Assessing the relationship between HIV infection and cervical cancer in Côte d'Ivoire: a case-control study

Precancerous cervical lesion and associated factors among HIV-infected women in Ethiopia: systematic review and meta- analysis

BACKGROUND

Despite several preventative and control measures Ethiopia continues to see an increase in cervical cancer. Comprehensive evidence is very important to suggest ministry of health. Therefore, the aim of this study is to estimate the pooled violence of Precancerous Cervical Lesion and to identify associated factors among women living with HIV AIDS in Ethiopia.

METHODS

From February 15, 2024 to March 17, 2024, systematic and methodical search of the literature was conducted using electronic databases such as PubMed, HINARI, Global Health, Scopus, EMBASE, Web of Science, African Journal online (AJOL), and Google Scholar. Quality appraisal was assessed based on Joanna Briggs Institute (JBI) critical appraisal checklist for analytical cross-sectional study using 9 criteria. The Cochrane Q and I2 test statistics were used to verify the heterogeneity of the studies. Using a fixed effect model, the pooled estimate prevalence of precancerous cervical lesion among women living with HIV was calculated.

RESULTS

After reviewing 9,470 studies, 9 studies involving 2,910 women with HIV were included. The pooled estimate of precancerous cervical cancer among women living with HIV in Ethiopia was 15.34% (95% CI: 8.97, 21.72). Having history of sexual infection (POR = 3.12; 95% CI: 1.38, 7.05), having multiple sexual partner (POR = 3.14; 95% CI: 2.29, 4.30), and parity greater than two (POR = 4.97; 95% CI: 3.17, 7.78) were identified factors associated with precancerous cervical lesion.

CONCLUSION

This study found that about one-six of HIV-positive women developed precancerous cervical lesion. According to this study, there was a substantial correlation between precancerous cervical lesion among HIV-positive women and having history of sexually transmitted infection, having multiple sexual partners, and being multipara. In order to reduce precancerous cervical lesion, FMOH, policy makers, and interested parties should pay particular attention to this issue.

Cervical cancer: Challenges and prevention strategies: A narrative review

Background and Aims

Human papillomavirus (HPV) infections that continue to exist are the main cause of cervical cancer (CC), two-thirds of CC occurrences worldwide are caused by HPV 16 and HPV 18, and 99.7% of CC tumors are linked to oncogenic HPV infection. To identify challenges of CC and its prevention and treatment modalities.

Methods

This review examined the epidemiology, predisposing factors, genetic factors, clinical assessment methods, current treatment options, and prevention approaches for CC. We had perform a narrative data synthesis rather than a pooled analysis. A thorough literature search in pertinent databases related to CC was done with the inclusion of data that were published in the English language.

Results

Early detection of CC is of utmost importance to detect precancerous lesions at an early stage. Therefore, all responsible agencies concerned with health should make all women aware of the benefits of CC screening and educate the general public. HPV vaccination coverage is very low in resource-limited settings.

Conclusion

To achieve the goal of eliminating CC as a public health problem in 2030, the World Health Organization will pay special attention to increasing HPV vaccination coverage throughout the world. To further improve HPV vaccine acceptability among parents and their children, safety-related aspects of the HPV vaccine should be further investigated through post-marketing surveillance and multicentre randomized clinical trials.

Precancerous lesion determinants in women attending cervical cancer screening at public health facilities in North Shoa Zone, Amhara, Ethiopia: an unmatched case-control study

BACKGROUND

Precancerous cervical lesions develop in the transformation zone of the cervix and progress through stages known as cervical intraepithelial neoplasia (CIN) 1, 2, and 3. If untreated, CIN2 or CIN3 can lead to cervical cancer. The determinants of cervical precancerous lesions are not well documented in Ethiopia. Therefore, this study aims to find the determinants of cervical precancerous lesions among women screened for cervical cancer at public health facilities.

