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Pimple SA, Pahwa V, Mishra GA, Anand KV, Pathuthara S, Biswas SK. Screening for Early Detection of Cervical Cancer in Women Living with HIV in Mumbai, India - Retrospective Cohort Study from a Tertiary Cancer Center. Indian J Med Paediatr Oncol 2022. [DOI: 10.1055/s-0042-1742662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Abstract
Introduction Women living with human immunodeficiency virus (HIV) have an increased risk of persistent human papillomavirus infection (HPV) of developing cervical cancer precursors and are, therefore, considered at higher risk for cervical cancer. Despite the higher risk, screening for cervical cancer is extremely low among HIV-positive women in India.
Objectives Given the limited usefulness of cytology-based screening programs, the current study retrospectively evaluated the comparative performance of visual inspection with 5% acetic acid (VIA), conventional cytology, and human papillomavirus (HPV) testing among HIV-positive women attending the cancer screening clinic at the tertiary cancer center.
Materials and Methods Retrospective analysis of 291 HIV-positive women attending cervical cancer screening services in a tertiary cancer center in Mumbai was undertaken. All underwent simultaneous screening with VIA, Pap cytology, and HPV DNA testing, followed by diagnostic colposcopy and histopathology. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) to detect cervical intraepithelial neoplasia (CIN) 2/3 on histology were estimated.
Results The screen positivity rate for cervical cancer screening by VIA, high-risk HPV DNA, and Pap cytology was 35.7, 34.4, and 6.2% respectively. At the CIN2+ disease threshold, the sensitivity, specificity, PPV, and NPV estimates were 80.00% (59.30–93.17), 68.42% (62.46–73.96), 19.23% (15.46–23.67), 97.33% (94.30–98.77) for VIA; 80.00% (68.78–97.45), 70.68% (64.81–76.08), 22.00% (18.22–26.32), 98.43% (95.58–99.45) for HPV DNA; and 64.00% (42.52–82.03), 98.12% (95.67–99.39), 76.19% (56.13–88.89), 96.67% (94.50–98.00) for cytology (HSIL cutoff).
Conclusion The diagnostic performance of VIA and HPV DNA was comparable and better than cytology indicating that VIA as a cost-effective cervical cancer screening test can be incorporated within the services under sexually transmitted diseases /HIV testing and counseling centers within the country.
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Affiliation(s)
- Sharmila A. Pimple
- Department of Preventive Oncology, Centre for Cancer Epidemiology (CCE), Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Vandita Pahwa
- Department of Preventive Oncology, Centre for Cancer Epidemiology (CCE), Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Gauravi A. Mishra
- Department of Preventive Oncology, Centre for Cancer Epidemiology (CCE), Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Kavita V. Anand
- Department of Preventive Oncology, Centre for Cancer Epidemiology (CCE), Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Saleem Pathuthara
- Department of Microbiology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sanjay K. Biswas
- Department of Microbiology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Knowledge, Attitude, and Practice (KAP) toward Cervical Cancer Screening among Adama Science and Technology University Female Students, Ethiopia. Int J Breast Cancer 2022; 2022:2490327. [PMID: 35070454 PMCID: PMC8776479 DOI: 10.1155/2022/2490327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 02/10/2021] [Accepted: 12/28/2021] [Indexed: 11/18/2022] Open
Abstract
Background Cervical cancer is a complication of Human Papillomavirus (HPV) infection is the second most common cancer in women worldwide. Eighty percent of the cases occur in low-resource countries. According to the 2009 World Health Organization report, the age-adjusted incidence rate of cervical cancer in Ethiopia was 35.9 per 100,000 patients with 7619 annual number of new cases and 60-81 deaths every year. The study is aimed at assessing the level of knowledge, attitude, and practice concerning cervical cancer among female students at Adama Science and Technology University. Methodology. An institutional based cross-sectional study was conducted among 667Adama Science and Technology University female students. A simple random sampling method was used to select the respondents. Structured self-administered questionnaire was used for data collection. Results About 404 (60.6%) of the participants heard about cervical cancer, 478 (71.7%) had positive attitude towards cervical cancer screening, and only 15 (2.2%) participants were screened for cervical cancer. Lack of information about cervical cancer was the most reported reason for not attending to cervical cancer screening. Conclusion and Recommendation. The study showed that there was low knowledge on cervical cancer and screening for premalignant lesion among women. There is a need to promote and encourage women to early cervical cancer screening at precancerous stage by informing their susceptibility to cervical cancer.
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Tilahun T, Tulu T, Dechasa W. Knowledge, attitude and practice of cervical cancer screening and associated factors amongst female students at Wollega University, western Ethiopia. BMC Res Notes 2019; 12:518. [PMID: 31426860 PMCID: PMC6701027 DOI: 10.1186/s13104-019-4564-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 08/13/2019] [Indexed: 12/05/2022] Open
Abstract
Objective This study aimed to assess the knowledge, attitude and practice of cervical cancer screening and associated factors among female students of Wollega University, western Ethiopia in 2017. Results More than half, 54.4%, of participants had heard about cervical cancer and its risk factors. Only 35.8% knew about screening procedures such as pap smear (61.1%) and visual inspection with application of acetic acid (38.8%). Study participants from age of 21 to 25 years were about six times more likely to have satisfactory knowledge on cervical cancer screening compared to other age groups. Less than half of the study participants (44.1%) had a positive attitude towards cervical cancer screening. None of the study participants had been screened for cervical cancer in the past 3 years. Thus, different governmental and nongovernmental stakeholders need to focus on awareness about cervical cancer, its screening and preventive strategies.
