening and vaccination among females at Oyibi Community

Background

Awareness about cervical cancer screening and vaccination in the developed countries are high as compared to the developing countries. Sixty to eighty percent (60–80%) of the women who develop cervical cancer in sub-Saharan Africa live in the rural areas with inadequate awareness of cervical cancer screening. However, cervical cancer knowledge remained a significant direct predictor of screening behaviors. The study therefore aim to explore the Knowledge on Cervical Cancer Screening and Vaccination among females at Oyibi Community.

Methods

A qualitative exploratory design was employed to purposively recruit 35 participants who were made up of 7 members in a group forming 5 Focus Group discussions in all. Data was retrieved using a semi-structured interview guide.

Results

The study revealed two main themes with 7 subthemes. The two main themes were cervical cancer screening and vaccination knowledge and cervical cancer vaccination effectiveness and cost. The subthemes were; knowledge on cervical cancer screening types, knowledge about cervical cancer screening and vaccination centers, knowledge about how cancer screening is performed, knowledge about cervical cancer vaccination, cervical cancer screening and vaccination sources of information, knowledge about the effectiveness of cervical cancer vaccination and awareness about cervical cancer screening cost and vaccination cost.

Conclusion

Ghanaian women are increasingly becoming aware of cervical cancer, nevertheless low knowledge on screening and vaccination of cervical cancer, and effectiveness was detected with high awareness about the screening and vaccination centers. There is therefore the need for heightened sensitization regarding cervical cancer screening and vaccination in rural communities to help reduce misconceptions and increase patronage rate.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01296-3.

Screening for cervical cancer in Africa: A proposal of a different combination of VIA test and cervical smear in Uganda

OBJECTIVE

To evaluate the efficacy of visual inspection with acetic acid (VIA) screening combined with a cervical smear in Uganda.

METHODS

Nine screening campaigns were held in Uganda between January 2011 and October 2019. In the last three campaigns, a new approach was used: the cervical smear was performed before the VIA test and, in case of a positive VIA test, the slide was sent for examination. The data collected were divided into two groups: the first six campaigns and the last three campaigns.

RESULTS

During the study period, 10 520 women were screened, of whom 911 had a positive VIA test. The VIA test showed 84.2% false positives. In the first group, the VIA test was positive in 516 women, of whom 93% were referred for further examinations. In the second group, the VIA test was positive in 395 women, but the cervical smear was positive in only 65 women. Thus, only 16.5% women were referred for further examinations.

CONCLUSION

Combining cervical smear, VIA test, and slide analysis in positive VIA tests may allow women who need treatment to be selected more effectively, while waiting for other more expensive solutions to become more affordable for this setting.

Evaluating the implementation of cervical cancer screening programs in low-resource settings globally: a systematized review

PURPOSE

Cervical cancer disproportionately burdens low-resource populations where access to quality screening services is limited. A greater understanding of sustainable approaches to implement cervical cancer screening services is needed.

METHODS

We conducted a systematized literature review of evaluations from cervical cancer screening programs implemented in resource-limited settings globally that included a formal evaluation and intention of program sustainment over time. We categorized the included studies using the continuum of implementation research framework which categorizes studies progressively from "implementation light" to more implementation intensive.

RESULTS

Fifty-one of 13,330 initially identified papers were reviewed with most study sites in low-resource settings of middle-income countries (94.1%) ,while 9.8% were in low-income countries. Across all studies, visual inspection of the cervix with acetic acid (58.8%) was the most prevalent screening method followed by cytology testing (39.2%). Demand-side (client and community) considerations were reported in 86.3% of the articles, while 68.6% focused scientific inquiry on the supply side (health service). Eighteen articles (35.3%) were categorized as "Informing Scale-up" along the continuum of implementation research.

CONCLUSIONS

The number of cervical cancer screening implementation reports is limited globally, especially in low-income countries. The 18 papers we classified as Informing Scale-up provide critical insights for developing programs relevant to implementation outcomes. We recommend that program managers report lessons learnt to build collective implementation knowledge for cervical cancer screening services, globally.

Barriers to the Uptake of Cervical Cancer Screening and Treatment among Rural Women in Ghana

Background

This study sought to explore the barriers to the uptake of cervical cancer screening and treatment in the North Tongu district of Ghana.

Methods

Twenty-five in-depth interviews were conducted, while three focus group discussions were held among respondents. The data were analysed with the R package for qualitative data analysis using a thematic analytical approach.

Results

Low level of knowledge about the disease and screening services, personal or psychological convictions, and cost of screening and treatment coupled with a low level of income were the barriers at the individual level. Perceived health personnel attitude, perceived lack of privacy, and misdiagnosis were the barriers at the institutional level while the sociocultural belief system of the communities about the etiology of the disease was the barrier at the community level. Inadequate education about the disease, lack of funding and access to screening facilities also constrained screening and treatment at the policy level.

Conclusions

Cervical cancer screening and treatment are constrained at multiple levels in rural Ghana. This study underscores the need to address the low uptake of cervical cancer screening and treatment at the individual, community, institutional, and policy levels simultaneously.

Awareness and Beliefs About Cervical Cancer, the HPV Vaccine, and Cervical Cancer Screening Among Ghanaian Women with Diverse Education Levels

Cervical cancer is the leading cause of cancer death among women in Ghana. Cost-effective tools for the primary and secondary prevention of cervical cancer, such as the Pap test, the HPV DNA test, and the HPV vaccine, are available in hospitals and clinics throughout Ghana. However, participation in cervical cancer prevention behaviors is low among Ghanaian women. Our objective was to determine if there were significant differences in cervical cancer awareness and stigmatizing beliefs about women with cervical cancer between Ghanaian women of different education levels. We surveyed 288 Ghanaian women who were at least 18 years old. Data on the participants' demographic characteristics, awareness of cervical cancer, cervical cancer screening, and the HPV vaccine, beliefs about cervical cancer screening, and stigmatizing beliefs about women with cervical cancer was collected. Chi-square tests for independence and Fisher's exact test of independence were preformed to determine if education level was associated with those factors. Participation in cervical cancer screening and uptake of the HPV vaccine was significantly lower among women with less than a senior high school education. Awareness about cervical cancer, cervical cancer screening, and the HPV vaccine was lower among women with less education. Women with lower levels of education were more likely to agree with the negative statements about cervical cancer screening and stigmatizing beliefs about women with cervical cancer. Cervical cancer education interventions that are tailored for Ghanaian women with different educational levels are needed to increase awareness of and participation in cervical cancer prevention strategies.

Cervical cancer screening decentralized policy adaptation: an African rural-context-specific systematic literature review

Background: Worldwide, nearly 570,000 women are diagnosed with cervical cancer each year, with 85% of new cases in low- and middle-income countries. The African continent is home to 35 of 40 countries with the highest cervical cancer mortality rates. In 2014, a partnership involving a rural region of Senegal, West Africa, was facing cervical cancer screening service sustainability barriers and began adapting regional-level policy to address implementation challenges.

Objective: This manuscript reports the findings of a systematic literature review describing the implementation of decentralized cervical cancer prevention services in Africa, relevant in context to the Senegal partnership. We report barriers and policy-relevant recommendations through Levesque’s Patient-Centered Access to Healthcare Framework and discuss the impact of this information on the partnership’s approach to shaping Senegal’s regional cervical cancer screening policy.

Methods: The systematic review search strategy comprised two complementary sub-searches. We conducted an initial search identifying 4272 articles, then applied inclusion criteria, and ultimately 19 studies were included. Data abstraction focused on implementation barriers categorized with the Levesque framework and by policy relevance.

Results: Our findings identified specific demand-side (clients and community) and supply-side (health service-level) barriers to implementation of cervical cancer screening services. We identify the most commonly reported demand- and supply-side barriers and summarize salient policy recommendations discussed within the reviewed literature.

Conclusions: Overall, there is a paucity of published literature regarding barriers to and best practices in implementation of cervical cancer screening services in rural Africa. Many articles in this literature review did describe findings with notable policy implications. The Senegal partnership has consulted this literature when faced with various similar barriers and has developed two principal initiatives to address contextual challenges. Other initiatives implementing cervical cancer visual screening services in decentralized areas may find this contextual reporting of a literature review helpful as a construct for identifying evidence for the purpose of guiding ongoing health service policy adaptation.