METHODS

A study conducted from January to April 2020 involved 216 women, consisting of 54 cases (positive for VIA during cervical cancer screening) and 162 controls (negative for VIA). It focused on women aged 30 to 49 undergoing cervical cancer screening. Multivariable logistic regression analysis assessed the link between precancerous lesions and different risk factors, considering a significance level of p < 0.05.

RESULTS

Women who used oral contraceptives for a duration exceeding five years showed a nearly fivefold increase in the likelihood of developing precancerous lesions (Adjusted Odds Ratio (AOR) = 4.75; 95% CI: 1.48, 15.30). Additionally, early age at first sexual intercourse (below 15 years) elevated the odds of developing precancerous lesions fourfold (AOR = 3.77; 95% CI: 1.46, 9.69). Furthermore, women with HIV seropositive results and a prior history of sexually transmitted infections (STIs) had 3.4 times (AOR = 3.45; 95% CI: 1.29, 9.25) and 2.5 times (AOR = 2.58; 95% CI: 1.10, 6.09) higher odds of developing cervical precancerous lesions compared to their counterparts.

CONCLUSION

In conclusion, women who have used oral contraceptives for over five years, started sexual activity before the age of 15 and have a history of sexually transmitted infections, including HIV, are at higher risk of developing precancerous cervical lesions. Targeted intervention strategies aimed at promoting behavioural change to prevent early sexual activity and STIs are crucial for avoiding cervical precancerous lesions. It is crucial to introduce life-course principles for female adolescents early on, acknowledging the potential to prevent and control precancerous lesions at critical stages in life, from early adolescence to adulthood, encompassing all developmental phases.

Association between HIV Serostatus and premalignant cervical lesions among women attending a cervical cancer screening clinic at a tertiary care facility in southwestern Uganda: a comparative cross-sectional study

BACKGROUND

Uganda has approximately 1.2 million people aged 15-64 years living with human immunodeficiency virus (HIV). Previous studies have shown a higher prevalence of premalignant cervical lesions among HIV-positive women than among HIV-negative women. Additionally, HIV-infected women are more likely to have human papilloma virus (HPV) infection progress to cancer than women not infected with HIV. We determined the prevalence of premalignant cervical lesions and their association with HIV infection among women attending a cervical cancer screening clinic at Mbarara Regional Referral Hospital (MRRH) in southwestern Uganda.

METHODS

We conducted a comparative cross-sectional study of 210 women aged 22-65 years living with HIV and 210 women not living with HIV who were systematically enrolled from March 2022 to May 2022. Participants were subjected to a structured interviewer-administered questionnaire to obtain their demographic and clinical data. Additionally, Papanicolaou smears were obtained for microscopy to observe premalignant cervical lesions. Multivariate logistic regression was performed to determine the association between HIV status and premalignant cervical lesions.

RESULTS

The overall prevalence of premalignant cervical lesions in the study population was 17% (n = 72; 95% C.I: 14.1-21.4), with 23% (n = 47; 95% C.I: 17.8-29.5) in women living with HIV and 12% (n = 25; 95% C.I: 8.2-17.1) in women not living with HIV (p < 0.003). The most common premalignant cervical lesions identified were low-grade squamous intraepithelial lesions (LSIL) in both women living with HIV (74.5%; n = 35) and women not living with HIV (80%; n = 20). HIV infection was significantly associated with premalignant lesions (aOR: 2.37, 95% CI: 1.27-4.42; p = 0.007).

CONCLUSION

Premalignant cervical lesions, particularly LSILs, were more common in HIV-positive women than in HIV-negative women, highlighting the need to strengthen the integration of cervical cancer prevention strategies into HIV care programs.

Correlation of menstrual hygiene management with cervical intraepithelial neoplasia and cervical cancer

Purpose

To find the correlation of menstrual hygiene management (MHM) with cervical intraepithelial neoplasia and cervical cancer.