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Affiliation(s)
- Temesgen Tilahun
- Institute of Health Sciences, Wollega University, Nekemte, Ethiopia.
| | - Tamirat Tulu
- East Wollega Zone Health Office, Nekemte, Ethiopia
| | - Worku Dechasa
- Institute of Health Sciences, Wollega University, Nekemte, Ethiopia
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Mapanga W, Girdler-Brown B, Feresu SA, Chipato T, Singh E. Prevention of cervical cancer in HIV-seropositive women from developing countries through cervical cancer screening: a systematic review. Syst Rev 2018; 7:198. [PMID: 30447695 PMCID: PMC6240280 DOI: 10.1186/s13643-018-0874-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 11/05/2018] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Witness Mapanga
- School of Health Systems and Public Health, Epidemiology & Biostatistics, University of Pretoria, 5-10 H.W. Snyman Building, Pretoria, South Africa. .,, Harare, Zimbabwe.
| | - Brendan Girdler-Brown
- School of Health Systems and Public Health, Epidemiology & Biostatistics, University of Pretoria, 5-10 H.W. Snyman Building, Pretoria, South Africa
| | - Shingairai A Feresu
- Faculty of Health Sciences, University of Fort Hare, 45 Church Street, Gasson Building, 7th Floor, P.O. Box 1054, East London, 5201, South Africa
| | - Tsungai Chipato
- Department of Obstetrics and Gynaecology, College of Health Sciences, University of Zimbabwe, Avondale, Harare, Zimbabwe
| | - Elvira Singh
- School of Health Systems and Public Health, Epidemiology & Biostatistics, University of Pretoria, 5-10 H.W. Snyman Building, Pretoria, South Africa.,Cancer Epidemiology Research Group, National Cancer Registry, National Health Laboratory Service, Johannesburg, South Africa
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Ekwunife OI, Lhachimi SK. Cost-effectiveness of Human Papilloma Virus (HPV) vaccination in Nigeria: a decision analysis using pragmatic parameter estimates for cost and programme coverage. BMC Health Serv Res 2017; 17:815. [PMID: 29216880 PMCID: PMC5721469 DOI: 10.1186/s12913-017-2758-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 11/23/2017] [Indexed: 02/06/2023] Open
Abstract
Background World Health Organisation recommends routine Human Papilloma Virus (HPV) vaccination for girls when its cost-effectiveness in the country or region has been duly considered. We therefore aimed to evaluate cost-effectiveness of HPV vaccination in Nigeria using pragmatic parameter estimates for cost and programme coverage, i.e. realistically achievable in the studied context. Methods A microsimulation frame-work was used. The natural history for cervical cancer disease was remodelled from a previous Nigerian model-based study. Costing was based on health providers’ perspective. Disability adjusted life years attributable to cervical cancer mortality served as benefit estimate. Suitable policy option was obtained by calculating the incremental costs-effectiveness ratio. Probabilistic sensitivity analysis was used to assess parameter uncertainty. One-way sensitivity analysis was used to explore the robustness of the policy recommendation to key parameters alteration. Expected value of perfect information (EVPI) was calculated to determine the expected opportunity cost associated with choosing the optimal scenario or strategy at the maximum cost-effectiveness threshold. Results Combination of the current scenario of opportunistic screening and national HPV vaccination programme (CS + NV) was the only cost-effective and robust policy option. However, CS + NV scenario was only cost-effective so far the unit cost of HPV vaccine did not exceed $5. EVPI analysis showed that it may be worthwhile to conduct additional research to inform the decision to adopt CS + NV. Conclusions National HPV vaccination combined with opportunist cervical cancer screening is cost-effective in Nigeria. However, adoption of this strategy should depend on its relative efficiency when compared to other competing new vaccines and health interventions.
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Affiliation(s)
- Obinna I Ekwunife
- Collaborative Research Group for Evidence-Based Public Health, Department of Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology - BIPS / University of Bremen, Bremen, Germany. .,Department of Clinical Pharmacy and Pharmacy Management, Nnamdi Azikiwe University, Awka, Nigeria.
| | - Stefan K Lhachimi
- Collaborative Research Group for Evidence-Based Public Health, Department of Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology - BIPS / University of Bremen, Bremen, Germany.,Institute for Public Health and Nursing Research - IPP, Health Sciences Bremen, University of Bremen, Bremen, Germany
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Poljak M, Šterbenc A, Lunar MM. Prevention of human papillomavirus (HPV)-related tumors in people living with human immunodeficiency virus (HIV). Expert Rev Anti Infect Ther 2017; 15:987-999. [PMID: 29027811 DOI: 10.1080/14787210.2017.1392854] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION In comparison to their HIV-negative counterparts, people living with HIV (PLWH) have a higher prevalence of human papillomavirus (HPV) infection in various anatomical sites coupled with increased HPV persistence, higher risk of HPV-related tumors, and faster disease progression. Areas covered: Gender-neutral prevention strategies for HPV-related cancers in PLWH discussed: ABC approach, HPV vaccination, antiretroviral treatment (ART), anal cancer screening, and smoking cessation. Gender specific strategies: cervical cancer screening reduces the incidence and mortality of cervical cancer and circumcision might reduce the risk of HPV infections in men. Expert commentary: HPV-related cancer incidence has not declined (e.g. cervical cancer) and has even increased (e.g. anal cancer) in the ART era, demanding an effective HPV prevention strategy. HPV vaccination should be introduced into national prevention programs worldwide immediately because current prophylactic vaccines are safe, tolerable, and immunogenic in PLWH. HPV vaccine efficacy trials in PLWH are essential to determine the most appropriate immunization schedule. The population most at risk of anal cancer is HIV-positive men who have sex with men, who are not protected by herd immunity if only the female population is vaccinated. Unvaccinated PLWH need enhanced surveillance for early detection of HPV-related cancers and their precursors.
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Affiliation(s)
- Mario Poljak
- a Institute of Microbiology and Immunology, Faculty of Medicine , University of Ljubljana , Ljubljana , Slovenia
| | - Anja Šterbenc
- a Institute of Microbiology and Immunology, Faculty of Medicine , University of Ljubljana , Ljubljana , Slovenia
| | - Maja M Lunar
- a Institute of Microbiology and Immunology, Faculty of Medicine , University of Ljubljana , Ljubljana , Slovenia
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Ghebre RG, Grover S, Xu MJ, Chuang LT, Simonds H. Cervical cancer control in HIV-infected women: Past, present and future. Gynecol Oncol Rep 2017; 21:101-108. [PMID: 28819634 PMCID: PMC5548335 DOI: 10.1016/j.gore.2017.07.009] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 07/18/2017] [Indexed: 01/17/2023] Open
Abstract
Since the initial recognition of acquired immunodeficiency syndrome (AIDS) in 1981, an increased burden of cervical cancer was identified among human immunodeficiency virus (HIV)-positive women. Introduction of antiretroviral therapy (ART) decreased risks of opportunistic infections and improved overall survival. HIV-infected women are living longer. Introduction of the human papillomavirus (HPV) vaccine, cervical cancer screening and early diagnosis provide opportunities to reduce cervical cancer associated mortality. In line with 2030 Sustainable Development Goals to reduce mortality from non-communicable diseases, increased efforts need to focus on high burden countries within sub-Saharan Africa (SSA). Despite limitations of resources in SSA, opportunities exist to improve cancer control. This article reviews advancements in cervical cancer control in HIV-positive women.