Acceptability and implementation challenges of smartphone-based training of community health nurses for visual inspection with acetic acid in Ghana: mHealth and cervical cancer screening

OBJECTIVE

To explore acceptability and feasibility of smartphone-based training of low-level to mid-level health professionals in cervical cancer screening using visual inspection with acetic acid (VIA)/cervicography.

DESIGN

In 2015, we applied a qualitative descriptive approach and conducted semi-structured interviews and focus groups to assess the perceptions and experiences of community health nurses (CHNs) (n=15) who performed smartphone-based VIA, patients undergoing VIA/cryotherapy (n=21) and nurse supervisor and the expert reviewer (n=2).

SETTING

Community health centres (CHCs) in Accra, Ghana.

RESULTS

The 3-month smartphone-based training and mentorship was perceived as an important and essential complementary process to further develop diagnostic and management competencies. Cervical imaging provided peer-to-peer learning opportunities, and helped better communicate the procedure to and gain trust of patients, provide targeted education, improve adherence and implement quality control. None of the patients had prior screening; they overwhelmingly accepted smartphone-based VIA, expressing no significant privacy issues. Neither group cited significant barriers to performing or receiving VIA at CHCs, the incorporation of smartphone imaging and mentorship via text messaging. CHNs were able to leverage their existing community relationships to address a lack of knowledge and misperceptions. Patients largely expressed decision-making autonomy regarding screening. Negative views and stigma were present but not significantly limiting, and the majority felt that screening strategies were acceptable and effective.

CONCLUSIONS

Our findings suggest the overall acceptability of this approach from the perspectives of all stakeholders with important promises for smartphone-based VIA implementation. Larger-scale health services research could further provide important lessons for addressing this burden in low-income and middle-income countries.

Early experiences in integrating cervical cancer screening and treatment into HIV services in Zomba Central Hospital, Malawi

Background

Malawi has the highest rate of cervical cancer globally and cervical cancer is six to eight times more common in women with HIV. HIV programmes provide an ideal setting to integrate cervical cancer screening.

Methods

Tisungane HIV clinic at Zomba Central Hospital has around 3,700 adult women receiving treatment. In October 2015, a model of integrated cervical cancer screening using visual inspection with acetic acid (VIA) was adopted. All women aged 20 and above in the HIV clinic were asked if they had cervical cancer screening in the past three years and, if not, were referred for screening. Screening was done daily by nurses in a room adjacent to the HIV clinic. Cold coagulation was used to treat pre-cancerous lesions. From October 2016, a modification to the HIV programme's electronic medical record was developed that assisted in matching numbers of women sent for screening with daily screening capacity and alerted providers to women with pre-cancerous lesions who missed referrals or treatment.

Results

Between May 2016 and March 2017, cervical cancer screening was performed in 957 women from the HIV clinic. Of the 686 (71%) women who underwent first ever screening, 23 (3.4%) were found to have VIA positive lesions suggestive of pre-cancer, of whom 8 (35%) had a same-day cold coagulation procedure, seven (30%) deferred cold coagulation to a later date (of whom 4 came for treatment), and 8 (35%) were referred to surgery due to size of lesion; 5/686 (0.7%) women had lesions suspicious of cancer.

Conclusion

Incorporating cervical cancer screening into services at HIV clinics is feasible. A structured approach to screening in the HIV clinic was important.

Urban-rural disparity in cervical cancer in China and feasible interventions for tackling the rural excess

According to GLOBOCAN 2012, age-standardized incidence rate (ASIR) of cervical cancer in developed and less developed countries is 9.9 vs. 15.7 per 100,000 population per year. This disparity is related to inequity in access to screening. Urban rural disparity in access to cervical cancer screening is similar in China. We aim to assess urban rural disparity in ASIR.Using population-based tumor registration data collected by us in urban Shijiazhuang city (with incidence data available for 1,217,437 women in 2012) and in Shexian County (with incidence data available for 197,416 women since 2000), we compared ASIR of cervical cancer between the two populations in 2012. We also analyzed the trend of biennial ASIR and averaged age at diagnosis of cervical cancer for 2000-2015 in Shexian County during which China was undergoing rapid changes in sexual mores. Finally, using previously published national death survey data, we compared age-standardized mortality rate (ASMR) of cervical cancer between Shijiazhuang city and Shexian County over the periods of 1973-1975 and 1990-1992.It was found that the ASIR of cervical cancer in rural Shexian County is 3 times higher than in Shijiazhuang city in 2012 (25.0 vs. 8.4 per 100,000 per year, P < .01); and the corresponding ASMR was 2 times higher over the period of 1973-1975 (25.0 vs. 13.0 per 100,000 per year, P < .01) and 8 times higher over the period of 1990-1992 (9.8 vs. 1.2 per 100,000 per year, P < .01). From 2000 to 2015 along with rapid changes in sexual behavior, the biennial ASIR of cervical cancer increased by +3.2% on average, from 19.3 to 28.5 per 100,000 per year (P < .01), and the biennial averaged age at diagnosis decreased from 55.8 to 52.1 (P < .01).Urban-rural disparity in ASIR of cervical cancer in present study is larger than that reported between developed and less developed countries in GLOBOCAN 2012, in which the disparity is considered "due to differences in access to screening." As in China, cytologists and infrastructure required for cervical cancer screening are similarly lacking in rural areas, we suggest cytological screening for cervical cancer be strengthened in disadvantaged rural settings.

Expanding the Single-Visit Approach for Cervical Cancer Prevention: Successes and Lessons From Burkina Faso

The single-visit approach was implemented with strong attention to systems in 14 health facilities. In the 2 largest facilities, nearly 14,000 women screened for cervical cancer over 4 years. Of approximately 9% who screened positive, about 66% received same-day cryotherapy. Attention is needed to ensure local technicians can repair cryotherapy equipment, supplies are consistently in stock, and user fees are not prohibitive to accessing care.

Background:

Cervical cancer accounts for 23% of cancer incidence and 22% of cancer mortality among women in Burkina Faso. These proportions are more than 2 and 5 times higher than those of developed countries, respectively. Before 2010, cervical cancer prevention (CECAP) services in Burkina Faso were limited to temporary screening campaigns.

Program Description:

Between September 2010 and August 2014, program implementers collaborated with the Ministry of Health and professional associations to implement a CECAP program focused on coupling visual inspection with acetic acid (VIA) for screening with same-day cryotherapy treatment for eligible women in 14 facilities. Women with larger lesions or lesions suspect for cancer were referred for loop electrosurgical excision procedure (LEEP). The program trained providers, raised awareness through demand generation activities, and strengthened monitoring capacity.

Methods:

Data on program activities, service provision, and programmatic lessons were analyzed. Three data collection tools, an individual client form, a client registry, and a monthly summary sheet, were used to track 3 key CECAP service indicators: number of women screened using VIA, proportion of women who screened VIA positive, and proportion of women screening VIA positive who received same-day cryotherapy.

Results:

Over 4 years, the program screened 13,999 women for cervical cancer using VIA; 8.9% screened positive; and 65.9% received cryotherapy in a single visit. The proportion receiving cryotherapy on the same day started at a high of 82% to 93% when services were provided free of charge, but dropped to 51% when a user fee of $10 was applied to cover the cost of supplies. After reducing the fee to $4 in November 2012, the proportion increased again to 78%. Implementation challenges included difficulties tracking referred patients, stock-outs of key supplies, difficulties with machine maintenance, and prohibitive user fees. Providers were trained to independently monitor services, identify gaps, and take corrective actions.

Conclusions:

Following dissemination of the results that demonstrated the acceptability and feasibility of the CECAP program, the Burkina Faso Ministry of Health included CECAP services in its minimum service delivery package in 2016. Essential components for such programs include provider training on VIA, cryotherapy, and LEEP; provider and patient demand generation; local equipment maintenance; consistent supply stocks; referral system for LEEP; non-prohibitive fees; and a monitoring data collection system.

Barriers and Facilitators to Cervical Cancer Screening, Diagnosis, Follow-Up Care and Treatment: Perspectives of Human Immunodeficiency Virus-Positive Women and Health Care Practitioners in Tanzania

BACKGROUND

This study was conducted to identify barriers and facilitators to cervical cancer screening, diagnosis, follow-up care, and treatment among human immunodeficiency virus (HIV)-infected women and clinicians and to explore the acceptability of patient navigators in Tanzania.

