Barriers to Cervical Cancer Screening Among Women Living With HIV in Low- and Middle-Income Countries: A Systematic Review

Uptake of cervical cancer screening and associated factors among HIV positive women attending adult art clinic at public hospitals in Addis Ababa, Ethiopia, 2022

BACKGROUND

Cervical cancer is the second most common malignancy in Ethiopia and first in some African countries. It is six times more likely to occur in positive cases of the human immunodeficiency virus than in the general population. If diagnosed and treated early enough, cervical cancer is both treatable and preventable. However, among Ethiopian women who test positive for HIV, the uptake of cervical cancer screening is low. Its determinant factors were not well studied in the study area. Hence, this study was aimed at filling this information gap.

OBJECTIVE

To assess uptake of cervical cancer screening services and associated factors among HIV-positive women attending an adult antiretroviral treatment clinic at public hospitals in Addis Ababa, Ethiopia, June 1-30, 2022.

METHODS

A cross-sectional investigation was carried out in a hospital. 407 participants in all were chosen using the systematic sampling technique. A pretested interviewer-administered questionnaire was used to collect the data from respondents. The data were entered into Epi data version 4.6 and exported to SPSS version 25 for analysis. Bivariable and multivariable logistic regression analysis was employed. Adjusted odds ratio with its 95% confidence interval and p value < 0.05 were used to estimate the strength and significance of the association.

RESULT

Among a total of 407 respondents, 238 (58.5%), 95% CI (53.5-63.3), HIV-positive women were screened at least once in the last five years. In multivariable analysis, age > 45 years old (AOR = 0.18, 95% CI: 0.053-0.644), number of children (3 children) (AOR = 0.19, 95% CI:0.036-0.979), perception of being susceptible to cervical cancer (AOR = 6.39, 95% CI: 1.79-22.74), knowledge of cervical cancer and its screening (AOR = 19.34, 95% CI: 7.87-47.75), and positive attitude towards cervical cancer screening (AOR = 8.06, 95% CI:3.62-17.91) were significantly associated factors with the uptake of cervical cancer screening.

CONCLUSION AND RECOMMENDATION

in this study, Age > 45 years, having less than three children, feeling susceptible, knowing about cervical cancer and screening, and having a positive attitude toward cervical cancer screening were significant factor of uptake of cervical cancer screening service. There is a need to strengthen the policy and health education on safe sexual practices and healthy lifestyles through information dissemination and communication to scale up screening service utilization.

Global perspectives of determinants influencing HPV vaccine introduction and scale-up in low- and middle-income countries

Achieving WHO cervical cancer elimination goals will necessitate efforts to increase HPV vaccine access and coverage in low-and-middle-income countries (LMICs). Although LMICs account for the majority of cervical cancer cases globally, scale-up of HPV vaccine programs and progress toward coverage targets in LMICs has been largely insufficient. Understanding the barriers and facilitators that stakeholders face in the introduction and scale-up of HPV vaccination programs will be pivotal in ensuring that LMICs are equipped to optimize the implementation of HPV vaccination programs. This qualitative study interviewed 13 global stakeholders categorized as either academic partners or global immunization partners to ascertain perspectives regarding factors affecting the introduction and scale-up of HPV vaccination programs in LMICs. Global stakeholders were selected as their perspectives have not been as readily highlighted within the literature despite their key role in HPV vaccination programming. The results of this investigation identified upstream (e.g., financial considerations, vaccine prioritization, global supply, capacity and delivery, and vaccine accessibility, equity, and ethics) and downstream (e.g., vaccine acceptability and hesitancy, communications, advocacy, and social mobilization) determinants that impact program introduction and scale-up and confirmed that strong political commitment and governance are significant in garnering support for HPV vaccines. As LMICs introduce HPV vaccines into their national immunization programs and develop plans for scaling up vaccination efforts, strategic approaches to communications and advocacy will also be needed to successfully meet coverage targets.

