Screening for cervical cancer among HIV-positive and HIV-negative women in Cameroon using simultaneous co-testing with careHPV DNA testing and visual inspection enhanced by digital cervicography: Findings of initial screening and one-year follow-up

Compliance Rate With Triage Test and Treatment for Participants Screening Positive in Cervical Cancer Screening Programs: A Systematic Review and Meta-analysis

OBJECTIVE

To assess the rates of adherence to triage testing after positive screening results and referral to treatment for precancerous lesions in global cervical cancer screening programs.

DATA SOURCES

We searched three electronic databases (Medline, EMBASE, and Web of Science) for articles published in the English language from January 1, 2018, to December 31, 2023. We included studies reporting the compliance rate of triage testing and precancer treatment in cervical cancer screening programs. ClinicalTrials.gov was reviewed, and no more studies were identified.

METHODS OF STUDY SELECTION

The combined search strategies identified 1,673 titles, of which 858 titles and abstracts were screened and 113 full-text articles were assessed for eligibility. A total of 33 studies met the inclusion criteria and were included in the meta-analysis.

TABULATION, INTEGRATION, AND RESULTS

Thirty-three studies were included in the systematic review and meta-analysis. The average compliance rate for women screening positive was 77.1% for triage testing and 69.4% for referral to treatment. Compliance varied by country income level, screening guideline approach, and target population.

CONCLUSION

The current compliance rate was lower than the 90% target set by the World Health Organization's global strategy to eliminate cervical cancer. Inadequate follow-up of participants screening positive revealed a gap between the screening program and clinical care.

Tritesting in Battor, Ghana: an integrated cervical precancer screening strategy to mitigate the challenges of multiple screening visits and loss to follow-up

Background

Human papillomavirus (HPV) DNA testing is more sensitive than cytology for detecting cervical precancer; however, increasing reports of high-risk HPV (hr-HPV)-negative cases of cervical intraepithelial neoplasia (CIN) and even malignancy motivate the use of combined testing. We present our experience with 'tritesting', defined as the performance of HPV DNA testing, cytology and visual inspection in a single session at the Cervical Cancer Prevention and Training Centre, Ghana. We further determined the prevalence rates of hr-HPV infection, abnormal cytology and cervical lesions among women screened using tritesting.

Methods

This descriptive retrospective cross-sectional study assessed all women screened via tritesting between April 2019 to April 2023. HPV DNA testing was performed using the Sansure MA-6000, GeneXpert or AmpFire platforms. Visual inspection was performed using enhanced visual assessment mobile colposcopy or visual inspection with acetic acid. Liquid-based cytology was performed using cervical samples taken with a Cervex-Brush® and fixed in PreservCyt, while samples for conventional cytology were taken using an Ayre spatula and cytobrush.

Results

Among 236 women screened (mean age, 39.1 years (standard deviation, 10.9)), the overall prevalence rates of hr-HPV infection and cervical lesions were 17.8% (95% confidence interval (CI), 13.1-23.3) and 11.9% (95% CI, 8.0-16.7), respectively. Cytology yielded findings of atypical squamous cells of undetermined significance or worse in 2.5% (95% CI, 0.9-5.5) of women. Histopathology following loop electrosurgical excision procedure revealed CIN I (tritest positive) and CIN III (hr-HPV-positive, visual inspection 'positive', cytology-negative) in one woman each. Factors independently associated with hr-HPV infection among 'tritested' women were age ≥ 39 years, tertiary level of education and current contraceptive use. Twenty-seven out of 39 hr-HPV-positive women (69.2%; 95% CI, 52.4-83.0) showed a type 3 transformation zone and would have needed to be recalled for a cytologic sample to be taken in a 'see and triage' approach with HPV DNA testing and a visual inspection method.

Conclusion

This study brings tritesting into the spotlight, as an alternative to other methods, particularly for women who prefer this due to the advantage of a single visit to a health facility and being more cost-effective, if they have to travel long distances to access cervical screening services.