MATERIALS AND METHODS

In 2012, we conducted four focus groups, two with HIV-positive women and two with clinicians who perform cervical cancer screening, diagnosis, follow-up care, and treatment. Transcriptions were analyzed using thematic analysis.

RESULTS

Findings from the patient focus groups indicate the prevalence of fear and stigma surrounding cervical cancer as well as a lack of information and access to screening and treatment. The clinician focus groups identified numerous barriers to screening, diagnosis, follow-up care, and treatment. Participants in both types of groups agreed that a patient navigation program would be an effective way to help women navigate across the cancer continuum of care including screening, diagnosis, follow-up care, and treatment.

CONCLUSION

Given the fear, stigma, misinformation, and lack of resources surrounding cervical cancer, it is not surprising that patient navigation would be welcomed by patients and providers.

IMPLICATIONS FOR PRACTICE

This article identifies specific barriers to cervical cancer screening and treatment from the perspectives of both clinicians and patients in Tanzania and describes the acceptability of the concept of patient navigation.

A systematic review and meta-analysis of studies evaluating the performance of point-of-care tests for human papillomavirus screening

BACKGROUND

High-risk human papillomavirus (HPV) is a necessary cause of high-grade cervical intraepithelial neoplasia (grade 2 or higher, CIN2+). Simplified and rapid HPV DNA assays designed for use in resource-limited settings have recently become available.

METHODS

We performed a systematic review and meta-analysis by searching Medline, Embase, Global Health and CINAHL databases for studies from 1 January 2004 to 25 February 2017 that reported the performance of careHPV or OncoE6 for the detection of histological CIN2+ in cervical cancer screening. We used bivariate models to estimate pooled sensitivity and specificity for CIN2+ and CIN3+.

RESULTS

A total of 29 657 women were included from seven studies evaluating the performance of careHPV for the detection of CIN2+ and four studies among 27 845 women for the detection of CIN3+. The pooled prevalence for CIN2+ and CIN3+ was 2.3% and 1.1%, respectively. careHPV had sensitivity and specificity of 88.1% (95% CI 81.4 to 92.7) and 83.7% (95% CI 74.9 to 89.8), respectively, for CIN2+ and 90.3% (95% CI 83.4 to 94.5) and 85.3% (95% CI 73.1 to 92.5), respectively, for CIN3+, using clinician-collected cervical specimen. The corresponding pooled estimates using self-collected vaginal swabs were 73.6% (95% CI 64.9 to 80.8) and 88.0% (95% CI 79.1 to 93.5) for CIN2+ and 75.2% (95% CI 66.8 to 82.0) and 90.6% (95% CI 83.4 to 94.9) for CIN3+. Two studies using OncoE6 reported sensitivity and specificity ranging from 31.3% to 42.4% and 99.1%-99.4% for CIN2+, and 53.5% and 98.9% for CIN3+ for one study.

CONCLUSION

CareHPV has good sensitivity and specificity for the detection of CIN2+ and CIN3+, but sensitivity was lower using self-collected vaginal samples. The specificity is lower in high HPV prevalence populations such as women living with HIV. OncoE6 assay warrants further evaluation.

Integrating cervical cancer screening and preventive treatment with family planning and HIV-related services

Cervical cancer is a leading cause of mortality in Sub-Saharan Africa-in large part because of inadequate coverage of screening and preventive treatment services. A number of programs have begun integrating cervical cancer prevention services into existing family planning or HIV/AIDS service delivery platforms, to rapidly expand "screen and treat" programs and mitigate cervical cancer burden. Drawing upon a review of literature and our experiences, we consider benefits and challenges associated with such programs in Sub-Saharan Africa. We then outline steps that can optimize uptake and sustainability of integrated sexual and reproductive health services. These include increasing coordination among implementing organizations for efficient use of resources; task shifting for services that can be provided by nonphysicians; mobilizing communities via trusted frontline health workers; strengthening management information systems to allow for monitoring of multiple services; and prioritizing an operational research agenda to provide further evidence on the cost-effectiveness and benefits of integrated service delivery.

Evidence-based policy choices for efficient and equitable cervical cancer screening programs in low-resource settings

Women in developing countries disproportionately bear the burden of cervical cancer. The availability of prophylactic vaccines against human papillomavirus (HPV) types 16 and 18, which cause approximately 70% of cervical cancers, provides reason for optimism as roll-out begins with support from Gavi, the Vaccine Alliance. However, for the hundreds of millions of women beyond the target age for HPV vaccination, cervical cancer screening to detect and treat precancerous lesions remains the only form of prevention. Here we describe the challenges that confront screening programs in low-resource settings, including (1) optimizing screening test effectiveness; (2) achieving high screening coverage of the target population; and (3) managing screen-positive women. For each of these challenges, we summarize the tradeoffs between resource utilization and programmatic attributes. We then highlight opportunities for efficient and equitable programming, with supporting evidence from recent mathematical modeling analyses informed by data from the PATH demonstration projects in India, Nicaragua, and Uganda.

mHealth to Train Community Health Nurses in Visual Inspection With Acetic Acid for Cervical Cancer Screening in Ghana

OBJECTIVE

There is a shortage of trained health care personnel for cervical cancer screening in low-/middle-income countries. We evaluated the feasibility and limited efficacy of a smartphone-based training of community health nurses in visual inspection of the cervix under acetic acid (VIA).

MATERIALS AND METHODS

During April to July 2015 in urban Ghana, we designed and developed a study to determine the feasibility and efficacy of an mHealth-supported training of community health nurses (CHNs, n = 15) to perform VIA and to use smartphone images to obtain expert feedback on their diagnoses within 24 hours and to improve VIA skills retention. The CHNs completed a 2-week on-site introductory training in VIA performance and interpretation, followed by an ongoing 3-month text messaging-supported VIA training by an expert VIA reviewer.

RESULTS

Community health nurses screened 169 women at their respective community health centers while receiving real-time feedback from the reviewer. The total agreement rate between all VIA diagnoses made by all CHNs and the expert reviewer was 95%. The mean (SD) rate of agreement between each CHN and the expert reviewer was 89.6% (12.8%). The agreement rates for positive and negative cases were 61.5% and 98.0%, respectively. Cohen κ statistic was 0.67 (95% CI = 0.45-0.88). Around 7.7% of women tested VIA positive and received cryotherapy or further services.

CONCLUSIONS

Our findings demonstrate the feasibility and efficacy of mHealth-supported VIA training of CHNs and have the potential to improve cervical cancer screening coverage in Ghana.

Interventions to close the divide for women with breast and cervical cancer between low-income and middle-income countries and high-income countries

Breast and cervical cancers are the commonest cancers diagnosed in women living in low-income and middle-income countries (LMICs), where opportunities for prevention, early detection, or both, are few. Yet several cost-effective interventions could be used to reduce the burden of these two cancers in resource-limited environments. Population- wide vaccination against human papillomavirus (HPV) linked to cervical screening, at least once, for adult women has the potential to reduce the incidence of cervical cancer substantially. Strategies such as visual inspection with acetic acid and testing for oncogenic HPV types could make prevention of cervical cancer programmatically feasible. These two cancers need not be viewed as inevitably fatal, and can be cured, particularly if detected and treated at an early stage. Investing in the health of girls and women is an investment in the development of nations and their futures. Here we explore ways to lessen the divide between LMICs and high-income countries for breast and cervical cancers.

Implementing visual cervical cancer screening in Senegal: a cross-sectional study of risk factors and prevalence highlighting service utilization barriers

BACKGROUND

Senegal ranks 15th in the world in incidence of cervical cancer, the number one cause of cancer mortality among women in this country. The estimated participation rate for cervical cancer screening throughout Senegal is very low (6.9% of women 18-69 years old), especially in rural areas and among older age groups (only 1.9% of women above the age of 40 years). There are no reliable estimates of the prevalence of cervical dysplasia or risk factors for cervical dysplasia specific to rural Senegal. The goals of this study were to estimate the prevalence of cervical dysplasia in a rural region using visual inspection of the cervix with acetic acid (VIA) and to assess risk factors for cervical cancer control.

PATIENTS AND METHODS

We conducted a cross-sectional study in which we randomly selected 38 villages across the Kédougou region using a three-stage clustering process. Between October 2013 and March 2014, we collected VIA screening results for women aged 30-50 years and cervical cancer risk factors linked to the screening result.