Development of a cervical cancer prevention text-messaging program for women living with HIV

Cervical cancer screening and human papillomavirus (HPV) vaccination are critical for those immunocompromised due to human immunodeficiency virus (HIV). Health education programs, including text messaging, can effectively improve knowledge of cervical cancer and recommended screening. This paper describes the data-driven development of a 4-week text-messaging intervention to improve HPV and cervical cancer knowledge among women living with HIV (WLH). This study reports data from surveys (n = 81; January 2020 to September 2021) and focus group discussions (FGDs, n = 39; April-June 2020) conducted among WLH in the DC area. While most WLH revealed that their usual sources of health information were through in-person group sessions, they pointed out that these were impractical options due to the coronavirus 2019 pandemic. They noted that a text-messaging intervention was feasible and acceptable. FGD participants' responses structured around the Protection Motivation Theory constructs informed the text-messaging library, covering topics such as (I) understanding of cervical cancer and HPV, (II) cervical cancer prevention and (III) HPV self-sampling. The utilization of low-cost and easily accessible health education interventions, such as mobile-based text messaging, can effectively increase knowledge and awareness of cervical cancer in populations that have been historically difficult to access and during times when health services are disrupted such as during a global pandemic or public health emergency.

Sociodemographics and health-literacy as predictors of cervical cancer screening practices among Haitian women: A secondary data analysis of 2016-17 DHS surveys

Cervical cancer screening rates in Haiti are concerningly low. Access to health-related information and health literacy may be important determinants of engagement in cervical cancer screening. This study explored the relationship between sociodemographics,literacy, and sources of information on cervical cancer screening among Haitian women. A secondary data analysis was conducted using USAID Demographics and Health Survey Haiti household data from 2016-2017. Univariate logistic regressions identified significant predictor covariates measuring sociodemographics and sources of information in cervical cancer screening uptake.Two multivariate logistic regression models with adjusted odds ratios were developed using the significant predictor variables from the univariate analysis. N = 610 women responded to questions pertaining to cervical cancer screening. The first multivariate model evaluating sociodemographics demonstrated an economic background of poorer (aOR = 4.06, 95% CI [1.16,14.27]) and richest (aOR = 19.10 , 95% CI[2.58,141.57]), higher education levels (aOR 7.58 , 95% CI [1.64,34.97]), and having insurance (aOR = 16.40, [95% CI 2.65, 101.42]) were significant predictors of cervical cancer screening. The second model evaluating literacy and sources of information indicated that access to a television (aOR = 4.28, 95% CI [1.21,9.34]), mobile phone ownership (aOR = 4.44, 95% CI [1.00,5.59]), and reading the newspaper (aOR = 3.57, [95% CI 1.10,11.59]) were significant predictors of cervical cancer screening. Diverse health communication initiatives that are adapted for literacy level and that incorporate multimedia components may effective in raising women's cervical cancer knowledge and awareness , and increasing intention and uptake of cervical cancer screening in Haiti.

No woman left behind: achieving cervical cancer elimination among women living with HIV

Cervical cancer is the fourth most common malignancy in women of reproductive age globally. The burden of this disease is highest in low-income and middle-income countries, especially among women living with HIV. In 2018, WHO launched a global strategy to accelerate cervical cancer elimination through rapid scale-up of prophylactic vaccination, cervical screening, and treatment of precancers and cancers. This initiative was key in raising a call for action to address the stark global disparities in cervical cancer burden. However, achieving elimination of cervical cancer among women with HIV requires consideration of biological and social issues affecting this population. This Position Paper shows specific challenges and uncertainties on the way to cervical cancer elimination for women living with HIV and highlights the scarcity of evidence for the effect of interventions in this population. We argue that reaching equity of outcomes for women with HIV will require substantial advances in approaches to HPV vaccination and improved understanding of the long-term effectiveness of HPV vaccines in settings with high HIV burden cervical cancer, just as HIV, is affected by social and structural factors such as poverty, stigma, and gender discrimination, that place the elimination strategy at risk. Global efforts must, therefore, be galvanised to ensure women living with HIV have optimised interventions, given their substantial risk of this preventable malignancy.