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Affiliation(s)
- Rahel G. Ghebre
- University of Minnesota Medical School, Minneapolis, MN, USA
- Human Resources for Health, Rwanda
- School of Medicine, Yale University, CT, USA
| | - Surbhi Grover
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Melody J. Xu
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Linus T. Chuang
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hannah Simonds
- Division of Radiation Oncology, Tygerberg Hospital/University of Stellenbosch, Stellenbosch, South Africa
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Viviano M, DeBeaudrap P, Tebeu PM, Fouogue JT, Vassilakos P, Petignat P. A review of screening strategies for cervical cancer in human immunodeficiency virus-positive women in sub-Saharan Africa. Int J Womens Health 2017; 9:69-79. [PMID: 28203108 PMCID: PMC5298303 DOI: 10.2147/ijwh.s103868] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Cervical cancer (CC) is a leading cause of cancer-related death and a major public health issue in sub-Saharan Africa. This heavy burden parallels that of the human immunodeficiency virus (HIV) infection, which increases the risk of developing CC. Despite the progressive reduction of HIV prevalence in the past decade, the CC incidence and mortality rates in sub-Saharan Africa remain high. The heterogeneity of the distribution of the two diseases in the African continent, together with the different availability of human and material resources, stands in the way of finding an appropriate screening strategy. The lack of high-quality evidence on the prevention of CC for HIV-positive women, which is necessary for the implementation of efficient screening and treatment strategies, results in the absence of a clearly defined program, which is responsible for the low screening uptake and high mortality rates in sub-Saharan Africa. By taking advantage of the HIV-positive women's frequent access to health facilities, one way to increase the CC screening coverage rates would be by providing integrated HIV and screening services within the same infrastructure. With the increasing availability of cost-effective methods, screening is becoming more and more available to women who have limited access to health care. Moreover, the introduction of point-of-care technologies for human papillomavirus testing and the subsequent implementation of screen-and-treat strategies, by reducing the number of clinical appointments and, in the long term, the loss to follow-up rates, open up new opportunities for all women, regardless of their HIV status. The purpose of this review is to provide an insight into the different screening practices for CC in order to help define one that is adapted to the resources and necessities of HIV-positive women living in middle-to-low income countries.
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Affiliation(s)
- Manuela Viviano
- Gynecology Division, Geneva University Hospitals, Geneva, Switzerland
| | - Pierre DeBeaudrap
- Centre Population et Développement - UMR 196, Institute of Research for the Development, University of Paris-Descartes, Paris, France
| | - Pierre-Marie Tebeu
- Faculty of Medicine and Biomedical Sciences and Centre Hospitalier Universitaire (CHUY), Yaoundé, Cameroon, Africa
| | - Jovanny T Fouogue
- Faculty of Medicine and Biomedical Sciences and Centre Hospitalier Universitaire (CHUY), Yaoundé, Cameroon, Africa
| | - Pierre Vassilakos
- Geneva Foundation for Medical Education and Research, Geneva, Switzerland
| | - Patrick Petignat
- Gynecology Division, Geneva University Hospitals, Geneva, Switzerland
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Evaluation of a cervicography-based program to ensure quality of visual inspection of the cervix in HIV-infected women in Johannesburg, South Africa. J Low Genit Tract Dis 2015; 19:7-11. [PMID: 24914887 PMCID: PMC4272220 DOI: 10.1097/lgt.0000000000000040] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Quality assurance with cervicography and specialist review significantly improved the sensitivity of visual inspection with acetic acid to detect cervical intraepithelial neoplasia grade 2 or worse. Objective To determine whether a quality assurance (QA) program using digital cervicography improved the performance of a visual inspection with acetic acid (VIA) to detect cervical intraepithelial neoplasia grade 2 or worse (CIN 2+) in HIV-infected women in Johannesburg, South Africa. Materials and Methods Visual inspection with acetic acid was performed among HIV-infected women, aged 18 to 65 years, in Johannesburg, South Africa. Nurses received 2 weeks of training on the VIA procedure. The VIA interpretation was performed in real time. The VIA results were then photographed using a retail available digital camera. A gynecologist and medical officer reviewed the VIA digital images within 2 weeks of the procedure. Colposcopic biopsy was performed on all women with positive VIA and 25% negative VIA results. Sensitivity and specificity of VIA for the detection of CIN 2+ were compared between the nurses and physicians at the beginning and at the end of the study. Results Positive VIA results were found in 541 (45%) of the 1,202 participating women. The sensitivity of VIA to predict CIN 2+ was improved from 65% to 75% (p = .001) with the addition of digital cervicography and specialist review. There was no statistical difference in the sensitivity of the VIA readings when comparing the first 600 participants to the final 593 participants between the nurses (p = .613) and physicians (p = .624). Conclusions Quality assurance performed by specialists using digital cervicography improved the sensitivity of VIA. There was no difference in sensitivity in interpreting VIA between the beginning and the end of the study. Quality assurance should form a cornerstone of any VIA program to improve sensitivity in detecting CIN 2+ lesions.
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Kress CM, Sharling L, Owen-Smith AA, Desalegn D, Blumberg HM, Goedken J. Knowledge, attitudes, and practices regarding cervical cancer and screening among Ethiopian health care workers. Int J Womens Health 2015; 7:765-72. [PMID: 26261427 PMCID: PMC4527576 DOI: 10.2147/ijwh.s85138] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Though cervical cancer incidence has dramatically decreased in resource rich regions due to the implementation of universal screening programs, it remains one of the most common cancers affecting women worldwide and has one of the highest mortality rates. The vast majority of cervical cancer-related deaths are among women that have never been screened. Prior to implementation of a screening program in Addis Ababa University-affiliated hospitals in Ethiopia, a survey was conducted to assess knowledge of cervical cancer etiology, risk factors, and screening, as well as attitudes and practices regarding cervical cancer screening among women's health care providers. METHODS Between February and March 2012 an anonymous, self-administered survey to assess knowledge, attitudes, and practices related to cervical cancer and its prevention was distributed to 334 health care providers at three government hospitals in Addis Ababa, Ethiopia and three Family Guidance Association clinics in Awassa, Adama, and Bahir Dar. Data were analyzed using SPSS software and chi-square test was used to test differences in knowledge, attitudes, and practices across provider type. RESULTS Overall knowledge surrounding cervical cancer was high, although awareness of etiology and risk factors was low among nurses and midwives. Providers had no experience performing cervical cancer screening on a routine basis with <40% having performed any type of cervical cancer screening. Reported barriers to performing screening were lack of training (52%) and resources (53%); however the majority (97%) of providers indicated cervical cancer screening is an essential part of women's health care. CONCLUSION There is a clear need among women's health care providers for education regarding cervical cancer etiology, risk factors and for training in low-tech, low-cost screening methods. Meeting these needs and improving the infrastructure necessary to implement appropriate screening programs is essential to reduce the burden of cervical cancer in Ethiopia.