Screening approaches for cervical cancer in Mozambique in HIV positive and negative women

OBJECTIVE

Cervical cancer (CC) is a global health issue, in Mozambique, 5300 new cases and 3800 deaths are reported each year. The WHO recommends the introduction of HPV molecular testing for CC screening, but Mozambique uses an approach based on visual inspection with acetic acid (VIA). This study aims to evaluate the feasibility of high-risk HPV (hrHPV) testing compared to actual approaches in Mozambique.

METHODS

An observational study was carried out in the DREAM center in Zimpeto, Mozambique. Women aged 30-55 were included. HPV testing was performed with the Cobas HPV test. They were then screened with the current national recommendations based on VIA. Cryotherapy was performed on-site or referred for colposcopy if necessary.

RESULTS

In the period, 1207 women were enrolled, 47.8% HIV+; 124 (10.3%) VIA+, and HPV DNA test was positive in 325 (26.9%) women. HPV positivity rates were higher in HIV-infected women. In the sample, 52.8% of the 124 VIA+ women were HPV uninfected and underwent unnecessary cryotherapy or colposcopy. Meanwhile, 24.7% of the 1083 VIA- women were actually HPV infected. In comparison, a screen, triage and treat approach based on hrHPV testing would only test and treat the 325 HPV-infected women.

CONCLUSION

The study found high rates of hrHPV infection, particularly in HIV-positive women, with many concurrent or multiple infections. The current screening method misses important hrHPV infections and results in many unnecessary treatments. These results support the use of HPV molecular testing as the initial screening test for CC.

Disparities in cervical cancer screening programs in Cameroon: a scoping review of facilitators and barriers to implementation and uptake of screening

BACKGROUND

Cervical cancer is the fourth most common cancer worldwide. Organized screening has achieved significant reductions in cervical cancer incidence and mortality in many high-income countries (HICs). But the gap between HICs and low-and-middle-income countries (LMICs) is still substantial as the highest burden of the disease is in LMICs. Cameroon is a LMIC, where cervical cancer is the leading cause of cancer-related deaths among women, only 3-5% of eligible women have been screened and there is no effective national cervical cancer prevention program.

OBJECTIVE(S)

Identify facilitators and barriers to the implementation and uptake of existing cervical cancer screening programs in Cameroon to inform the implementation of a comprehensive national program.

METHODS

We conducted a scoping review using the Preferred Reporting Items for Systematic Reviews and Meta-analysis, extension for Scoping Reviews (PRISMA-ScR). Google Scholar and five electronic databases (PubMed, CINAHL, Embase, Cochrane library and Web of Science) were searched systematically from 2012 to 2022. Articles on cervical cancer screening programs in Cameroon were eligible for inclusion. Two reviewers independently screened search results and extracted relevant data.

RESULTS

A total of 182 articles were identified using our search strategy, and 20 were included. There was scarcity of publications from the North, Adamawa, East and South regions of Cameroon. Barriers and facilitators found were presented using the World Health Organisation framework for health systems. Cross-cutting barriers were: (1) the lack of a national training curriculum for screening providers with no elaborate, harmonized screening and treatment algorithm for cervical precancers; and (2) women's lack of information about cervical cancer screening activities. Conversely, provision of screening services at a low or no cost to women in some programs and the feasibility of using novel point of care screening methods like the Human Papillomavirus DNA test were identified as facilitators.

CONCLUSION

This scoping review indicates that there are knowledge and research gaps concerning the state of cervical cancer screening services in some regions of Cameroon. Moreover, it underlines the need for comprehensive cancer control policies and practices integrating all six-health system building blocks to reduce disparities between regions, and rural versus urban areas in Cameroon.