RESULTS

We screened 509 women; 5.6% of the estimated target population (9,041) in the region. The point prevalence of cervical dysplasia (positive VIA test) was 2.10% (95% confidence interval [CI]: 0.99-3.21). Moreover, 287 women completed the cervical cancer risk factor survey (56.4% response rate) and only 38% stated awareness of cervical cancer; 75.9% of the screened women were less than 40 years of age.

CONCLUSION

The overall prevalence of dysplasia in this sample was lower than anticipated. Despite both overall awareness and screening uptake being less than expected, our study highlights the need to address challenges in future prevalence estimates. Principally, we identified that the highest-risk women are the ones least likely to seek screening services, thus illustrating a need to fully understand demand-side barriers to accessing health services in this population. Targeted efforts to educate and motivate older women to seek screenings are needed to sustain an effective cervical cancer screening program.

Knowledge and Awareness of Cervical Cancer among HIV-Infected Women in Ethiopia

Introduction. Cervical cancer is one of the leading causes of cancer death among Ethiopian women. Low awareness of cervical cancer, in combination with low health care seeking behavior, is a key challenge for cervical cancer prevention. This study assessed the knowledge of cervical cancer among HIV-infected women in Ethiopia. Methods. A facility-based cross-sectional survey was conducted from August to September 2012 among HIV-infected women between 21 and 49 years of age. Basic descriptive statistics were performed using SPSS. Results. A total of 432 HIV-infected women participated in this study. About 71% of participants had ever heard of cervical cancer. Among women who had ever heard of cervical cancer, 49% did not know the cause while 74% were able to identify at least one risk factor for cervical cancer. Only 33% of women were able to correctly address when women should seek care and 33% identified at least one treatment option for cervical cancer. Conclusion. This study revealed that knowledge about cervical cancer was generally low, in particular for health care seeking behavior and treatment of cervical cancer. Health awareness programs should be strengthened at both community and health facility levels with emphasis highlighting the causes, risk factors, care seeking behaviors, and treatment options for cervical cancer.

A Low-Cost HPV Immunochromatographic Assay to Detect High-Grade Cervical Intraepithelial Neoplasia

Objective

To evaluate the reproducibility and accuracy of the HPV16/18-E6 test.

Methods

The study population was comprised of 448 women with a previously abnormal Pap who were referred to the Barretos Cancer Hospital (Brazil) for diagnosis and treatment. Two cervical samples were collected immediately before colposcopy, one for the hr-HPV-DNA test and cytology and the other for the HPV16/18-E6 test using high-affinity monoclonal antibodies (mAb). Women with a histologic diagnosis of cervical intraepithelial neoplasia grade 2 or 3 were considered to be positive cases. Different strategies using a combination of screening methods (HPV-DNA) and triage tests (cytology and HPV16/18-E6) were also examined and compared.

Results

The HPV16/18-E6 test exhibited a lower positivity rate compared with the HPV-DNA test (19.0% vs. 29.3%, p<0.001) and a moderate/high agreement (kappa = 0.68, 95%CI: 0.60–0.75). It also exhibited a significantly lower sensitivity for CIN2+ and CIN3+ detection compared to the HPV-DNA test and a significantly higher specificity. The HPV16/18-E6 test was no different from cytology in terms of sensitivity, but it exhibited a significantly higher specificity in comparison to ASCH+. A triage test after HPV-DNA detection using the HPV16/18-E6 test exhibited a significantly higher specificity compared with a triage test of ASCH+ to CIN2+ (91.8% vs. 87.4%, p = 0.04) and CIN3+ (88.6% vs. 84.0%, p = 0.05).

Conclusion

The HPV16/18-E6 test exhibited moderate/high agreement with the HPV-DNA test but lower sensitivity and higher specificity for the detection of CIN2+ and CIN3+. In addition, its performance was quite similar to cytology, but because of the structural design addressed for the detection of HPV16/18-E6 protein, the test can miss some CIN2/3+ lesions caused by other high-risk HPV types.

Prevalence, Predictors, and Same Day Treatment of Positive VIA Enhanced by Digital Cervicography and Histopathology Results in a Cervical Cancer Prevention Program in Cameroon

Background

In 2007, the Cameroon Baptist Convention Health Services (CBCHS) implemented a screen-and-treat cervical cancer prevention program using visual inspection with acetic acid enhanced by digital cervicography (VIA-DC).

Methods

We retrospectively analyzed 46,048 medical records of women who received care through the CBCHS Women’s Health Program from 2007 through 2014 to determine the prevalence and predictors of positive VIA-DC, rates of same day treatment, and cohort prevalence of invasive cervical cancer (ICC).

Results

Of the 44,979 women who were screened for cervical cancer, 9.0% were VIA-DC-positive, 66.8% were VIA-DC-negative, 22.0% were VIA-DC-inadequate (normal ectocervix, but portions of the transformation zone were obscured), and 2.2% were VIA-DC-uncertain (cervical abnormalities confounding VIA-DC interpretation). Risk factors significantly associated with VIA-DC-positive screen were HIV-positivity, young age at sexual debut, higher lifetime number of sexual partners, low education status and higher gravidity. In 2014, 31.1% of women eligible for cryotherapy underwent same day treatment. Among the 32,788 women screened from 2007 through 2013, 201 cases of ICC were identified corresponding to a cohort prevalence of 613 per 100,000.

Conclusions

High rate of VIA-DC-positive screens suggests a significant burden of potential cervical cancer cases and highlights the need for expansion of cervical cancer screening and prevention throughout the 10 regions of Cameroon. VIA-DC-inadequate rates were also high, especially in older women, and additional screening methods are needed to confirm whether these results are truly negative. In comparison to similar screening programs in sub-Saharan Africa there was low utilization of same day cryotherapy treatment. Further studies are required to characterize possible program specific barriers to treatment, for example cultural demands, health system challenges and cost of procedure. The prevalence of ICC among women who presented for screening was high and requires further investigation.

Cervical cancer prevention and treatment research in Africa: a systematic review from a public health perspective

BACKGROUND

Women living in Africa experience the highest burden of cervical cancer. Research and investment to improve vaccination, screening, and treatment efforts are critically needed. We systematically reviewed and characterized recent research within a broader public health framework to organize and assess the range of cervical cancer research in Africa.

METHODS

We searched online databases and the Internet for published articles and cervical cancer reports in African countries. Inclusion criteria included publication between 2004 and 2014, cervical cancer-related content pertinent to one of the four public health categories (primary, secondary, tertiary prevention or quality of life), and conducted in or specifically relevant to countries or regions within the African continent. The study design, geographic region/country, focus of research, and key findings were documented for each eligible article and summarized to illustrate the weight and research coverage in each area. Publications with more than one focus (e.g. secondary and tertiary prevention) were categorized by the primary emphasis of the paper. Research specific to HIV-infected women or focused on feasibility issues was delineated within each of the four public health categories.

RESULTS

A total of 380 research articles/reports were included. The majority (54.6 %) of cervical cancer research in Africa focused on secondary prevention (i.e., screening). The number of publication focusing on primary prevention (23.4 %), particularly HPV vaccination, increased significantly in the past decade. Research regarding the treatment of precancerous lesions and invasive cervical cancer is emerging (17.6 %), but infrastructure and feasibility challenges in many countries have impeded efforts to provide and evaluate treatment. Studies assessing aspects of quality of life among women living with cervical cancer are severely limited (4.1 %). Across all categories, 11.3 % of publications focused on cervical cancer among HIV-infected women, while 17.1 % focused on aspects of feasibility for cervical cancer control efforts.

CONCLUSIONS

Cervical cancer research in African countries has increased steadily over the past decade, but more is needed. Tertiary prevention (i.e. treatment of disease with effective medicine) and quality of life of cervical cancer survivors are two severely under-researched areas. Similarly, there are several countries in Africa with little to no research ever conducted on cervical cancer.

The Single-Visit Approach as a Cervical Cancer Prevention Strategy Among Women With HIV in Ethiopia: Successes and Lessons Learned

With the single-visit approach for cervical cancer prevention, women with positive “visual inspection of the cervix with acetic acid wash” (VIA) test results receive immediate treatment of the precancerous lesion with cryotherapy. The approach worked successfully for women with HIV in Ethiopia in secondary and tertiary health facilities, with high screening and cryotherapy treatment rates. Sustainability and appropriate scale-up of such programs must address wider health system challenges including human resource constraints and shortage of essential supplies.