Materials and Methods

This case-control study was conducted in a tertiary care teaching hospital for 1 year. One hundred cases (CIN or cervical cancer) and 135 controls (normal cervical cytology, Swede's score below 5, or normal cervical histology) were surveyed about MHM practices through a predesigned, semi-structured questionnaire by interview method. Data were analyzed on SPSS version 17.0 statistical analysis software through Chi-square test and bivariate regression analysis.

Results

All Poor MHM practices except frequency of change of absorbent were significantly more commonly seen in women with CIN or Cervical cancer as compared to controls (P < 0.001). The bivariate regression analysis showed that old age, illiteracy, and the use of old cloth are significant risk factors for cervical cancer.

Conclusion

Poor menstrual hygiene practices of using old cloth and disposal in open are significant risk factors of cervical cancer. Good MHM practices should be widely publicized and implemented in the community to reduce the risk of cervical cancer.

Age-specific burden of cervical cancer associated with HIV: A global analysis with a focus on sub-Saharan Africa

HIV substantially worsens human papillomavirus (HPV) carcinogenicity and contributes to an important population excess of cervical cancer, particularly in sub-Saharan Africa (SSA). We estimated HIV- and age-stratified cervical cancer burden at a country, regional and global level in 2020. Proportions of cervical cancer (a) diagnosed in women living with HIV (WLHIV), and (b) attributable to HIV, were calculated using age-specific estimates of HIV prevalence (UNAIDS) and relative risk. These proportions were validated against empirical data and applied to age-specific cervical cancer incidence (GLOBOCAN 2020). HIV was most important in SSA, where 24.9% of cervical cancers were diagnosed in WLHIV, and 20.4% were attributable to HIV (vs 1.3% and 1.1%, respectively, in the rest of the world). In all world regions, contribution of HIV to cervical cancer was far higher in younger women (as seen also in empirical series). For example, in Southern Africa, where more than half of cervical cancers were diagnosed in WLHIV, the HIV-attributable fraction decreased from 86% in women ≤34 years to only 12% in women ≥55 years. The absolute burden of HIV-attributable cervical cancer (approximately 28 000 cases globally) also shifted toward younger women: in Southern Africa, 63% of 5341 HIV-attributable cervical cancer occurred in women <45 years old, compared to only 17% of 6901 non-HIV-attributable cervical cancer. Improved quantification of cervical cancer burden by age and HIV status can inform cervical cancer prevention efforts in SSA, including prediction of the impact of WLHIV-targeted vs general population approaches to cervical screening, and impact of HIV prevention.

High parity is associated with increased risk of cervical cancer: Systematic review and meta-analysis of case-control studies

Background:

Cervical cancer is the fourth most common cancer among women. High parity has long been suspected with an increased risk of cervical cancer. Evidence from the existing epidemiological studies regarding the association between parity and cervical cancer is variable and inconsistent. Therefore, the objective of this systematic review and meta-analysis was to synthesize the best available evidence on the epidemiological association between parity and cervical cancer.

Methods:

Case–control studies reporting the association between parity and cervical cancer were systematically searched in databases like MEDLINE/PubMed, HINARI, Google scholar, Science direct, and Cochrane Libraries. All studies fulfilling the inclusion criteria and published between 2000 and 7 March 2020 were included in this meta-analysis. This study reported according to PRISMA guideline. Cochran’s Q-statistics and I² tests were performed to assess heterogeneity among included studies. Egger’s regression analysis was performed to assess publication bias. A random-effect meta-analysis model was used to compute pooled odds ratio of the association between parity and cervical cancer.

Results:

A total of 6685 participants (3227 patients and 3458 controls) were incorporated in the 12 studies included in this meta-analysis. The meta-analysis revealed that women with high parity had 2.65 times higher odds of developing cervical cancer compared to their counterparts (odds ratio = 2.65, 95% confidence interval = 2.08–3.38).

Conclusion:

High parity is positively associated with cervical cancer. Strong epidemiological studies are recommended to further explore the mechanisms and role of parity in the causation of cervical cancer.