Acceptability of an integrated school-based HPV vaccination program within two districts of Tanzania: A qualitative descriptive study

Tanzania has one of the highest cervical cancer incidence and mortality rates in sub-Saharan Africa. The Tanzanian Ministry of Health developed an integrated adolescent health program, HPV-Plus, that combines HPV vaccination with additional health services: nutritional assessments, vision screening, and vaccination for adolescent girls, and education for all genders. This qualitative descriptive study evaluated the acceptability of the HPV-Plus program in two districts in Tanzania. Key informants comprising of adolescent girls, parents, program planners, and program implementers in Njombe and Dar es Salaam Tanzania were interviewed to assess the program acceptability. Transcripts were analyzed using a team-based iterative thematic analysis approach, consisting of both inductive and deductive coding. The Theoretical Framework of Acceptability was used to guide analysis, with themes categorized according to theoretical constructs of intervention coherence, affective attitudes and perceptions, and perceived effectiveness. Overall acceptability of the HPV-Plus program was high among stakeholders. The most salient finding regarding factors that influenced HPV vaccine acceptability was largely related to education and knowledge levels surrounding the HPV, cervical cancer, and HPV vaccines. The educational component of the HPV-Plus program was key in increasing acceptability. Parents reported the lowest acceptability towards the program. This was found to be primarily due to perceptions of not being sufficiently engaged throughout program implementation. Increasing acceptability of HPV vaccination programs among key stakeholders is critical to facilitating vaccine uptake and meeting vaccination coverage targets. Our results demonstrate that the inclusion of a comprehensive education component within the HPV-Plus program was key in facilitating HPV vaccine acceptability amongst stakeholders.

Distance to Multidisciplinary Team Clinic in Gaborone, Botswana, and Stage at Cervical Cancer Presentation for Women Living With and Without HIV

PURPOSE

Cervical cancer is the leading cause of cancer death for women in Botswana. Barriers in access to cancer care can lead to later stages at diagnosis and increased mortality. This study evaluated access, defined as travel time from a patient's residential village to a multidisciplinary team clinic in Gaborone, with stage of cervical cancer at presentation. In addition, because of the high HIV prevalence in Botswana, we explored the association between travel time and HIV status.

METHODS

Eligible patients with cervical cancer presenting to the multidisciplinary team between 2015 and 2020 were included. Data were abstracted from questionnaires and hospital records. Google Maps was used to calculate travel time. Multinomial regression was used to examine travel time and cancer stage, and multivariable logistic regression was used to investigate travel time and HIV status.

RESULTS

We identified 959 patients with cervical cancer of which 70.1% were women living with HIV. The median travel time was approximately 2 hours. Using a reference group of stage I disease and a travel time of < 1 hour, the odds of presenting with stage II increased for patients traveling 3-5 hours (adjusted odds ratio [OR], 2.00; 95% CI, 1.14 to 3.52) and > 5 hours (OR, 2.19; 95% CI, 1.15 to 4.19). There were no significant associations for stage III. For stage IV disease, the odds were increased for patients traveling 3-5 hours (OR, 2.93; 95% CI, 1.26 to 6.79) and > 5 hours (adjusted OR, 4.05; 95% CI, 1.62 to 10.10). In addition, the odds of patients presenting living with HIV increased with increasing travel time (trend test = 0.004).

CONCLUSION

This study identified two potential factors, travel time and HIV status, that influence access to comprehensive cervical cancer care in Botswana.

A comparison of behavioural models explaining cervical cancer screening uptake

BACKGROUND

Cervical cancer represents a very high burden of disease, especially in Low- and Middle-income economies. Screening is a recommended prevention method in resource-poor settings. Cervical cancer screening (CCS) uptake is influenced by various psycho-social factors, most of which are included in behavioural models. Unlike demographic characteristics, these factors are modifiable. While few studies have compared these models in terms of their capacity to predict health behaviour, this study considers three health behaviour theories to assess and compare the predictors of CCS behaviour and intention.

METHODS

A survey was conducted among 607 sexually active women in the South Indian state of Karnataka. Data was collected regarding socio-demographic factors, health literacy, knowledge on CCS, and the socio-cognitive factors related to CCS that are represented in the Health Belief Model (HBM), Theory of Planned Behaviour (TPB) and Theory of Care-Seeking Behaviour (TCSB). Logistic regression analyses tested to what extent each of the theoretical models explained cervical cancer screening (CCS) intention and regular screening behaviour, comparing the variance explained by each of the models.

RESULTS

CCS intention was best explained by the TPB, followed by the HBM. Of the constructs included in these models, positive attitude towards the screening procedure and perceived benefits contributed most significantly to screening intention, followed by fear, anxiety or embarrassment related to the disease or screening procedure, and context specific barriers.

CONCLUSION

Health behavioural models such as the TPB and HBM can help to identify the main socio-cognitive factors explaining the intention of women to participate in CCS. As such, they can inform interventions to target specific determinants of screening intention and behaviour, and enhance their effectiveness by addressing women's screening attitude, perceived benefits, and emotions as well as reducing context specific barriers to screening.