Uptake and barriers to cervical cancer screening among human immunodeficiency virus-positive women in Sub Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Cervical cancer is the leading cause of disability and mortality among women in Africa. Despite a significant correlation between HIV/AIDS and cervical cancer, there is unacceptably low coverage of the uptake of cervical cancer screening among human immunodeficiency virus-positive women in Sub-Saharan Africa. Individual primary studies are limited in explaining the patterns of uptake of cervical cancer screening. This review therefore considers the uptake of cervical cancer screening and its barriers among human immunodeficiency virus-positive women in Sub-Saharan Africa.

METHODS

We systematically searched articles published until December ³¹, 2019, from the PubMed, Cochrane Library, POP LINE, Google Scholar, African Journals Online and JURN databases. The quality of the included articles was assessed by using the Newcastle‒Ottawa Scale, and the coverage of uptake of cervical cancer screening was pooled after checking for heterogeneity and publication bias. The random effect model was used, and subgroup analysis estimates were performed by country.

RESULTS

Twenty-one studies comprising 20,672 human immunodeficiency virus-positive women were included. Applying a random effect model, the overall cervical cancer screening uptake among this group of women in Sub-Saharan Africa was estimated to be 30% (95% CI: 19, 41, I² = 100%). The main barriers to uptake of cervical screening include poor knowledge about cervical cancer and screening, low risk perception of cervical cancer, fear of test result and fear of screening as painful, lack of access to screening services, high cost of screening service, and poor partner attitude and acceptance of the service. The perception of an additional burden of having a cervical cancer diagnosis was found to be a unique barrier among this population of women.

CONCLUSION

The unacceptably low coverage of uptake of cervical cancer screening would indicate that the need to scale up the opportunities to these groups of women as well. This review revealed that in addition to structural and health care system barriers, sociocultural and personal barriers are powerful barriers in HIV-positive women. For these cohorts of population, a particular obstacle was discovered to be perception of an additional burden of having cervical cancer.

Cytology compared with Hybrid Capture 2 human papilloma virus cervical cancer screening in HIV positive and HIV negative South African women

OBJECTIVES

Cervical cancer is preventable and caused by persistent infection with oncogenic human papilloma virus (HPV) types. HPV screening is more sensitive and is the preferred screening test. HPV screening data are mainly from developed settings, and the purpose of this study was to investigate the performance of HPV screening in previously unscreened HIV positive and negative women.

METHODS

In this cross sectional multicenter study, liquid based cytology and HPV testing were performed on women attending different clinics. Patients with positive screening tests had colposcopy and biopsy or large loop excision of the transformation zone. Some women with normal screening had colposcopy and biopsy. Data of women with histology results, and data of HIV positive and negative women were analyzed for comparison. For women without histology results, data were imputed using a statistical model.

RESULTS

In 903 women with known HIV status, 683 (75.6%) had negative cytology, 202 women (22.4%) had abnormal cytology, and in 18 patients (2.0%) the results were uncertain. Mean age was 41.4 years (range 25-65). HPV tests were negative in 621 women (68.8%). In HIV positive women, 54.5% tested negative compared with 79.7% HIV negative women (p<0.0001). HPV screening had higher sensitivity (60.9%), but lower specificity (82.4%), compared with cytology (48.6% and 86.7%) for detection of cervical intraepithelial neoplasia (CIN) 2+ in all women. For detection of CIN 3+, HPV screening had higher sensitivity (70.4%) compared with cytology (62.9%), and specificity (75.5%) was lower compared with cytology at a threshold of atypical squamous cells of undetermined significance (ASCUS+) (82.4%).

CONCLUSION

HPV screening was more sensitive than cytology in HIV positive and HIV negative women, but specificity was lower. Although HPV screening should be the preferred screening test, cytology is a suitable screening test in HIV positive women in low resource settings.

TRIAL REGISTRATION NUMBER

NCT02956031.