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Affiliation(s)
- Catherine M Kress
- Department of Gynecology and Obstetrics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lisa Sharling
- Division of Infectious Diseases, Department of Medicine, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Ashli A Owen-Smith
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Dawit Desalegn
- Department of Gynecology and Obstetrics, Addis Ababa University School of Medicine, Addis Ababa, Ethiopia
| | - Henry M Blumberg
- Division of Infectious Diseases, Department of Medicine, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jennifer Goedken
- Department of Gynecology and Obstetrics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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A systematic review of the effects of visual inspection with acetic acid, cryotherapy, and loop electrosurgical excision procedures for cervical dysplasia in HIV-infected women in low- and middle-income countries. J Acquir Immune Defic Syndr 2015; 68 Suppl 3:S350-6. [PMID: 25768874 DOI: 10.1097/qai.0000000000000488] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cervical cancer, almost all of which is caused by human papillomavirus, accounts for 12% of female cancers worldwide and is more common among HIV-infected women. Nine of 10 deaths from cervical cancer occur in low- and middle-income countries (LMICs). Simple screening methods and outpatient treatment of precursor lesions save lives but the benefit of these interventions among HIV-infected women is uncertain. OBJECTIVE We reviewed evidence of the effects of screening with visual inspection with acetic acid (VIA), and outpatient treatment for cervical precancer among HIV-infected women in LMIC. METHODS A systematic review of articles published from January 1995 through July 2013 was conducted using key terms for VIA cervical screening, cervical precancer treatment with cryotherapy or loop electrosurgical excision procedure, HIV-infected women, low-resource settings, and outcomes, including morbidity and mortality. RESULTS Of 2159 articles screened, 14 met inclusion criteria; all considered only morbidity outcomes. No articles dealt with the long-term impact of screening/treatment on cervical cancer incidence or mortality among HIV-infected women. Articles reported on performance of VIA, prevalence of cervical dysplasia, and complications and rates of recurrent dysplasia after treatment. CONCLUSIONS Dysplasia prevalence and recurrence were higher among HIV-infected compared with HIV-uninfected women but morbidity from treatment was similar. Few data exist on long-term outcomes of VIA, cryotherapy, or loop electrosurgical excision procedure interventions among HIV-infected women in LMIC; longer-term outcomes research is needed to assess the effects of VIA or other screening modalities and outpatient treatment on prevention of cervical cancer among HIV-infected women.
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Zahedi L, Sizemore E, Malcolm S, Grossniklaus E, Nwosu O. Knowledge, attitudes and practices regarding cervical cancer and screening among Haitian health care workers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2014; 11:11541-52. [PMID: 25390794 PMCID: PMC4245628 DOI: 10.3390/ijerph111111541] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 11/04/2014] [Accepted: 11/05/2014] [Indexed: 11/28/2022]
Abstract
It is estimated that Haiti has the highest incidence of cervical cancer in the Western Hemisphere. There are currently no sustainable and affordable cervical cancer screening programs in Haiti. The current status of screening services and knowledge of health care professionals was assessed through a Knowledge, Attitudes, and Practices survey on cervical cancer screening and prevention. It was distributed to Project Medishare for Haiti health care workers (n = 27) in the Central Plateau. The majority (22/27) of participants stated pre-cancerous cells could be detected through screening, however, only four had ever performed a pap smear. All of the participants felt a screening program should be started in their area. Our data establishes that knowledge is fairly lacking among healthcare workers and there is an opportunity to train them in simple, cost effective "screen-and-treat" programs that could have a great impact on the overall health of the population.
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Affiliation(s)
- Leilah Zahedi
- Department of Obstetrics and Gynecology, Emory University, 69 Jesse Hill Junior Drive South East, Atlanta, GA 30303, USA.
| | - Emma Sizemore
- Rollins School of Public Health, Emory University, 1518 Clifton Rd. North East, Atlanta, GA 30322, USA.
| | - Stuart Malcolm
- School of Medicine, Emory University, 201 Dowman Drive, Atlanta, GA 30322, USA.
| | - Emily Grossniklaus
- School of Medicine, Emory University, 201 Dowman Drive, Atlanta, GA 30322, USA.
| | - Oguchi Nwosu
- Department of Family and Preventive Medicine, Emory University, 201 Dowman Drive, Atlanta, GA 30322, USA.
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Huchko MJ, Sneden J, Sawaya G, Smith-McCune K, Maloba M, Abdulrahim N, Bukusi EA, Cohen CR. Accuracy of visual inspection with acetic acid to detect cervical cancer precursors among HIV-infected women in Kenya. Int J Cancer 2014; 136:392-8. [PMID: 24889387 DOI: 10.1002/ijc.28996] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 05/15/2014] [Indexed: 01/06/2023]
Abstract
Visual inspection with acetic acid (VIA) is becoming a more widely recommended and implemented screening tool for cervical cancer prevention programs in low-resource settings. Many of these settings have a high prevalence of HIV-infected women. We carried out a cross-sectional validation study to define the sensitivity, specificity and predictive values of VIA among HIV-infected women. Women enrolled in HIV care at the Family AIDS Care and Education Services clinic in Kisumu, Kenya, were recruited for participation. All participants underwent VIA followed by colposcopy performed by a second blinded clinician. At colposcopy, lesions suspicious for cervical intraepithelial neoplasia 2 or greater (CIN2+) were biopsied. Disease status was determined by final histopathologic diagnosis in women who underwent biopsies. A satisfactory colposcopy with no lesions was considered a negative result. From October 2010 to June 2012, 1,432 women underwent VIA and colposcopy. A total of 514 (35.7%) women had a positive VIA, and 179 (12.2%) had CIN2+ confirmed by colposcopically directed biopsy. Sensitivity, specificity, positive and negative predictive values of VIA for CIN2+ were 86.6, 71.6, 30.3 and 97.4%, respectively. Specificity, but not sensitivity, increased with older age. Among older women, sensitivity was affected by CD4+ count and use of antiretroviral therapy. Although they are impacted by age and immune status, test characteristics for VIA among HIV-infected women are similar to what has been reported for general populations. Recommendations to use VIA as a screening tool should not vary by HIV status.