Cervical cancer prevention: Human papillomavirus testing as primary screening

Low- and middle-income countries carry a high burden of preventable cervical cancer cases and deaths. Because human papillomavirus DNA-based testing is increasingly becoming the preferred method of screening for cervical cancer prevention, this commentary discusses next steps and key considerations for its expansion.

Prevalence and Risk Factors of Infection with High Risk Human Papilloma Viruses among HIV-Positive Women with Clinical Manifestations of Tuberculosis in a Middle-Income Country

Women living with HIV-1 are at high risk of infection with human papillomavirus of high carcinogenic risk (HR HPVs). M. tuberculosis (TB) promotes HPV infection and increases the risk to develop HPV-associated cancer. Our knowledge of persisting HR HPVs genotypes, and of the factors promoting HR HPV infection in people living with HIV-1 with clinical TB manifestations is sparse. Here, we analyzed 58 women living with HIV-1 with clinical TB manifestations (WLWH with TB) followed up in specialized centers in Russia, a middle income country endemic for HIV-1 and TB, for the presence in cervical smears of DNA of twelve HR HPV genotypes. DNA encoding HPV16 E5, E6/E7 was sequenced. Sociodemographic data of patients was collected by questionnaire. All women were at C2-C3 stages of HIV-infection (by CDC). The majority were over 30 years old, had secondary education, were unemployed, had sexual partners, experienced 2–3 pregnancies and at least one abortion, and were smokers. The most prevalent was HPV16 detected in the cervical smears of 38% of study participants. Altogether 34.5% of study participants were positive for HR HPV types other than HPV16; however, but none of these types was seen in more than 7% of tested samples. Altogether, 20.7% of study participants were positive for several HR HPV types. Infections with HPVs other than HPV16 were common among WLWH with generalized TB receiving combined ART/TB-therapy, and associated with their ability to work, indirectly reflecting both their health and lifestyle. The overall prevalence of HR HPVs was associated with sexual activity of women reflected by the number of pregnancies, and of HPV 16, with young age; none was associated to CD4+-counts, route of HIV-infection, duration of life with HIV, forms of TB-infection, or duration of ART, characterizing the immune status. Thus, WLWH with TB—especially young—were predisposed to infection with HPV16, advancing it as a basis for a therapeutic HPV vaccine. Phylogenetic analysis of HPV16 E5, E6/E7 DNA revealed no common ancestry; sequences were similar to those of the European and American HPV16 strains, indicating that HPV vaccine for WLWH could be the same as HPV16 vaccines developed for the general population. Sociodemographic and health correlates of HR HPV prevalence in WLWH deserve further analysis to develop criteria/recommendations for prophylactic catch-up and therapeutic HPV vaccination of this highly susceptible and vulnerable population group.

Developing Culturally Tailored mHealth Tools to Address Sexual and Reproductive Health Outcomes Among Black and Latina Women: A Systematic Review

BACKGROUND

In addressing the sexual and reproductive health (SRH) disparities for Black and Latina women, there is a need for the development of innovative programs, framed using theoretical underpinnings that are culturally and contextually tailored so that they align with lived experiences. Mobile health (mHealth) interventions offer considerable potential as a means of providing effective SRH education and services. However, there has been a lack of research assessing culturally and contextually tailored mHealth SRH interventions for Black and Latina women.

METHOD

A comprehensive literature search was undertaken using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Literature was reviewed to evaluate whether a culturally and contextually tailored approach was utilized in the development and implementation of mHealth interventions for Black and Latina women.

RESULTS

A total of 12 articles were included in our synthesis, which encompassed mobile phone-, telephone-, and computer-based mHealth interventions for Black and Latina women. Cultural and/or gender-specific tailoring was included in 10 studies. Reduction of risky sexual behaviors and increased contraception usage were reported in 92% (n = 11) of the studies. Interventions that incorporated tailored content and fostered interaction reported high rates of follow-up.

CONCLUSIONS

Tailored mHealth interventions can be effective in promoting behavior change and improving SRH outcomes for Black and Latina women. However, there is a need for more research assessing user engagement and retention for Black and Latina women, and whether improvements in SRH outcomes are sustainable over the long term.