Prevalence and Distribution of Vaccine-Preventable Genital Human Papillomavirus(HPV) Genotypes in Ghanaian Women Presenting for Screening

BACKGROUND

Cervical cancer is the most common gynaecologic cancer in Ghana where it is also the second most common cause of all female cancers. A number of vaccines are available to provide both individual and population-level protection against persistent infection with high-risk human papillomaviruses (HR-HPV) and reduce the burden of cervical cancer. Data on the epidemiology of vaccine-preventable papillomaviruses in Ghana is scant.

METHODS

A cross-sectional observational study was implemented from May 2011 to November 2014 to understand the epidemiology of genital human papillomavirus (HPV) genotypes and cervical dysplasia in the Greater Kumasi area of Ghana. A nested multiplex polymerase chain reaction (NMPCR) assay incorporating degenerate E6/E7 consensus primers and type-specific primers was used for the detection and typing of eighteen (18) HPV genotypes among women who had never attended cervical screening prior to this study.

RESULTS

The general prevalence of HPV infection in Kumasi was 37.2%. The age-standardized prevalence was 40.9% overall. The frequency of HR-HPV genotypes present in decreasing order were HPV-52, -56, -35, -18, -58, -68, -51, -39, -45, -16, -59, -33 and -31. Low-risk HPVs were also detected in the following order: HPV-42, -43, -66, -6/11 and -44.

CONCLUSIONS

The study shows that currently available prophylactic vaccines have the potential to be useful in the primary prevention of HPV infections in the country. This study strengthens the belief that prophylactic HPV vaccination could be a long-term strategy to reduce the burden of HPV infections and potentially reduce the burden of HPV-associated cancers and epithelial cell abnormalities among health-seeking women in Kumasi. Efforts to make vaccines available to young girls should be prioritized.

Human immune deficiency virus among cervical cancer patients at Tikur Anbessa Specialized Hospital, Ethiopia: a cross sectional study

Background

The discrepancy in cervical cancer incidence between women with HIV and women without HIV is highest in low and middle-income countries. In Africa, cervical cancer is the most common cause of cancer death. As a result, HIV-infected women are 6 times more likely to develop cervical cancer than uninfected women. In addition, HIV is associated with several triggering factors for cervical cancer, including multiple sexual partners, early sexual debut, economic status and substance use.

Objective

To assess the prevalence and associated factors of HIV among cervical cancer patients at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

Methods

A cross sectional study was conducted among 1057 cervical cancer patients registered from January 1, 2014 to December 31, 2018 at Oncology Center of Tikur Anbessa Specialized Hospital. A structured English version checklist was used to collect the data from patient charts. The pre coded data were entered in to EPI-data version 3.1 then exported to STATA version 14.0 for analysis. Both bivariable and multivariable regression analysis were carried out. Variables with p value < 0.05 in multivariable logistic regression were consider as significant predictors of the outcome variable.

Result

The prevalence of HIV among cervical cancer patients was 18.35%. HIV among cervical cancer patients was significantly associated with age group 30–39 [AOR = 2.83; 95%CI (1.27, 6.22)] and 40–49 [AOR = 2.39; 95%CI (1.07, 5.32)], employed [AOR = 2.23; 95%CI (1.46, 3.41)] and substance users [AOR = 3.92; 95%CI (2.04, 6.28)].

Conclusion

This study revealed that about 18% of cervical cancer patients were HIV seropositive. HIV seropositivity was significantly increased with 30–49 age group, employed and substance users. Authors recommended that it is better to screen all HIV seropositive patients for cervical cancer and give greater attention for women with cervical cancer in the age groups of 30–49 years, employed and substance users.

Cervical cancer screening outcomes in Zambia, 2010-19: a cohort study

BACKGROUND

Globally, cervical cancer is the fourth leading cause of cancer-related death among women. Poor uptake of screening services contributes to the high mortality. We aimed to examine screening frequency, predictors of screening results, and patterns of sensitisation strategies by age group in a large, programmatic cohort.