Introduction:

Cervical cancer is the second most common form of cancer for women in Ethiopia. Using a single-visit approach to prevent cervical cancer, the Addis Tesfa (New Hope) project in Ethiopia tested women with HIV through visual inspection of the cervix with acetic acid wash (VIA) and, if tests results were positive, offered immediate cryotherapy of the precancerous lesion or referral for loop electrosurgical excision procedure (LEEP). The objective of this article is to review screening and treatment outcomes over nearly 4 years of project implementation and to identify lessons learned to improve cervical cancer prevention programs in Ethiopia and other resource-constrained settings.

Methods:

We analyzed aggregate client data from August 2010 to March 2014 to obtain the number of women with HIV who were counseled, screened, and treated, as well as the number of annual follow-up visits made, from the 14 tertiary- and secondary-level health facilities implementing the single-visit approach. A health facility assessment (HFA) was also implemented from August to December 2013 to examine the effects of the single-visit approach on client flow, staff workload, and facility infrastructure 3 years after initiating the approach.

Results:

Almost all (99%) of the 16,632 women with HIV counseled about the single-visit approach were screened with VIA during the study period; 1,656 (10%) of them tested VIA positive (VIA+) for precancerous lesions. Among those who tested VIA+ and were thus eligible for cryotherapy, 1,481 (97%) received cryotherapy treatment, but only 80 (63%) women eligible for LEEP actually received the treatment. The HFA results showed frequent staff turnover, some shortage of essential supplies, and rooms that were judged by providers to be too small for delivery of cervical cancer prevention services.

Conclusion:

The high proportions of VIA screening and cryotherapy treatment in the Addis Tesfa project suggest high acceptance of such services by women with HIV and feasibility of implementation in secondary- and tertiary-level health facilities. However, success of cervical cancer prevention programming must address wider health system challenges to ensure sustainability and appropriate scale-up to the general population of Ethiopia and other resource-constrained settings.

Qualitative study of barriers to cervical cancer screening among Nigerian women

OBJECTIVES

To explore the barriers to cervical cancer screening, focusing on religious and cultural factors, in order to inform group-specific interventions that may improve uptake of cervical cancer screening programmes.

DESIGN

We conducted four focus group discussions among Muslim and Christian women in Nigeria.

SETTING

Discussions were conducted in two hospitals, one in the South West and the other in the North Central region of Nigeria.

PARTICIPANTS

27 Christian and 22 Muslim women over the age of 18, with no diagnosis of cancer.

RESULTS

Most participants in the focus group discussions had heard about cervical cancer except Muslim women in the South Western region who had never heard about cervical cancer. Participants believed that wizardry, multiple sexual partners and inserting herbs into the vagina cause cervical cancer. Only one participant knew about the human papillomavirus. Among the Christian women, the majority of respondents had heard about cervical cancer screening and believed that it could be used to prevent cervical cancer. Participants mentioned religious and cultural obligations of modesty, gender of healthcare providers, fear of disclosure of results, fear of nosocomial infections, lack of awareness, discrimination at hospitals, and need for spousal approval as barriers to uptake of screening. These barriers varied by religion across the geographical regions.

CONCLUSIONS

Barriers to cervical cancer screening vary by religious affiliations. Interventions to increase cervical cancer awareness and screening uptake in multicultural and multireligious communities need to take into consideration the varying cultural and religious beliefs in order to design and implement effective cervical cancer screening intervention programmes.

Cervical Cancer Screening in the United States-Affiliated Pacific Islands: Options and Opportunities

OBJECTIVE

Successful cervical cancer screening in the United States-Affiliated Pacific Islands (USAPI) is limited by geographic, political, economic, and logistic factors. An expert panel convened to examine screening in each of the 6 island jurisdictions and to explore options beyond cytology-based screening.

MATERIALS AND METHODS

Forty-one representatives of American Congress of Obstetrics and Gynecology, American Society for Colposcopy and Cervical Pathology, government agencies, the World Health Organization, Pan American Health Organization, health representatives of the 6 Pacific island jurisdictions, Puerto Rico, and several academic institutions met in a 2-day meeting to explore options to improve access and coverage of cervical cancer screening in the USAPI.

RESULTS

Cytology-based screening is less widely accessed and less successful in the USAPI than in the United States in general. Barriers include geographic isolation, cultural factors, and lack of resources. Cytology-based screening requires multiple visits to complete the process from screening to treatment. Screen-and-treat regimens based on visual inspection with acetic acid or human papillomavirus requiring 1 or 2 visits have the potential to improve cervical cancer prevention in the USAPI.

CONCLUSIONS

The standard US algorithm of cytology screening followed by colposcopy and treatment is less effective in geographically and culturally isolated regions such as the USAPI. Alternate technologies, both high tech, such as primary human papillomavirus screening, and low tech, such as visual inspection with acetic acid, have shown promise in resource-poor countries and may have applicability in these US jurisdictions.

Perception and satisfaction of cervical cancer screening by Visual Inspection with Acetic acid (VIA) at Meknes-Tafilalet Region, Morocco: a population-based cross-sectional study

BACKGROUND

This study aims to explore the perception and satisfaction of cervical cancer screening by Visual Inspection with Acetic acid (VIA) in Meknes-Tafilalet Region among target women.

METHODS

A cross-sectional study was conducted using face-to-face interviews with women, routinely attending health centers, who met the inclusion criteria. Descriptive analysis was undertaken to report data.

RESULTS

A total of 324 women were included in the study. Results revealed low awareness about cervical cancer (19.6 %) and a very high acceptability of VIA screening (94.5 %). Of the 306 women screened, 99 % stated that they would recommend the VIA testing to their friends and female relatives. All those women who were screened negative expressed their intent to repeat the test every three years. Those found VIA positive affirmed they would perform confirmatory explorations. The majority (96.3 %) of the women believed that screening by VIA could save their lives; cervical cancer was a concern for 98.6 %; and only 11.6 % felt anxious about repeating the VIA test. The majority of women (98.6 %) were satisfied with the service received at the health center.

CONCLUSIONS

This study showed that the participants had a strong perception about cervical cancer screening and were willing to have further confirmation or future retests.

Cervical Cancer Screening Program by Visual Inspection: Acceptability and Feasibility in Health Insurance Companies

Objective. To assess willingness to participate and diagnostic accuracy of visual inspection for early detection of cervical neoplasia among women in a health insurance company. Patients and Method. Cervical cancer screening was systematically proposed to 800 women after consecutive information and awareness sessions. The screening method was visual inspection with acetic acid (VIA) or Lugol's iodine (VILI). Results. Among the 800 identified women, 640 (82%) have accepted the screening, their mean age was 39 years, and 12.0% of them were involved in a polygamist couple. 28.2% of women had prior cervical screening. VIA has been detected positive in 5.9% of women versus 8.6% for VILI. The sensitivity was 72.9% and specificity was 95.2% for VIA versus 71.2% and 97.3% for VILI respectively. The histological examination highlighted a nonspecific chronic cervicitis in 4.6%, CIN1 lesions in 5.91%, and CIN2/3 in 1.2% of the cases. Conclusion. Cervical cancer screening by visual inspection showed appropriate diagnostic accuracy when used to detect early cervical lesions. It is a simple and easy to perform method that could be introduced progressively in the health insurance policy while waiting for a national screening program.

Performance of alternative strategies for primary cervical cancer screening in sub-Saharan Africa: systematic review and meta-analysis of diagnostic test accuracy studies

OBJECTIVE

To assess and compare the accuracy of visual inspection with acetic acid (VIA), visual inspection with Lugol's iodine (VILI), and human papillomavirus (HPV) testing as alternative standalone methods for primary cervical cancer screening in sub-Saharan Africa.

DESIGN

Systematic review and meta-analysis of diagnostic test accuracy studies.

DATA SOURCES

Systematic searches of multiple databases including Medline, Embase, and Scopus for studies published between January 1994 and June 2014.