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Affiliation(s)
- Megan J Huchko
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA
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The association between HIV infection, antiretroviral therapy and cervical squamous intraepithelial lesions in South Western Nigerian women. PLoS One 2014; 9:e97150. [PMID: 24809726 PMCID: PMC4014606 DOI: 10.1371/journal.pone.0097150] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 04/15/2014] [Indexed: 11/19/2022] Open
Abstract
Introduction Findings from studies that evaluated the effect of antiretroviral drug use on the development of cervical squamous intraepithelial lesion differed in their conclusions. This study investigated the association between HIV infection, antiretroviral drug use and cervical squamous intraepithelial lesion in a high HIV and cervical cancer burden setting- Nigeria. Methods A cross sectional study among 1140 women of known HIV status enrolled in a randomised study to determine the test characteristics of visual inspection in detecting cytology diagnosed squamous intraepithelial lesion. Multivariate analysis was used to determine the association between HIV infection, antiretroviral drug use and the twin outcome variables of cervical squamous intraepithelial lesion (SIL) and High grade squamous intraepithelial lesion (HSIL) while controlling for confounders. Results Prevalence of cervical squamous intraepithelial lesion was 8.5%, with a higher prevalence of 14.3% in HIV positive compared to 3.3% in HIV negative women (aOR: 5.4; 95% CI: 2.9–8.8). Not using antiretroviral drugs was found to be associated with an increased risk of SIL (aOR: 2.1; 95% CI: 1.4–3.5) and HSIL (aOR: 2.6; 95% CI: 1.1–6.4). Participants who had a CD4 cell count <200 cells/mm3, were also found to be at increased risk for SIL (aOR: 1.9; 95% CI: 1.1–5.9) and HSIL (aOR: 5.7; 95% CI: 1.1–7.2). Conclusion HIV infection and severe immunosuppression were found to be associated with increased risk of cervical squamous intraepithelial lesion but not viral load. For the first time, in the West African sub-region with specific HIV type and strains, we established the protective effect of antiretroviral drug use against the development of SIL. Integration of cervical cancer screening programme into HIV services and early initiation of antiretroviral drug in HIV positive women especially those with severe immune-suppression could therefore prove to be useful in preventing and controlling cervical cancer development in HIV positive women.
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Comparing Papanicolau smear, visual inspection with acetic acid and human papillomavirus cervical cancer screening methods among HIV-positive women by immune status and antiretroviral therapy. AIDS 2013; 27:2909-19. [PMID: 23842133 DOI: 10.1097/01.aids.0000432472.92120.1b] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND A rigorous comparison of cervical cancer screening methods utilizing data on immune status, antiretroviral therapy (ART) and colposcopy-directed biopsy has not been performed among HIV-positive women. METHODS Between June and November 2009, 500 HIV-positive women were enrolled at an HIV treatment clinic in Nairobi, Kenya, and underwent Papanicolau (Pap) smear, visual inspection with acetic acid (VIA), human papillomavirus (HPV) and colposcopy-directed biopsy (gold standard). Positive Pap smear (ASCUS+, LSIL+, HSIL+), VIA, HPV and their combinations were compared with CIN2/3+. Sensitivity, specificity and AUC (sensitivity and 1-specificity) were compared using pairwise tests and multivariate logistic regression models that included age, CD4⁺ cell count and ART duration. RESULTS Of 500 enrolled, 498 samples were collected. On histology, there were 172 (35%) normal, 186 (37%) CIN1, 66 (13%) CIN2, 47 (9%) CIN3 and 27 (5%) indeterminate. Pap (ASCUS+) was the most sensitive screening method (92.7%), combination of both Pap (HSIL+) and VIA positive was the most specific (99.1%) and Pap (HSIL+) had the highest AUC (0.85). In multivariate analyses, CD4⁺ cell count of 350 cells/μl or less was associated with decreased HPV specificity (P = 0.002); ART duration of less than 2 years was associated with decreased HPV (P = 0.01) and VIA (P = 0.03) specificity; and age less than 40 years was associated with increased VIA sensitivity (P < 0.001) and decreased HPV specificity (P = 0.005). CONCLUSION Pap smear is a robust test among HIV-positive women regardless of immune status or ART duration. Results should be cautiously interpreted when using HPV among those younger, immunosuppressed or on ART less than 2 years, and when using VIA among those aged 40 years or more.
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Huchko MJ, Leslie H, Sneden J, Maloba M, Abdulrahim N, Bukusi EA, Cohen CR. Risk factors for cervical precancer detection among previously unscreened HIV-infected women in Western Kenya. Int J Cancer 2013; 134:740-5. [PMID: 23900762 DOI: 10.1002/ijc.28401] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 07/09/2013] [Indexed: 11/11/2022]
Abstract
HIV and cervical cancer are intersecting epidemics in many low-resource settings, yet there are few accurate estimates of the scope of this public health challenge. To understand disease prevalence and risk factors for cervical intraepithelial neoplasia 2 or greater (CIN2+), we conducted a cross-sectional study of women undergoing cervical cancer screening as part of routine HIV care in Kisumu, Kenya. Women were offered screening with visual inspection with acetic acid, followed by confirmation with colposcopy and biopsy as needed. Univariable and multivariable analyses were carried out to determine clinical and demographic predictors of prevalent CIN2+. Among 3,241 women screened, 287 (9%) had an initial diagnosis of biopsy-confirmed CIN2+. On multivariable analysis, combined oral contraceptives remained significantly associated with detection of CIN2+ among women on HAART (AOR 1.84, CI 1.20-2.82), and not on HAART (AOR 1.72, 95% CI 1.08-2.73), while use of a progesterone implant was associated with increased detection of CIN2+ (AOR 9.43, 95% CI 2.85-31.20) only among women not on HAART. CD4+ nadir over 500 cells/mm(3) was associated with reduced detection of CIN2+ (AOR 0.61, CI 0.38, 0.97) in the overall group, but current CD4+ was only associated with reduced detection of CIN2+ among women not on HAART (AOR 0.42, CI 0.22, 0.80). In conclusion, a history of less severe immunosuppression appeared to reduce the risk of CIN2+ detection, but current CD4+ count was significant only in non-HAART users. The association of CIN2+ with hormonal contraception should be explored more in prospective studies designed to better control for confounding factors.