METHODS

We did a cohort study including 11 government health facilities in Lusaka, Zambia, in which we reviewed routine programmatic data collected through the Cervical Cancer Prevention Program in Zambia (CCPPZ). Participants who underwent cervical cancer screening in one of the participating study sites were considered for study inclusion if they had a screening result. Follow-up was accomplished per national guidelines. We did descriptive analyses and mixed-effects logistic regression for cervical cancer screening results allowing random effects at the individual and clinic level.

FINDINGS

Between Jan 1, 2010, and July 31, 2019, we included 183 165 women with 204 225 results for visual inspection with acetic acid and digital cervicography (VIAC) in the analysis. Of all those screened, 21 326 (10·4%) were VIAC-positive, of whom 16 244 (76·2%) received treatment. Of 204 225 screenings, 92 838 (45·5%) were in women who were HIV-negative, 76 607 (37·5%) were in women who were HIV-positive, and 34 780 (17·0%) had an unknown HIV status. Screening frequency increased 65·7% between 2010 and 2019 with most appointments being first-time screenings (n=158 940 [77·8%]). Women with HIV were more likely to test VIAC-positive than women who were HIV-negative (adjusted odds ratio 3·60, 95% CI 2·14-6·08). Younger women (≤29 years) with HIV had the highest predictive probability (18·6%, 95% CI 14·2-22·9) of screening positive.

INTERPRETATION

CCPPZ has effectively increased women's engagement in screening since its inception in 2006. Customised sensitisation strategies relevant to different age groups could increase uptake and adherence to screening. The high proportion of screen positivity in women younger than 20 years with HIV requires further consideration. Our data are not able to discern if women with HIV have earlier disease onset or whether this difference reflects misclassification of disease in an age group with a higher sexually transmitted infection prevalence. These data inform scale-up efforts required to achieve WHO elimination targets.

FUNDING

US President's Emergency Plan for AIDS Relief.

Trends in Premature Deaths among Women Living with HIV/AIDS and Cervical Cancer

OBJECTIVES

There is a lack of updated information on premature death and years of potential life lost (YPLL) among human immunodeficiency (HIV)-positive women with cervical cancer. We hypothesize that increased access to preventive resources such as antiretroviral therapy, preexposure prophylaxis, and human papillomavirus vaccines has reduced premature mortality and YPLL in these women in the previous decades.

METHODS

We used data from the National Inpatient Sample database from 2003 to the third quarter of 2015, and restricted the analysis to HIV-positive women with or without cervical cancer. Joinpoint regression models were run to identify trends in the rates of HIV and cervical cancer. Overall and age-stratified YPLL were calculated for HIV-positive women with cervical cancer. Adjusted survey logistic regression models were built to determine the predictive factors of in-hospital mortality among women living with HIV.

RESULTS

Among hospitalized women, low-income, non-Hispanic Blacks, and patients aged 40 to 59 years experienced greater frequencies of HIV/cervical cancer comorbidity. The prevalence of HIV hospitalizations increased by an average annual percentage of 0.9% (95% confidence interval 0.3-1.6). YPLL decreased in HIV-positive women living with and without cervical cancer by 4.9% and 4.3%, respectively. The trajectory for YPLL was not uniform across age groups. YPLL decreased substantially in women aged 20 to 29 years with HIV/cervical cancer comorbidity. Cervical cancer remained a significant predictor of mortality among HIV-positive women when adjusted for age, race, and insurance coverage.

CONCLUSIONS

Within a large, national sample from 2003 to 2015, we found an overall declining trend in YPLL in women living with HIV/cervical cancer comorbidity. In-hospital mortality among HIV-positive women was associated with cervical cancer, age, race, and insurance coverage. We recommend further investigation into the quality of HIV and cervical cancer treatment and prevention services for the sociodemographic groups described.

Cell-free nucleic acid patterns in disease prediction and monitoring-hype or hope?