REVIEW METHODS

Inclusion criteria for studies were: alternative methods to cytology used as a standalone test for primary screening; study population not at particular risk of cervical cancer (excluding studies focusing on HIV positive women or women with gynaecological symptoms); women screened by nurses; reference test (colposcopy and directed biopsies) performed at least in women with positive screening results. Two reviewers independently screened studies for eligibility and extracted data for inclusion, and evaluated study quality using the quality assessment of diagnostic accuracy studies 2 (QUADAS-2) checklist. Primary outcomes were absolute accuracy measures (sensitivity and specificity) of screening tests to detect cervical intraepithelial neoplasia grade 2 or worse (CIN2+).

RESULTS

15 studies of moderate quality were included (n=61,381 for VIA, n=46,435 for VILI, n=11,322 for HPV testing). Prevalence of CIN2+ did not vary by screening test and ranged from 2.3% (95% confidence interval 1.5% to 3.3%) in VILI studies to 4.9% (2.7% to 7.8%) in HPV testing studies. Positivity rates of VILI, VIA, and HPV testing were 16.5% (9.8% to 24.7%), 16.8% (11.0% to 23.6%), and 25.8% (17.4% to 35.3%), respectively. Pooled sensitivity was higher for VILI (95.1%; 90.1% to 97.7%) than VIA (82.4%; 76.3% to 87.3%) in studies where the reference test was performed in all women (P<0.001). Pooled specificity of VILI and VIA were similar (87.2% (78.1% to 92.8%) v 87.4% (77.1% to 93.4%); P=0.85). Pooled sensitivity and specificity were similar for HPV testing versus VIA (both P ≥ 0.23) and versus VILI (both P ≥ 0.16). Accuracy of VIA and VILI increased with sample size and time period.

CONCLUSIONS

For primary screening of cervical cancer in sub-Saharan Africa, VILI is a simple and affordable alternative to cytology that demonstrates higher sensitivity than VIA. Implementation studies are needed to assess the effect of these screening strategies on the incidence and outcomes of cervical cancer in the region.

Mexican Cervical Cancer Screening Study II: 6-month and 2-year follow-up of HR-HPV women treated with cryotherapy in a low-resource setting

OBJECTIVE

To determine the efficacy and tolerance of cryotherapy in a visual inspection with acetic acid (VIA) triage protocol after primary human papillomavirus (HPV) screening in a low-resource setting.

MATERIALS AND METHODS

This continuous series conducted over 2 years enrolled nonpregnant, high-risk HPV (HR-HPV)-positive women between the ages of 30 and 50 years, who resided in the state of Michoacán, Mexico, and had a history of no Pap smear screening or knowledge of Pap smear results within the last 3 years. These women were initially enrolled in the Mexican Cervical Cancer Screening Study II (MECCS II) trial and were treated with cryotherapy after VIA triage. They subsequently followed up at 6 months and 2 years for repeat VIA, colposcopy, and biopsy.

RESULTS

A total of 291 women were treated with cryotherapy, of whom 226 (78%) followed up at 6 months. Of these 226 women, 153 (68%) were HR-HPV-negative; there were no findings of cervical intraepithelial neoplasia grade 2 (CIN2) or worse. The remaining 73 women (32%) were HR-HPV-positive; of these women, 2 had CIN2 and 3 had CIN3. Only 137 women followed up at 2 years. Of these 137 women, 116 were HR-HPV-negative and 21 were HR-HPV-positive. Of the 21 women positive for HR-HPV, 9 had negative biopsy results, 11 had CIN1, and 1 had no biopsy. The clearance rate of HR-HPV was 83% (95% confidence interval: 0.78-0.87). There were no biopsy findings of CIN2 or worse at 2 years. Before cryotherapy, of the 226 women, 15 (6.6%) were positive for endocervical curettage (ECC) and 5 (2.2%) were referred for surgical management. Of these 15 ECC-positive women, 10 (67%) followed up at 6 months and it was shown that no patient was ECC positive at that time point. Moreover, of the 15 ECC-positive women, 11 (73%) followed up at 2 years and it was shown that no patient was ECC positive at that time point. In our study, VIA had a false-positive rate of 5%.

CONCLUSIONS

Cryotherapy was an effective, acceptable, and well-tolerated means of treating cervical dysplasia in a low-resource setting.

Cervical cancer screening: Safety, acceptability, and feasibility of a single-visit approach in Bulawayo, Zimbabwe

BACKGROUND

Cervical cancer is the commonest cancer amongst African women, and yet preventative services are often inadequate.

AIM

The purpose of the study was to assess the safety, acceptability and feasibility of visual inspection with acetic acid and cervicography (VIAC) followed by cryotherapy or a loop electrical excision procedure (LEEP) at a single visit for prevention of cancer of the cervix.

SETTING

The United Bulawayo Hospital, Zimbabwe.

METHODS

The study was descriptive, using retrospective data extracted from electronic medical records of women attending the VIAC clinic. Over 24 months 4641 women visited the clinic and were screened for cervical cancer using VIAC. Cryotherapy or LEEP was offered immediately to those that screened positive. Treated women were followed up at three months and one year.

RESULTS

The rate of positive results on VIAC testing was 10.8%. Of those who were eligible, 17.0% received immediate cryotherapy, 44.1% received immediate LEEP, 1.9% delayed treatment, and 37.0% were referred to a gynaecologist. No major complications were recorded after cryotherapy or LEEP. Amongst those treated 99.5% expressed satisfaction with their experience. Only 3.2% of those treated at the clinic had a positive result on VIAC one year later. The service was shown to be feasible to sustain over time with the necessary consumables. There were no service-related treatment postponements and the clinic staff and facility were able to meet the demand for the service.

CONCLUSION

A single-visit approach using VIAC, followed by cryotherapy or LEEP, proved to be safe, acceptable and feasible in an urban African setting in Bulawayo, Zimbabwe. Outcomes a year later suggested that treatment had been effective.

Evaluation of a single-visit approach to cervical cancer screening and treatment in Guyana: feasibility, effectiveness and lessons learned

AIM

To evaluate a cervical cancer prevention project in Guyana utilizing visual inspection with acetic acid (VIA) and immediate cryotherapy in a single-visit approach; and to identify lessons learned to inform the improvement of cervical cancer prevention programs in Guyana and other low-resource settings.

METHODS

Service records from January 2009 to June 2012 were analyzed for 18 cervical cancer prevention sites across Guyana. Records included women's HIV status, data on visual inspection with acetic acid screening and treatment status for women's initial and 1-year follow-up screenings, provider training and retention. A process evaluation was conducted in 2011 to identify programmatic strengths and interventions for integration, scale-up and sustainability.

RESULTS

During the 42-month interval, 21,597 new screenings were performed, reaching 95% of HIV(+) women enrolled in care and 17% of women aged 25-49 years in Guyana. The VIA(+) rate was 13% (n = 2806); 85% of women eligible for cryotherapy received immediate treatment. Half of VIA(+) women treated with cryotherapy or loop electrosurgical excision procedure returned for a 1-year follow-up screening (n = 1027); 95% were VIA(-) at the second screening. Non-physician providers were more likely to continue offering services than physicians. Most programmatic challenges were related to systemic rather than technical/clinical issues.

CONCLUSION

The single-visit approach-based program is feasible, effective, and when scaled up, likely to have an impact on overall incidence of cervical cancer. Services can be shifted to non-physicians for scale-up of high-quality cervical cancer prevention services nationally. To ensure sustainability and expansion, support structures should be prioritized.

Is screen-and-treat approach suited for screening and management of precancerous cervical lesions in Sub-Saharan Africa?

The World Health Organization guidelines for screening and management of cervical precancerous lesions updated in 2013 made an emphasis on the use of the 'screen-and-treat' approach for cervical cancer prevention. In order to facilitate scaling-up in low income settings, most of these screen-and-treat strategies do not involve confirmatory biopsy. This yields a certain rate of overtreatment. In other words, a majority of people undergoing screen-and-treat intervention who are treated does not necessarily benefit from the treatment. Therefore, the issue of potential short term and long term complications of the recommended treatment procedures (cryotherapy and Loop Electrosurgical Excision Procedure) arises. This question has seldom been studied in resource poor countries, particularly in Sub-Saharan Africa where Human Immunodeficiency Virus infection is rampant in an epidemic fashion and where the procreative capacities are socially rewarding for women. We draw the attention of the scientific community and policy makers to the fact that the lack of evidence supporting the safety of these treatment procedures in African populations may have an impact on the acceptability of these strategies and therefore on the effectiveness of screening programs.