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Affiliation(s)
- Megan J Huchko
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA
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Odafe S, Torpey K, Khamofu H, Oladele E, Adedokun O, Chabikuli O, Mukaddas H, Usman Y, Aiyenigba B, Okoye M. Integrating cervical cancer screening with HIV care in a district hospital in Abuja, Nigeria. Niger Med J 2013; 54:176-84. [PMID: 23901180 PMCID: PMC3719244 DOI: 10.4103/0300-1652.114590] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Human immunodeficiency virus positive (HIV+) women have a higher risk of developing invasive cervical cancer compared with uninfected women. This study aims to document programmatic experience of integrating cervical cancer screening using Visual Inspection and Acetic Acid (VIA) into HIV care as well as to describe patients' characteristics associated with positive VIA findings amongst HIV+ women. MATERIALS AND METHODS A cross-sectional study analysed routine service data collected at the antiretroviral therapy (ART) and cervical cancer screening services. Our program integrated screening for cervical cancer using VIA technique to HIV care and treatment services through a combination of stakeholder engagement, capacity building for health workers, creating a bi-directional referral between HIV and reproductive health (RH) services and provider initiated counselling and screening for cervical cancer. Information on patients' baseline and clinical characteristics were captured using an electronic medical records system and then exported to Statistical Package for the Social Sciences (SPSS). Logistic regression model was used to estimate factors that influence VIA results. RESULTS A total of 834 HIV+ women were offered VIA screening between April 2010 and April 2011, and 805 (96.5%) accepted it. Complete data was available for 802 (96.2%) women. The mean age at screening and first sexual contact were 32.0 (SD 6.6) and 18.8 (SD 3.5) years, respectively. VIA was positive in 52 (6.5%) women while 199 (24.8%) had a sexually transmitted infection (STI). Of the 199 who had a STI, eight (4.0%) had genital ulcer syndrome, 30 (15.1%) had lower abdominal pain syndrome and 161 (80.9%) had vaginal discharge syndrome. Presence of lower abdominal pain syndrome was found to be a significant predictor of a positive VIA result (P = 0.001). Women with lower abdominal pain syndrome appeared to be more likely (OR 47.9, 95% CI: 4.8-480.4, P = 0.001) to have a positive VIA result. CONCLUSION The high burden of both HIV and cervical cancer in developing countries makes it a necessity for integrating services that offer early detection and treatment for both diseases. The findings from our study suggest that integrating VIA screening into the package of care offered to HIV+ women is feasible and acceptable.
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Affiliation(s)
- Solomon Odafe
- Department of Prevention, Care and Treatment, FHI 360, Garki, Nigeria
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Firnhaber C, Mayisela N, Mao L, Williams S, Swarts A, Faesen M, Levin S, Michelow P, Omar T, Hudgens MG, Williamson AL, Allan B, Lewis DA, Smith JS. Validation of cervical cancer screening methods in HIV positive women from Johannesburg South Africa. PLoS One 2013; 8:e53494. [PMID: 23326441 PMCID: PMC3543403 DOI: 10.1371/journal.pone.0053494] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 11/29/2012] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND HIV-infected women are at increased risk for developing cervical cancer. Women living in resource-limited countries are especially at risk due to poor access to cervical cancer screening and treatment. We evaluated three cervical cancer screening methods to detect cervical intraepithelial neoplasia grade 2 and above (CIN 2+) in HIV-infected women in South Africa; Pap smear, visual inspection with 5% acetic acid (VIA) and human papillomavirus detection (HPV). METHODS HIV-infected women aged 18-65 were recruited in Johannesburg. A cross-sectional study evaluating three screening methods for the detection of the histologically-defined gold standard CIN-2 + was performed. Women were screened for cervical abnormalities with the Digene HC2 assay (HPV), Pap smear and VIA. VIA was performed by clinic nurses, digital photographs taken and then later reviewed by specialist physicians. The sensitivity, specificity and predictive valves for CIN-2 + were calculated using maximum likelihood estimators. RESULTS 1,202 HIV-infected women participated, with a median age of 38 years and CD4 counts of 394 cells/mm(3). One third of women had a high grade lesion on cytology. VIA and HPV were positive in 45% and 61% of women respectively. Estimated sensitivity/specificity for HPV, Pap smear and VIA for CIN 2+ was 92%/51.4%, 75.8%/83.4% and 65.4/68.5% (nurse reading), respectively. Sensitivities were similar, and specificities appeared significantly lower for the HPV test, cytology and VIA among women with CD4 counts ≤200 cells/mm(3) as compared to CD4 counts >350 cells/mm(3). CONCLUSIONS Although HPV was the most sensitive screening method for detecting CIN 2+, it was less specific than conventional cytology and VIA with digital imaging review. Screening programs may need to be individualized in context of the resources and capacity in each area.
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Affiliation(s)
- Cynthia Firnhaber
- Faculty of Health Science Centre, Department of Medicine, University of Witwatersrand, Johannesburg, South Africa.