Digital cervicography for cervical cancer screening in low-resource settings: A scoping review

Introduction

Digital cervicography (DC) is a method of capturing images for analysis during visual inspection with acetic acid (VIA) for cervical cancer screening. Cervical cancer is the 3rd leading cause of female cancer in the world with approximately 90 % of deaths due to cervical cancer occurring in low and middle income countries (LMICs). The need for cost-effective and sustainable methods for screening is vital in these settings. This scoping review systematically synthesizes published data illustrating the use of DC in screening programs. We aim to understand how digital cervicography is used, implemented, and impacted on programs.

Methods

Search of eight online databases identified 53 studies published between 1993 and 2021. Inclusion of articles were English language, cervical cancer screening program located in an LMIC, and DC as an intervention.

Results

All studies were cross-sectional studies (n = 53), with variation in terminology, uses, and device methods. Devices were grouped as either smartphones (n = 14), commercially available digital cameras (n = 17), or other (EVA®, n = 4; Cerviscope, n = 12; custom device, n = 4; or not specified, n = 2). Nineteen studies found acceptability and feasibility for DC in their screening programs. Various programs using DC found benefits such as task sharing, healthcare worker training, patient education and using images for review from a remote specialist or mentor.

Conclusion

The use of DC in LMICs is beneficial for support of healthcare workers, enhances quality improvement and demonstrates overall acceptability in screening programs. Advancing technologies for human papillomavirus (HPV) testing and cytology are common methods for cervical cancer screening, although are limited in LMICs. This scoping review demonstrates the different methods, uses, and benefit of digital cervicography in cervical cancer screening programs.

Development, Implementation, and Evaluation of a Distance Learning and Telementoring Program for Cervical Cancer Prevention in Cameroon

Importance

Although Africa has the highest burden of cervical cancer in the world, educational resources to achieve the 90-70-90 targets set by the World Health Organization in its strategy to eliminate cervical cancer are lacking in the region.

Objectives

To adapt, implement, and evaluate the Project Extension for Community Health Care Outcomes (ECHO), an innovative learning tool, to build capacity of clinicians to better incorporate new evidence-based guidelines into cervical cancer control policies and clinical practices.

Design, Setting, and Participants

This cross-sectional study assessed knowledge and practices of clinicians and support staff regarding cervical cancer prevention and control and compared them among respondents who had attended Project ECHO sessions (prior ECHO attendees) with those who had not but were planning on attending in the near future (newcomers) as part of the Cameroon Cervical Cancer Prevention Project ECHO. Satisfaction of prior ECHO attendees was also evaluated. Data were analyzed from January to March 2022.

Main Outcomes and Measures

Main outcomes were practices and knowledge regarding cervical cancer education and prevention and preinvasive management procedures compared among prior ECHO attendees and newcomers.

Results

Of the 75 participants (mean [SD] age, 36.4 [10.0] years; 65.7% [95% CI, 54.3%-77.1%] women) enrolled in this study, 41 (54.7%; 95% CI, 43.1%-66.2%) were prior ECHO attendees, and most were clinicians (55 respondents [78.6%; 95% CI, 68.7%-88.4%]). Overall, 50% (95% CI, 37.8%-62.2%) of respondents reported performing cervical cancer screening with visual inspection of the cervix after application of acetic acid (VIA) and/or visual inspection of the cervix after application of Lugol's iodine (VILI), 46.3% (95% CI, 34.0%-58.5%) of respondents reported performing human papillomavirus (HPV) testing, and 30.3% (95% CI, 18.9%-41.7%) of respondents reported performing cervical cytological examination in their practices, Approximately one-fourth of respondents reported performing cryotherapy (25.4% [95% CI, 14.7%-36.1%]), thermal ablation (27.3% [95% CI, 16.2%-38.3%]) or loop electrosurgical excisional procedure (LEEP, 25.0% [95% CI, 14.4%-35.6%]) for treatment of preinvasive disease. The clinical use of many of these screening and treatment tools was significantly higher among prior ECHO attendees compared with newcomers (VIA/VILI: 63.2% [95% CI, 47.4%-78.9%] vs 33.3% [95% CI, 16.0%-50.6%]; P = .03; cryotherapy: 40.5% [95% CI, 24.3%-56.8%] vs 6.7% [95% CI, 0.0%-15.8%]; P = .002; thermal ablation: 43.2% [95% CI, 26.9%-59.6%] vs 6.9% [95% CI, 0.0%-16.4%]; P = .002). Knowledge about cervical cancer education, prevention, and management procedures was satisfactory in 36.1% (95% CI, 23.7%-48.5%) of respondents; this proportion was significantly higher among prior ECHO attendees (53.8% [95% CI, 37.7%-69.9%]) compared with newcomers (4.5% [95% CI, 0.0%-13.5%]; P < .001). Approximately two-thirds of participants (68.8% [95% CI, 51.8%-85.8%]) reported that they had applied knowledge learned in our ECHO sessions to patient care in their practice or adopted best-practice care through their participation in this ECHO program.