Interest in the use of cell-free nucleic acids (CFNAs) as clinical non-invasive biomarker panels for prediction and prevention of multiple diseases has greatly increased over the last decade. Indeed, circulating CFNAs are attributable to many physiological and pathological processes such as imbalanced stress conditions, physical activities, extensive apoptosis of different origin, systemic hypoxic-ischemic events and tumour progression, amongst others. This article highlights the involvement of circulating CFNAs in local and systemic processes dealing with the question, whether specific patterns of CFNAs in blood, their detection, quantity and quality (such as their methylation status) might be instrumental to predict a disease development/progression and could be further utilised for accompanying diagnostics, targeted prevention, creation of individualised therapy algorithms, therapy monitoring and prognosis. Presented considerations conform with principles of 3P medicine and serve for improving individual outcomes and cost efficacy of medical services provided to the population.

Precancerous lesions of the cervix and its determinants among Ethiopian women: Systematic review and meta-analysis

Introduction

Precancerous lesions of the cervix are changes in cervical cells that make them more likely to develop into cancer. Understanding the prevalence and determinants of the precancerous lesions of the cervix among women helps to take an action like vaccination programs, improving screening coverage, and close management and follow-up which could decrease the morbidity and mortality caused by cervical cancer.

Materials and methods

The international databases, PubMed/MEDLINE, Web of Science, EMBASE, CINAHL, Google Scholar, Science Direct and Cochrane Library and unpublished reports were systematically searched. Two authors independently extracted all necessary data using a standardized data extraction format. STATA 14 statistical software was employed to analyse the data. The Cochrane Q test statistics and I² tests were used to assess the heterogeneity between the studies. A random-effect model was computed to estimate the pooled prevalence of precancerous lesions of the cervix in Ethiopia. Determinants of the precancerous lesion of cervix (early initiation of sexual intercourse, multiple sexual partners, and history of sexually transmitted infection) were analysed.

Results

Thirteen studies fulfilled the inclusion criteria and included in the meta-analysis. The I² test result showed high heterogeneity (I2, 93.2%, p = <0.001). Using the random effect analysis, the pooled prevalence of precancerous lesions of the cervix among women in Ethiopia was 14.21% (95% CI (10.49, 17.94). After adjusting of publication bias using trim-and-fill method, the pooled prevalence was 9.43% (95% CI (5.23, 13.62). Women who had multiple sexual partners in their lifetime (OR:2.67 CI: 1.49,4.79) and had a history of sexually transmitted infections (OR:6.22 CI: 2.99,12.92) were more likely to have a precancerous lesion of the cervix.

Conclusion

The pooled prevalence of the precancerous lesions of the cervix among Ethiopian women was 9.43%. It was associated with having multiple sexual partners and a history of sexually transmitted infections.

Self-Collected Specimens Revealed a Higher Vaccine- and Non-Vaccine-Type Human Papillomavirus Prevalences in a Cross-Sectional Study in Akuse

Background

Population-specific epidemiologic data on human Papillomavirus infection, which are limited in most of the SubSaharan African countries, are necessary for effective cervical cancer prevention. This study aimed to generate population-specific data on human Papillomavirus infections, and determine which of these, self-collected and provider-collected specimens, gives a higher estimate of the prevalence of human Papillomaviruses, including vaccine and non-vaccine-type human Papillomavirus.

Methods

In this cross-sectional study, following a questionnaire-based collection of epidemiological data, self-, and provider-collected specimens, obtained from women 15−65 years of age, were analysed for human Papillomavirus types by a nested-multiplex polymerase chain reaction, and for cervical lesions by Pap testing. HPV data were categorised according to risk type and vaccine types for further analysis.

Results

The difference between the overall human Papillomavirus infection prevalences obtained with the self-collected specimens, 43.1% (95% CI of 38.0–51.0%) and that with the provider-collected samples, 23.3% (95% CI of 19.0–31.0%) were significant (p ≤ 0.001). The prevalence of quadrivalent vaccine-type human Papillomaviruses was 12.3% with self-collected specimens, but 6.0% with provider-collected specimens. For the nonavalent vaccine-types, the prevalences were 26.6% and 16.7% respectively. There were multiple infections involving both vaccine-preventable and nonvaccine preventable high-risk human Papillomavirus genotypes.