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Zhang HY, Tiggelaar SM, Sahasrabuddhe VV, Smith JS, Jiang CQ, Mei RB, Wang XG, Li ZA, Qiao YL. HPV prevalence and cervical intraepithelial neoplasia among HIV-infected women in Yunnan Province, China: a pilot study. Asian Pac J Cancer Prev 2012; 13:91-6. [PMID: 22502720 DOI: 10.7314/apjcp.2012.13.1.091] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES To determine the prevalence of HPV and cervical neoplasia among HIV-infected women in southwestern China. METHODS Cervical cytology, HPV detection by Hybrid Capture-2™ assay, and diagnostic colposcopy were followed by cervical biopsy if indicated. Logistic regression analysis was used to analyze associations between HPV co-infection and cervical intraepithelial neoplasia (CIN), and HIV-related clinical and laboratory parameters. RESULTS Colposcopic-histopathologically proven CIN2+ lesions were present in 7/83 (8.4%) HIV-infected women. Nearly half (41/83, 43%) were co-infected with carcinogenic HPV genotypes. HPV co-infection was higher in women with colposcopic-histopathologically proven CIN2+ lesions than women with <CIN1 after adjusting for age (OR: 8.3, 95% CI: 0.9, 73.4). Women with CD4+ cell counts less than 350 cells/μL had higher CIN2+ prevalence after adjusting for current ART status and age (adjusted OR: 6.3, 95% CI: 1.1, 36.5). CONCLUSIONS HIV/AIDS care and treatment programs should integrate effective cervical cancer prevention services to mitigate the risk of invasive cervical cancer among HIV-infected women in China.
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Albert SO, Oguntayo OA, Samaila MOA. Comparative study of visual inspection of the cervix using acetic acid (VIA) and Papanicolaou (Pap) smears for cervical cancer screening. Ecancermedicalscience 2012; 6:262. [PMID: 22855689 PMCID: PMC3408898 DOI: 10.3332/ecancer.2012.262] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Indexed: 11/30/2022] Open
Abstract
This article is a comparative study of two screening methods for pre-invasive lesions of the cervix. The Papanicolaou (Pap) smear, an old and tested screening method, is compared with the findings from visual inspection of the cervix following acetic acid (VIA) wash. VIA is a new screening method being advocated by the World Health Organization as an alternative to Pap smear in low-resource settings.
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Affiliation(s)
- SO Albert
- Department of Obstetrics and Gynaecology, ABU Teaching Hospital, Zaria, Nigeria
| | - OA Oguntayo
- Department of Obstetrics and Gynaecology, ABU Teaching Hospital, Zaria, Nigeria
| | - MOA Samaila
- Department of Pathology, ABU Teaching Hospital, Zaria, Nigeria
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Comparison of conventional cervical cytology versus visual inspection with acetic acid among human immunodeficiency virus-infected women in Western Kenya. J Low Genit Tract Dis 2012; 16:92-7. [PMID: 22126834 DOI: 10.1097/lgt.0b013e3182320f0c] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE This study aimed to determine the accuracy of visual inspection with acetic acid (VIA) versus conventional Pap smear as a screening tool for cervical intraepithelial neoplasia/cancer among human immunodeficiency virus (HIV)-infected women. MATERIALS AND METHODS A total of 150 HIV-infected women attending the Moi Teaching and Referral Hospital HIV clinic in Eldoret underwent conventional Pap smear, VIA, colposcopy, and biopsy. Both VIA and Pap smears were done by nurses, whereas colposcopy and biopsy were done by a physician. Receiver operating characteristic analysis was conducted to compare the accuracies between VIA and Pap smear in sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS Among the study participants: VIA was abnormal in 55.3% (83/150, 95% confidence interval [CI] = 47.0%-63.5%); Pap smear showed atypical squamous cells of undetermined significance or worse in 43.7% (59/135, 95% CI = 35.2%-52.5%) and 10% (15/150) of the Pap smears were unsatisfactory. Of the abnormal Pap smears, 3% (2/59) had atypical squamous cells of undetermined significance, 7% (4/59) had high-grade atypical squamous cells, 60% (35/59) had low-grade squamous intraepithelial lesions, 29% (17/59) had high-grade squamous intraepithelial lesions, and 2% (1/59) was suspicious for cervical cancer. Using cervical intraepithelial neoplasia 2 or higher disease on biopsy as an end point, VIA has a sensitivity of 69.6% (95% CI = 55.1%-81.0%), specificity of 51.0% (95% CI = 41.5%-60.4%), PPV of 38.6% (95% CI = 28.8%-49.3%), and NPV of 79.1% (95% CI = 67.8%-87.2%). For conventional Pap smear, sensitivity was 52.5% (95% CI = 42.1%-71.5%), specificity was 66.3% (95% CI = 52.0%-71.2%), PPV was 39.7% (95% CI = 27.6%-51.8%), and NPV was 76.8% (95% CI = 67.0%-85.6%). CONCLUSIONS Visual inspection with acetic acid is comparable to Pap smear and acceptable for screening HIV-infected women in resource-limited settings such as Western Kenya.
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Dim CC, Ezegwui HU, Ikeme AC, Nwagha UI, Onyedum CC. Prevalence of cervical squamous intraepithelial lesions among HIV-positive women in Enugu, South-eastern Nigeria. J OBSTET GYNAECOL 2011; 31:759-62. [DOI: 10.3109/01443615.2011.598967] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
Cervical cancer remains the second commonest cancer among women worldwide, and more than 85% of the global burden of this disease occurs in the developing world. HIV-infected women have a higher likelihood of developing persistent high-risk human papillomavirus (HPV) infection, precancer, and invasive cervical cancer than seronegative women. Although highly effective primary and secondary prevention strategies are currently available, they remain inaccessible to the vast majority of women. Because of their simplicity and affordability, see-and-treat cervical cancer screening modalities have the potential to substantially improve women's access to cancer prevention, as well as to create much needed infrastructure for future molecular-based cervical screening and HPV vaccination programs. Additional data addressing the effectiveness of see-and-treat approaches for HIV-infected women are urgently needed. Studies informing best practice guidelines on when to start, when to stop, and how frequently to screen HIV-infected women within the see-and-treat paradigm would be of great value.