Conclusions and Relevance

These findings suggest that the Project ECHO e-learning and telementoring program was associated with improved skills for clinicians and support staff and enhanced quality of care for patients. In the COVID-19 era and beyond, reinforced efforts to strengthen cervical cancer knowledge and best practices through distance learning and collaboration are needed.

Predictive value of 'Smartscopy' for the detection of preinvasive cervical lesions during the COVID-19 pandemic: a diagnostic study

Objective

To evaluate the performance of “Smartscopy” in diagnosing preinvasive cervical lesions among patients with abnormal cervical cancer screening results obtained during the coronavirus disease 2019 (COVID-19) pandemic.

Methods

This diagnostic study enrolled non-pregnant women with abnormal cervical cancer screening results obtained at the colposcopy clinic at Srinagarind Hospital (Khon Kaen, Thailand) between September 2020 and March 2021. Two colposcopists independently evaluated the uterine cervix using a smartphone and colposcopy. Cervical biopsies and endocervical curettage were performed in accordance with standard procedures. The diagnostic performance of a smartphone in detecting low-grade squamous intraepithelial lesions or worse plus (LSIL+) and high-grade squamous intraepithelial lesions plus (HSIL+) was assessed.

Results

In total, 247 patients were included. There was high agreement between the two colposcopists (κ=0.88; 95% confidence interval [CI], 0.82–0.93). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the smartphone to detect LSIL+ were 96.6% (95% CI, 91.6–99.1), 12.9% (95% CI, 8.06–19.2), 46.2% (95% CI, 39.7–52.4), 83.3% (95% CI, 62.6–95.3), and 0.49% (95% CI, 0.43–0.55), respectively. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of smartscopy in diagnosing HSIL+ were 67.6% (95% CI, 55.2–78.5), 85.4% (95% CI, 79.9–90.0), 60.5% (95% CI, 48.6–71.6), 88.9% (95% CI, 83.7–92.9), and 81.0% (95% CI, 0.75–0.85), respectively.

Conclusion

Smartscopy demonstrated a remarkable correlation with colposcopy and a high diagnostic performance value for the detection of preinvasive cervical lesions. Therefore, smartscopy may be an alternative tool for detecting abnormal cervical lesions in low to medium medical resource settings. Smartscopy may be applied in telemedicine during the COVID-19 pandemic.

A Framework for Cervical Cancer Elimination in Low-and-Middle-Income Countries: A Scoping Review and Roadmap for Interventions and Research Priorities