Conclusion

The Akuse subdistrict can, therefore, be said to have a high burden of human Papillomavirus infections, which included nonvaccine types, as detected with both self-collected and provider-collected specimens. These imply that self-collection is to be given a higher consideration as a means for a population-based high-risk human Papillomavirus infections burdens assessment/screening. Additionally, even with a successful implementation of the HPV vaccination, if introduced in Ghana, there is still the need to continue with the screening of women.

Effects of malaria/helminthic coinfections on cervical cancer progression among sub Saharan African women on highly active antiretroviral therapy: A scoping review

In Africa, the HIV prevalence in rural areas has begun to reach levels estimated within urban settings, where women are also more at risk for both malaria and intestinal parasitic infections. The objective of this review is to assess whether concomitant infections with malaria and/or helminthic diseases have an impact on cervical disease progression in women on HAART. This scoping review was conducted in August 2018. To conduct this scoping review, we searched the relevant studies in electronic databases such as PUBMED, Global Health, EMBASE, CINAHL and SCOPUS published in the year between 1960 and 2018 using the following search terms HAART AND malaria OR Helminth and Female OR women. Eight studies qualified for this review. The literature underscores the need for women on HAART with multiple co-infections to use adjuncts to retain immune recovery and undetectable HIV viral load, to reduce risk of cervical disease progression. A trend for higher risk of CIN3+ in HIV+ women reporting recent malarial infection was observed in one study. Given the public health impact of synergistic interactions between malaria and helminthic infections in HIV/HPV co-infected women on HAART, it is urgent that these interactions are elucidated.

Precancerous cervical lesion and associated factors among HIV-infected women on ART in Amhara Regional State, Ethiopia: A hospital-based cross-sectional study

OBJECTIVE

Cervical cancer, which is caused by human papillomavirus, is one of the common cancers in women worldwide. The proportion of precancerous cervical lesion among HIV-infected women has not been investigated yet in this study area. The aim of this study was to determine the proportion of precancerous cervical lesion and associated factors among HIV-infected women on ART in Woldia and Dessie Hospitals, Amhara Regional State, Ethiopia.

METHODS

A hospital-based cross-sectional study was conducted on 284 HIV patients. Data were collected using a structured questionnaire and visual inspection. Pap smear test was employed for confirmation of cancer. Descriptive statistics were used to summarize findings. A logistic regression model was considered to identify predictors of precancerous cervical lesions. Those variables with P < 0.05 at a 95% confidence interval were considered as statistically significant.

RESULTS

The overall proportion of precancerous lesion among HIV-infected women in this study was 9.9%. Among HIV-infected women age greater than 30 years old, single in marital status, commercial sex worker, had any other sexually transmitted infection, more than one sexual partner, more than two children and with vaginal wall abnormality were factors associated with the occurrence of precancerous cervical lesion.

CONCLUSION

The proportion of precancerous cervical lesion among HIV-infected women was low compared to some previous studies conducted among HIV-infected women in Ethiopia. Therefore, regular screening of HIV-infected women for precancerous cervical lesion is very important by giving especial consideration to identified associated factors.

Prevalence of precancerous cervical lesions in women attending Mezam Polyclinic Bamenda, Cameroon

Introduction

Precancerous cervical lesion is significantly a health problem globally. Thus, screening targeting women between the ages of 17-60 is being undertaken in developing countries, including Cameroon. Over 50% (7.8 per 100,000) women die of cervical cancer every year. This study was to determine the prevalence of precancerous cervical lesion, the age demography and access the risk factor.