Infrastructure requirements for human papillomavirus vaccination and cervical cancer screening in sub-Saharan Africa

The availability of both human papillomavirus (HPV) vaccination and alternative screening tests has greatly improved the prospects of cervical cancer prevention in sub-Saharan African (SSA) countries. The inclusion of HPV vaccine in the portfolio of new vaccines offered by the Gobal Alliance for Vaccines and Immunization (GAVI) to GAVI-eligible countries has vastly improved the chances of introducing HPV vaccination. Further investments to improve vaccine storage, distribution and delivery infrastructure and human resources of the Extended Programme of Immunization will substantially contribute to the faster introduction of HPV vaccination in SSA countries through both school- and campaign-based approaches. Alternative methods to cytology for the prevention of cervical cancer through the early detection and treatment of cervical cancer precursors have been extensively evaluated in the past 15 years, in Africa as well as in other low-resource settings. Visual inspection with 3-5% dilute acetic acid (VIA) and HPV testing are the two alternative screening methods that have been most studied, in both cross-sectional and randomised clinical trials. VIA is particularly suitable to low-resource settings; however, its efficacy in reducing cervical cancer is likely to be significantly lower than HPV testing. The introduction of VIA screening programmes will help develop the infrastructure that will, in turn, facilitate the introduction of affordable HPV testing in future. Links with the existing HIV/AIDS control programmes is another strategy to improve the infrastructure and screening services in SSA. Infrastructural requirements for an integrated approach aiming to vaccinate single-year cohorts of girls in the 9-13 years age-range and to screen women over 30 years of age using VIA or affordable rapid HPV tests are outlined in this manuscript. This article forms part of a regional report entitled "Comprehensive Control of HPV Infections and Related Diseases in the Sub-Saharan Africa Region" Vaccine Volume 31, Supplement 5, 2013. Updates of the progress in the field are presented in a separate monograph entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.

High-risk human papillomavirus in HIV-infected women undergoing cervical cancer screening in Lilongwe, Malawi: a pilot study

Rates of abnormal visual inspection with acetic acid and prevalence of high-risk human papillomavirus (HPV) subtypes have not been well characterized in HIV-infected women in Malawi. We performed a prospective cohort study of visual inspection with acetic acid (N = 440) in HIV-infected women aged 25--59 years, with a nested study of HPV subtypes in first 300 women enrolled. Of 440 women screened, 9.5% (N = 42) had abnormal visual inspection with acetic acid with 69.0% (N = 29) having advanced disease not amenable to cryotherapy. Of 294 women with HPV results, 39% (N = 114) of women were positive for high-risk HPV infection. Only lower CD4 count (287 cells/mm(3) versus 339 cells/mm(3), p = 0.03) and high-risk HPV (66.7% versus 35.6%, p < 0.01) were associated with abnormal visual inspection with acetic acid. The most common high-risk HPV subtypes in women with abnormal visual inspection with acetic acid were 35 (33.3%), 16 (26.7%), and 58 (23.3%). Low CD4 cell count was associated with abnormal visual inspection with acetic acid and raises the importance of early antiretroviral therapy and expanded availability of visual inspection with acetic acid. HPV vaccines targeting additional non-16/18 high-risk HPV subtypes may have greater protective advantages in countries such as Malawi.

Assessment of psychological barriers to cervical cancer screening among women in Kumasi, Ghana using a mixed methods approach

BACKGROUND

Cervical cancer is the leading cause of cancer death among women in Ghana, West Africa. The cervical cancer mortality rate in Ghana is more than three times the global cervical cancer mortality rate. Pap tests and visual inspection with acetic acid wash are widely available throughout Ghana, yet less that 3% of Ghanaian women get a cervical cancer screening at regular intervals.

OBJECTIVE

This exploratory study was to identify psychological barriers to cervical cancer screening among Ghanaian women with and without cancer using a mixed methods approach.

METHODS

Semi-structured interviews were conducted with 49 Ghanaian women with cancer and 171 Ghanaian women who did not have cancer.

RESULTS

The results of the quantitative analysis indicated that cancer patients where not more likely to have greater knowledge of cancer signs and symptoms than women without cancer. Analysis of the qualitative data revealed several psychological barriers to cervical cancer screening including, common myths about cervical cancer, misconceptions about cervical cancer screening, the lack of spousal support for screening, cultural taboos regarding the gender of healthcare providers, and the stigmatization of women with cervical cancer.

CONCLUSION

The results of this study can be used to inform the development of culturally relevant cervical cancer education interventions aimed at addressing the psychological barriers to cervical cancer screening perceived by Ghanaian women.

Utilization of cervical cancer screening services and trends in screening positivity rates in a 'screen-and-treat' program integrated with HIV/AIDS care in Zambia

Background

In the absence of stand-alone infrastructures for delivering cervical cancer screening services, efforts are underway in sub-Saharan Africa to dovetail screening with ongoing vertical health initiatives like HIV/AIDS care programs. Yet, evidence demonstrating the utilization of cervical cancer prevention services in such integrated programs by women of the general population is lacking.

Methods

We analyzed program operations data from the Cervical Cancer Prevention Program in Zambia (CCPPZ), the largest public sector programs of its kind in sub-Saharan Africa. We evaluated patterns of utilization of screening services by HIV serostatus, examined contemporaneous trends in screening outcomes, and used multivariable modeling to identify factors associated with screening test positivity.

Results

Between January 2006 and April 2011, CCPPZ services were utilized by 56,247 women who underwent cervical cancer screening with visual inspection with acetic acid (VIA), aided by digital cervicography. The proportion of women accessing these services who were HIV-seropositive declined from 54% to 23% between 2006–2010, which coincided with increasing proportions of HIV-seronegative women (from 22% to 38%) and women whose HIV serostatus was unknown (from 24% to 39%) (all p-for trend<0.001). The rates of VIA screening positivity declined from 47% to 17% during the same period (p-for trend <0.001), and this decline was consistent across all HIV serostatus categories. After adjusting for demographic and sexual/reproductive factors, HIV-seropositive women were more than twice as likely (Odds ratio 2.62, 95% CI 2.49, 2.76) to screen VIA-positive than HIV-seronegative women.

Conclusions

This is the first ‘real world’ demonstration in a public sector implementation program in a sub-Saharan African setting that with successful program scale-up efforts, nurse-led cervical cancer screening programs targeting women with HIV can expand and serve all women, regardless of HIV serostatus. Screening program performance can improve with adequate emphasis on training, quality control, and telemedicine-support for nurse-providers in clinical decision making.

Effectiveness of cryotherapy for histologically confirmed cervical intraepithelial neoplasia grades 1 and 2 in an Indian setting

OBJECTIVE

To describe the effectiveness of cryotherapy for treating women who were histologically confirmed to have cervical intraepithelial neoplasia (CIN) in India.

METHODS

Data were analyzed retrospectively from screening projects that collected data from January 2001 to May 2008 in Trivandrum, India. Women with CIN were appropriately treated with cryotherapy by a trained nurse or physician and followed up for cure, adverse events, and complications. Cure was defined as absence of CIN during any follow-up visit at least 1 year after treatment.

RESULTS

Among 236 women identified with CIN and appropriately treated with cryotherapy, 173 (81.6%) were followed up (158 CIN 1 and 15 CIN 2 cases). The percentage cure for CIN 1 and 2 lesions was 93.0% and 86.7% respectively. An odds ratio of 0.2 (95% confidence interval, 0.0-0.9) was observed for treatment received more than 2 months after screening as compared with treatment received within 2 months. Complications were observed in 1.2% of treated women and adverse events (discharge and mild pain) in 26.6%.

CONCLUSION

The study affirms that trained mid-level providers can appropriately perform cryotherapy in primary healthcare services and that expanding such services in low-resource settings would increase the availability and accessibility of precancer treatment.

Evaluation of a 5-year cervical cancer prevention project in Indonesia: opportunities, issues, and challenges

AIM

The Cervical and Breast Cancer Prevention (CECAP) Project sought to develop a national model for cervical cancer prevention in Indonesia based on visual inspection with acetic acid (VIA) to detect abnormal changes in the cervix. The purpose of this study was to evaluate a pilot project introducing VIA and cryotherapy in Indonesia and to identify lessons learned that could be applied to the national scale-up of cervical cancer prevention services.