The World Health Organization announced an ambitious call for cervical cancer elimination worldwide. With existing prevention and treatment modalities, cervical cancer elimination is now within reach for high-income countries. Despite limited financing and capacity constraints in low-and-middle-income countries (LMICs), prevention and control efforts can be supported through integrated services and new technologies. We conducted this scoping review to outline a roadmap toward cervical cancer elimination in LMICs and highlight evidence-based interventions and research priorities to accelerate cervical cancer elimination. We reviewed and synthesized literature from 2010 to 2020 on primary and secondary cervical cancer prevention strategies. In addition, we conducted expert interviews with gynecologic and infectious disease providers, researchers, and LMIC health officials. Using these data, we developed a logic model to summarize the current state of science and identified evidence gaps and priority research questions for each prevention strategy. The logic model for cervical cancer elimination maps the needs for improved collaboration between policy makers, production and supply, healthcare systems, providers, health workers, and communities. The model articulates responsibilities for stakeholders and visualizes processes to increase access to and coverage of prevention methods. We discuss the challenges of contextual factors and highlight innovation needs. Effective prevention methods include HPV vaccination, screening using visual inspection and HPV testing, and thermocoagulation. However, vaccine coverage remains low in LMICs. New strategies, including single-dose vaccination could enhance impact. Loss to follow-up and treatment delays could be addressed by improved same-day screen-and-treat technologies. We provide a practical framework to guide cervical cancer elimination in LMICs. The scoping review highlights existing and innovative strategies, unmet needs, and collaborations required to achieve elimination across implementation contexts.

Feasibility and Acceptability of Smartphone-Based Cervical Cancer Screening Among HIV-Positive Women in Western Kenya

PURPOSE

Adjunct cervical cancer screening methods are under evaluation to improve the diagnostic accuracy of human papillomavirus (HPV)-based screening in low- and middle-income countries. We evaluated the feasibility and acceptability of smartphone-based cervicography among HPV-positive women living with HIV (WLWH) in Western Kenya.

METHODS

HPV-positive WLWH of 25-49 years of age enrolled in a clinical trial (ClinicalTrials.gov identifier: NCT04191967) had digital images of the cervix taken using a smartphone by a nonphysician provider following visual inspection with acetic acid. All participants had colposcopy-directed biopsy before treatment. Cervical images were evaluated by three off-site colposcopists for quality, diagnostic utility, and assigned a presumed diagnosis. We determined the proportion of images rates as low, medium, or high quality, interobserver agreement using Cohen's Kappa statistic, and the off-site colposcopist's sensitivity and specificity for diagnosis of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) compared with histopathology. Acceptability was evaluated using a questionnaire.

RESULTS

One hundred sixty-four HPV-positive WLWH underwent cervicography during the study period. Mean age was 37.3 years. Images from the first 94 participants were evaluated by off-site colposcopists, with a majority (70.9%) rated as high quality. Off-site colposcopists had a sensitivity ranging from 21.4% (95% CI, 0.06 to 0.43) to 35.7% (95% CI, 0.26 to 0.46) and a specificity between 85.5% (95% CI, 0.81 to 0.90) to 94.9% (95% CI, 0.92 to 0.98) for diagnosis of CIN2+ based compared with histopathology. The majority of women, 99.4%, were comfortable having an image of their cervix taken as part of screening.

CONCLUSION

Cervicography by a nonphysician provider as an adjunct to HPV-based screening among WLWH in a low- and middle-income country setting is feasible and acceptable. However, low sensitivity for diagnosis of CIN2+ by off-site expert colposcopists highlights the limitations of cervicography.

Novel concepts in cervical cancer screening: a comparison of VIA, HPV DNA test and p16INK4a/Ki-67 dual stain cytology in Western Kenya

BACKGROUND

Screening of unvaccinated women remains essential to mitigate the high morbidity/mortality of cervical cancer. Here, we compared visual inspection with acetic acid (VIA), recommended by WHO as the most cost-effective screening approach in LMICs, with HPV-based screening, and usage of p16INK4a/Ki-67 dual stain cytology.

METHODS

We prospectively enrolled women participating in a VIA-based cervical cancer screening program in two peri-urban health centers of Kenya. Consenting women had a VIA examination preceded by collection of a liquid-based cytology sample from the cervix stored in PreservCyt medium (Hologic®). Analysis of all samples included a hrHPV DNA test and evaluation of a p16INK4a /Ki-67 (CINtecPLUS®) dual stained slide that was prepared using the ThinPrep® 2000 Processor and evaluated by a pathologist trained in the methodology.