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Sahasrabuddhe VV, Bhosale RA, Kavatkar AN, Nagwanshi CA, Joshi SN, Jenkins CA, Shepherd BE, Kelkar RS, Sahay S, Risbud AR, Vermund SH, Mehendale SM. Comparison of visual inspection with acetic acid and cervical cytology to detect high-grade cervical neoplasia among HIV-infected women in India. Int J Cancer 2011; 130:234-40. [PMID: 21387289 DOI: 10.1002/ijc.25971] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Accepted: 01/10/2011] [Indexed: 12/12/2022]
Abstract
Human immunodeficiency virus (HIV)-infected women in India and other developing country settings are living longer on antiretroviral therapy, yet their risk for human papillomavirus (HPV)-induced cervical cancer remains unabated because of lack of cost-effective and accurate secondary prevention methods. Visual inspection after application of dilute acetic acid on the cervix (VIA) has not been adequately studied against the current standard: conventional cervical cytology (Pap smears) among HIV-infected women. We evaluated 303 nonpregnant HIV-infected women in Pune, India, by simultaneous and independent screening with VIA and cervical cytology with disease ascertainment by colposcopy and histopathology. At the cervical intraepithelial neoplasia (CIN2+) disease threshold, the sensitivity, specificity and positive and negative predictive value estimates of VIA were 80, 82.6, 47.6 and 95.4% respectively, compared to 60.5, 59.6, 22.4 and 88.7% for the atypical squamous cells of undetermined significance or severe (ASCUS+) cutoff on cytology, 60.5, 64.6, 24.8 and 89.4% for the low-grade squamous intraepithelial cells or severe (LSIL+) cutoff on cytology and 20.9, 96.0, 50.0 and 86.3% for high-grade squamous intraepithelial lesion or severe (HSIL+) cutoff on cytology. A similar pattern of results was found for women with the presence of carcinogenic HPV-positive CIN2+ disease, as well as for women with CD4+ cell counts <200 and <350 μL(-1) . Overall, VIA performed better than cytology in this study with biologically rigorous endpoints and without verification bias, suggesting that VIA is a practical and useful alternative or adjunctive screening test for HIV-infected women. Implementing VIA-based screening within HIV/acquired immunodeficiency syndrome care programs may provide an easy and practical means of complementing the highly anticipated low-cost HPV-based rapid screening tests in the near future, thereby contributing to improve program effectiveness of screening.
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Pantanowitz L, Michelow P. Review of Human Immunodeficiency Virus (HIV) and squamous lesions of the uterine cervix. Diagn Cytopathol 2010; 39:65-72. [DOI: 10.1002/dc.21364] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Parham GP, Mwanahamuntu MH, Sahasrabuddhe VV, Westfall AO, King KE, Chibwesha C, Pfaendler KS, Mkumba G, Mudenda V, Kapambwe S, Vermund SH, Hicks ML, Stringer JS, Chi BH. Implementation of cervical cancer prevention services for HIV-infected women in Zambia: measuring program effectiveness. ACTA ACUST UNITED AC 2010; 4:703-722. [PMID: 25419240 DOI: 10.2217/hiv.10.52] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Cervical cancer kills more women in low-income nations than any other malignancy. A variety of research and demonstration efforts have proven the efficacy and effectiveness of low-cost cervical cancer prevention methods but none in routine program implementation settings of the developing world, particularly in HIV-infected women. METHODS In our public sector cervical cancer prevention program in Zambia, nurses conduct screening using visual inspection with acetic acid aided by digital cervicography. Women with visible lesions are offered same-visit cryotherapy or referred for histologic evaluation and clinical management. We analyzed clinical outcomes and modeled program effectiveness among HIV-infected women by estimating the total number of cervical cancer deaths prevented through screening and treatment. RESULTS Between 2006 and 2008, 6572 HIV-infected women were screened, 53.6% (3523) had visible lesions, 58.5% (2062) were eligible for cryotherapy and 41.5% (1461) were referred for histologic evaluation. A total of 75% (1095 out of 1462) of patients who were referred for evaluation complied. Pathology results from 65% (715 out of 1095) of women revealed benign abnormalities in 21% (151), cervical intraepithelial neoplasia (CIN) I in 30% (214), CIN 2/3 in 33% (235) and invasive cervical cancer in 16.1% (115, of which 69% were early stage). Using a conditional probability model, we estimated that our program prevented 142 cervical cancer deaths (high/low range: 238-96) among the 6572 HIV-infected women screened, or one cervical cancer death prevented per 46 (corresponding range: 28-68) HIV-infected women screened. CONCLUSION Our prevention efforts using setting-appropriate human resources and technology have reduced morbidity and mortality from cervical cancer among HIV-infected women in Zambia. Financial support for implementing cervical cancer prevention programs integrated within HIV/AIDS care programs is warranted. Our prevention model can serve as the implementation platform for future low-cost HPV-based screening methods, and our results may provide the basis for comparison of programmatic effectiveness of future prevention efforts.
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Affiliation(s)
- Groesbeck P Parham
- University of Alabama at Birmingham, AL, USA ; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia ; University Teaching Hospital, Lusaka, Zambia
| | - Mulindi H Mwanahamuntu
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia ; University Teaching Hospital, Lusaka, Zambia
| | | | | | | | - Carla Chibwesha
- University of Alabama at Birmingham, AL, USA ; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | - Gracilia Mkumba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia ; University Teaching Hospital, Lusaka, Zambia
| | | | - Sharon Kapambwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia ; University Teaching Hospital, Lusaka, Zambia
| | | | | | - Jeffrey Sa Stringer
- University of Alabama at Birmingham, AL, USA ; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Benjamin H Chi
- University of Alabama at Birmingham, AL, USA ; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
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Abstract
PURPOSE OF REVIEW Sub-Saharan Africa has the largest population of people living with AIDS in the world, with Nigeria having the third largest after South Africa and India. With the advent of treatment programs, more people in Nigeria are now living with the virus but are at increased risk of cancer similar to the experience in other parts of the world. This review uses publications on HIV-associated cancers emanating from Nigeria in 2008 to map the current landscape of prevention, diagnosis and treatment of these conditions. The opportunities and challenges identified in this review will provide a template for designing appropriate clinical and public health intervention to stem another epidemic, this time of AIDS-associated malignancies. RECENT FINDINGS There is a paucity of literature on AIDS-associated cancers from Nigeria, and most reports are based on hospital or pathology case series. Poor case identification and diagnosis and rudimentary cancer registration militate against adequate quantification of the prevalence of AIDS-associated cancers in Nigeria. Several initiatives, working with the HIV treatment programs, governmental and nongovernmental local and international agencies, are rising to the challenge and creating new opportunities for cancer prevention, treatment and research that takes advantage of improved treatment infrastructure provided for people living with HIV/AIDS. SUMMARY Nigeria is about to witness substantial increase in the background incidence of cancers due to high prevalence of HIV and expanded treatment programs. Creative methods are needed to deploy effective prevention, case identification, registration and treatment programs that are consistent with the socioeconomic development of the country.
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