MATERIAL AND METHODS

Fifty-four months (July 2007 to December 2011) of service records at 17 health centers were abstracted and analyzed. The data were used to calculate the proportion of all women aged 30-50 who received VIA screening, the VIA-positive rate, the treatment rate, and the interval between screening and treatment.

RESULTS

The 45 050 women screened during the project included 24.4% of the total female population in the target age group in the catchment area. Throughout the 5-year project, 83.1% of VIA-positive women sought cryotherapy. During the last 18 months of the project, after data collection tools were revised to more accurately reflect when cryotherapy was received, 13% of women were treated on the same day that they were screened. Among the 74% of women treated within 1 month of screening, the mean interval between screening and treatment was 7.2 days.

CONCLUSION

As cervical cancer prevention services are scaled up throughout Indonesia, changes in the service delivery model and program management are needed to increase screening coverage, promote a single-visit approach, and ensure the quality of services.

Influencing women's actions on cervical cancer screening and treatment in Karawang District, Indonesia

INTRODUCTION

The impact of cervical cancer prevention programs depends on persuading women to go for screening and, if needed, treatment. As part of an evaluation of a pilot project in Indonesia, qualitative research was conducted to explore the factors that influence women's decisions regarding screening and treatment and to generate practical recommendations to increase service coverage and reduce loss to follow up.

METHODS

Research was conducted at 7 of the 17 public health centers in Karawang District that implemented the pilot project. Interviews and focus group discussions were held with 20 women, 20 husbands, 10 doctors, 18 midwives, 3 district health officials, and 16 advocacy team members.

RESULTS

Free services and mobile outreach events encouraged women to go for screening, along with promotional efforts by community health workers, advocacy teams, and the mass media. Knowledge and perceptions were the most important barriers to screening: women were not aware of cervical cancer risks, did not know the disease was treatable, and were fatalistic. Factors facilitating treatment were social support from husbands, relatives, and friends and the encouragement and role modeling of health workers. Barriers to prompt treatment included limited access to services and the requirement for husband's consent for cryotherapy.

CONCLUSION

As cervical cancer prevention services are scaled up throughout Indonesia, the findings suggest three strategies to expand screening coverage and ensure prompt treatment: strengthening community mobilization and advocacy activities, modifying the service delivery model to encourage a single visit approach to screening and treatment, and working to gain men's support.

Screening of cervical neoplasia in HIV-infected women in India

OBJECTIVE

To evaluate an accurate, affordable, and feasible method to screen and treat HIV-infected women so that cervical cancer can be prevented among them.

DESIGN

A cross-sectional study was conducted in India in which eligible HIV-infected women underwent visual inspection with acetic acid (VIA), visual inspection with Lugol's iodine (VILI), cytology, human papillomavirus (HPV) testing, and colposcopy.

METHODS

We screened women with cytology, HPV testing, VIA, and VILI. All screened women had colposcopy and women with colposcopic abnormalities had directed biopsies. Women with suspected cervical intraepithelial neoplasia (CIN) on colposcopy were treated with cold coagulation or loop excision. Sensitivity, specificity, and predictive values of the screening tests were calculated.

RESULTS

: Among 1128 women screened, 55 (4.9%) had CIN2-3 lesions. Sensitivity for VIA, VILI, cytology at atypical squamous cells of undetermined significance (ASCUS) threshold and HPV testing was 83.6, 89.1, 63.3, and 94.6%, and specificity was 88.8, 89.3, 94.5, and 77.4%, respectively, in detecting CIN2/3 lesions. Cytology had significantly lower sensitivity and higher specificity than VIA, VILI, and HPV testing. Sequential testing with VIA/VILI, HPV testing/VIA, HPV testing/VILI, and HPV testing/VIA/VILI had more balanced sensitivity and specificity than the single tests. Cold coagulation was well tolerated and cured 80% of CIN2-3 based on preliminary results at 6-month to 1-year follow-up periods.

CONCLUSIONS

Sequential testing with VIA and VILI is the most feasible screening approach for cervical cancer screening in HIV-infected women in low-resource countries. When HPV testing becomes feasible and affordable, HPV testing followed by VIA/VILI may be considered.

Meta-analysis of the effectiveness of cryotherapy in the treatment of cervical intraepithelial neoplasia

BACKGROUND

Cryotherapy can be used for the ablation of cervical intraepithelial neoplasia (CIN).

OBJECTIVES

To provide an updated and comprehensive estimate of the efficacy of cryotherapy for CIN.

SEARCH STRATEGY

A literature search identified original studies (randomized controlled trials and clinical reports).

SELECTION CRITERIA

Studies reporting cure rates, acceptability, and safety of cryotherapy were included in the analysis.

DATA COLLECTION AND ANALYSIS

Number of persistent or recurrent lesions at follow-up, adverse events, and complications were recorded. Quality of the methodology was also assessed. Meta-analyses were performed according to CIN thresholds, geographic region, study year, setting, study design, presence of endocervical involvement, freezing method, duration of follow-up, and status of the cryotherapy provider.

MAIN RESULTS

A total of 146 articles were retrieved; 77 papers--equivalent to 28,827 cases of treated CIN--were included in the meta-analysis. Cryotherapy achieved cure rates of 94.0% (CIN1), 92.0% (CIN2), and 85.0% (CIN3). Use of the double-freeze method and absence of endocervical involvement significantly increased cure rates. Minimal complications were reported as adverse effects.

CONCLUSIONS

Cryotherapy is an effective, safe, and acceptable treatment for CIN. It has been shown to be successful in low-resource settings, enabling availability and accessibility of early detection services.

Acceptability of cervical cancer screening via visual inspection with acetic acid or Lugol's iodine at Mulago Hospital, Uganda

OBJECTIVE

To assess acceptability of cervical cancer screening via visual inspection with acetic acid or Lugol's iodine (VIA/VILI) at Mulago Hospital, Uganda.

METHODS

Exit interviews were conducted among women who had undergone opportunistic screening by VIA/VILI at 2 family planning clinics based within the hospital. Measures of acceptability were willingness to undergo the procedure in future if required and willingness to recommend the procedure to others. Focus group discussions were conducted to determine reasons for declining VIA/VILI.

RESULTS

A total of 384 participants were recruited into the study. Of the 229 women who agreed to undergo screening by VIA/VILI, 209 (91.3%) were willing to recommend the service to other women, while 223 (97.4%) stated that they would undergo VIA/VILI again if the need arose. Education level showed a significant association with screening uptake (P=0.007). In all, 155 women declined screening. Reasons for refusal included fears about privacy, fear of pain or discomfort, and worry about the test results.

CONCLUSION

Cervical cancer screening by VIA/VILI was rated highly acceptable among women who underwent the procedure. Women with a positive attitude toward screening could be trained as peer educators and community champions to improve uptake.

Cervical cancer screening by visual inspection in Côte d'Ivoire, operational and clinical aspects according to HIV status

Background

Cervical cancer screening is not yet standard of care of women attending HIV care clinics in Africa and presents operational challenges that need to be addressed.

Methods

A cervical cancer screening program based on visual inspection methods was conducted in clinics providing antiretroviral treatment (ART) in Abidjan, Côte d'Ivoire. An itinerant team of midwives was in charge of proposing cervical cancer screening to all HIV-positive women enrolled in ART clinics as well as to HIV-negative women who were attending the Abidjan national blood donor clinic. Positively screened women were systematically referred to a colposcopic examination. A phone-based tracking procedure was implemented to reach positively screened women who did not attend the medical consultation. The association between HIV status and cervical cancer screening outcomes was estimated using a multivariate logistic model.

Results

The frequency of positive visual inspection was 9.0% (95% CI 8.0-10.0) in the 2,998 HIV-positive women and 3.9% (95% CI 2.7-5.1) in the 1,047 HIV-negative ones (p < 10^-4). In multivariate analysis, HIV infection was associated with a higher risk of positive visual inspection [OR = 2.28 (95% CI 1.61-3.23)] as well as more extensive lesions involving the endocervical canal [OR = 2.42 (95% CI 1.15-5.08)]. The use of a phone-based tracking procedure enabled a significant reduction of women not attending medical consultation after initial positive screening from 36.5% to 19.8% (p < 10^-4).

Conclusion

The higher frequency of positive visual inspection among HIV-positive women supports the need to extend cervical cancer screening program to all HIV clinics in West Africa. Women loss to follow-up after being positively screened is a major concern in cervical screening programs but yet, partly amenable to a phone tracking procedure.