RESULTS

In 701 of a total of 800 women aged 18-64 years, all three investigations were performed and data could be analyzed. The HPV, VIA and dual stain cytology positivity were 33%, 7%, and 2% respectively. The HPV positivity rate of VIA positive cases was 32%. The five most common HPV types were HPV16, 52, 68, 58 and 35. The OR among HIV infected women of an HPV infection, VIA positivity and positive dual stain cytology were 2.6 (95%CI 1.5-4.3), 1.9 (95%CI 0.89-4.4) and 3.4 (95%CI 1.07-10.9) respectively. The sensitivity of VIA to detect a p16INK4a/Ki-67 positive transforming infection was 13% (95%CI 2-38).

CONCLUSIONS

Primary HPV testing appears feasible and should be considered as a primary screening test also in LMICs. The poor sensitivity of VIA renders it unsuitable as a triage test for HPV positive women. The utility of p16INK4a/Ki-67 dual stain cytology as a triage test for HPV positive women in LMICs should be further studied.

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.

<p>Factors Associated with Treatment Uptake Among Women with Acetic Acid/Lugol’s Iodine Positive Lesions of the Cervix in Cameroon</p>

Purpose

Treatment of cervical precancer is the primary aim in secondary prevention of cervical cancer. The purpose of this study was to examine factors associated with treatment uptake among women with acetic acid/Lugol’s iodine positive lesions identified by digital cervicography (DC) in a cervical cancer prevention program in Cameroon.

Patients and Methods

We conducted a cross-sectional survey of medical records from 2013 to 2018 of 755 women in Cameroon who screened positive with acetic acid/Lugol’s iodine in 2013.

Results

Of the 755 women, 422 (55.9%) had treatment/biopsy on the same day or followed up later, but only 344 (45.6%) received treatment/biopsy and 333 (44.1%) were lost to follow-up. Overall, 180 (52.3%) of the 344 women were treated/biopsied the same day they were screened, and 164 (47.7%) were treated/biopsied after the initial visit. Women aged 30–49 and HIV-positive women were significantly more likely to have received treatment or returned for treatment than women less than 30 and HIV-negative women. Of the 266 women who followed up at a later date, the lesions of 78 (29.3%) women regressed spontaneously without treatment. Women with low-grade lesions, HIV-negative women and women who had follow-up more than a year after the initial exam were significantly more likely to have spontaneous regression with regression rates of 30.6%, 32.1% and 62.2%, respectively (p<0.001). Age was not a significant determinant of spontaneous regression (p=0.149).

Conclusion

Efforts to increase treatment uptake are needed in this population, including adherence to same day “See and treat” policies.

Home-based HPV self-sampling assisted by a cloud-based electronic data system: Lessons learnt from a pilot community cervical cancer screening campaign in rural Ethiopia

Primary HPV testing and triage of HPV-positive women is an effective cervical cancer screening strategy. Such a multi-visit screening algorithm is also promising for community-based screening in resource-poor communities, provided a robust tracking system is in place.

A cervical cancer screening campaign was conducted in a rural community in Ethiopia. All women aged 25–65 years were offered genital self-sampling using the Evalyn Brush®. Samples were HPV-DNA-tested at a central laboratory. Key indicators were captured on tablet computers and linked by a cloud-based information system. HPV-positive women were examined at the local clinic using portable colposcopy, p16/Ki-67 dual stain cytology and biopsy examination. CIN2+ women were referred for LEEP to the referral hospital.

Of 749 enumerated age-eligible women 634 (85%, (95% CI 82–88)) consented to screening, 429 samples were adequate for HPV testing, giving a total testing coverage of 57% (95% CI 53–62). The hrHPV prevalence was 14% (95% CI 5–22), 72% (95% CI 60–84) attended the clinic for a triage examination. Home-based HPV-DNA self-sampling and clinic-based triage assisted by cloud-based information technology is feasible in rural Ethiopia. Key components of such strategy are broad community awareness, high competency of community workers, and establishment of an adequate self-sampling and HPV-DNA testing platform.

Barriers and facilitators of follow-up among women with precancerous lesions of the cervix in Cameroon: a qualitative pilot study

Purpose

This pilot study explores the barriers to adherence to follow-up among women with cervical precancer in urban Cameroon. While follow-up of women with a positive screening of cervical precancer is the most important aspect of cervical cancer secondary prevention, women with cervical precancer do not adhere frequently to recommended follow-up schedule in Cameroon. The aim of the study was to explore and describe the barriers and facilitators to follow-up for cervical precancer among women infected and uninfected with HIV in Cameroon.

Participants and methods

A qualitative research design was used to answer the research questions. Participants included eight HIV-infected and -uninfected women diagnosed with cervical precancer and 19 nurses. Data were collected by in-depth individual patient interviews and focus groups with nurses. An interview guide with open-ended questions, using the social ecological model as a framework, included questions that addressed the complexities of the lives of individuals and professionals within a relational context. The interviews were audio-taped and transcribed verbatim in English language. Thematic analysis of data was completed with no epistemological or theoretical perspective underpinning the analyses.

Results

Four major themes emerged from the study. They were clinic, personal, and social barriers, and strategies to improve follow-up.

Conclusion

The use of reminder phone calls and fee reduction, coupled with peer counseling and navigation of women who have been diagnosed with cervical precancer, could be effective ways of improving adherence to follow-up. Further research is needed to explore the same phenomenon among women in rural areas, especially those who were initially attended to in mobile clinics.

Prevention of cervical cancer in HIV-seropositive women from developing countries through cervical cancer screening: a systematic review

BACKGROUND

There is scanty or inconclusive evidence on which cervical cancer screening tool is effective and suitable for human immunodeficiency virus (HIV)-seropositive women. The aim of this review was to assess, synthesise and document published evidence relating to the available cervical cancer screening modalities for HIV-seropositive women in developing countries. This paper did not review the issue of human papillomavirus (HPV) prophylactic vaccine on HIV-seropositive women.

METHODS

Five electronic databases were systematically searched from inception to January 2018 for relevant published original research examining cervical cancer prevention modalities for HPV infection, abnormal cytology and direct visualisation of the cervix amongst HIV-seropositive women in developing countries. Extra studies were identified through reference list and citation tracking.

RESULTS

Due to methodological and clinical heterogeneity, a narrative synthesis was presented. Of the 2559 articles, 149 underwent full-text screening and 25 were included in the review. Included studies were of moderate quality, and no exclusions were made based on quality or bias. There is no standard cervical cancer screening test or programme for HIV-seropositive women and countries screening according to available resources and expertise. The screening methods used for HIV-seropositive women are the same for HIV-negative women, with varying clinical performance and accuracy. The main cervical cancer screening methods described for HIV-seropositive women are HPV deoxyribonucleic acid/messenger RNA (DNA/mRNA) testing (n = 16, 64.0%), visual inspection with acetic acid (VIA) (n = 13, 52.0%) and Pap smear (n = 11, 44.0%). HPV testing has a better accuracy/efficiency than other methods with a sensitivity of 80.0-97.0% and specificity of 51.0-78.0%. Sequential screening using VIA or visual inspection with Lugol's iodine (VILI) and HPV testing has shown better clinical performance in screening HIV-seropositive women.

CONCLUSION

Although cervical cancer screening exists in almost all developing countries, what is missing is both opportunistic and systematic organised population-based screenings. Cervical cancer screening programmes need to be integrated into already existing HIV services to enable early detection and treatment. There is a need to offer opportunistic and coordinated screening programmes that are provider-initiated to promote early identification of cervical precancerous lesions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018095702.