Methods

A hospital-based cross-sectional study was conducted from August 09th to October 17th 2017. A total of 60 women participated, and were screened for precancerous cervical lesion. Data were collected by using a questionnaire. Visual inspection with acetic acid and visual inspection with Lugol’s iodine was applied for the screening. SPSS version 16.0 was used for data entry and analysis. Logistic regression analysis was fitted and odds ratios with 95% confidence intervals and p-values were computed to identify factors associated with precancerous cervical cancer lesion.

Results

Out of 60 study participants, 2(3.33%) were found to be positive for precancerous cervical cancer lesion.

Conclusion

The prevalence of precancerous cervical lesion in women that consulted at the Mezam polyclinic is high.

Barriers to accessing cervical cancer screening among HIV positive women in Kgatleng district, Botswana: A qualitative study

Background

Low and middle-income countries have a greater share of the cervical cancer burden, but lower screening coverage, compared to high-income countries. Moreover, screening uptake and disease outcomes are generally worse in rural areas as well as in the HIV positive population. Efforts directed at increasing the screening rates are important in order to decrease cancer-related morbidity and mortality. This study aimed to explore the barriers to women with HIV accessing cervical cancer screening in Kgatleng district, Botswana.

Methods

A phenomenological qualitative study utilising semi-structured interviews with fourteen HIV positive women, selected by purposive sampling. The interviews were transcribed verbatim and the 5-steps of the framework method, assisted by Atlas-ti software, was used for qualitative data analysis.

Results

Contextual factors included distance, public transport issues and work commitments. Health system factors highlighted unavailability of results, inconsistent appointment systems, long queues and equipment shortages and poor patient-centred communication skills, particularly skills in explanation and planning. Patient factors identified were lack of knowledge of cervical cancer, benefits of screening, effectiveness of treatment, as well as personal fears and misconceptions.

Conclusion

Cervical cancer screening was poorly accessed due to a weak primary care system, insufficient health promotion and information as well as poor communication skills. These issues could be partly addressed by considering alternative technology and one-stop models of testing and treating.

A case-control study of HIV infection and cancer in the era of antiretroviral therapy in Rwanda

The aim of this study was to assess the association between HIV infection and cancer risk in Rwanda approximately a decade after the introduction of antiretroviral therapy (cART). All persons seeking cancer care at Butaro Cancer Center of Excellence (BCCOE) in Rwanda from 2012 to 2016 were routinely screened for HIV, prior to being confirmed with or without cancer (cases and controls, respectively). Cases were coded according to ICD-O-3 and converted to ICD10. Associations between individual cancer types and HIV were estimated using adjusted unconditional logistic regression. 2,656 cases and 1,196 controls differed by gender (80.3% vs. 70.8% female), age (mean 45.5 vs. 37.7 years), place of residence and proportion of diagnoses made by histopathology (87.5% vs. 67.4%). After adjustment for these variables, HIV was significantly associated with Kaposi Sarcoma (n = 60; OR = 110.3, 95%CI 46.8-259.6), non-Hodgkin lymphoma (NHL) (n = 265; OR = 2.5, 1.4-4.6), Hodgkin lymphoma (HL) (n = 76; OR = 5.2, 2.3-11.6) and cancers of the cervix (n = 560; OR = 5.9, 3.8-9.2), vulva (n = 23; OR = 17.8, 6.3-50.1), penis (n = 29; OR = 8.3, 2.5-27.4) and eye (n = 17; OR = 4.7, 1.0-25.0). Associations varied by NHL/HL subtype, with that for NHL being limited to DLBCL (n = 56; OR = 6.6, 3.1-14.1), particularly plasmablastic lymphoma (n = 6, OR = 106, 12.1-921). No significant associations were seen with other commonly diagnosed cancers, including female breast cancer (n = 559), head and neck (n = 116) and colorectal cancer (n = 106). In conclusion, in the era of cART in Rwanda, HIV is associated with increased risk of a range of infection-related cancers, and accounts for an important fraction of cancers presenting to a referral hospital.

Human papillomaviruses in Western Africa: prevalences and risk factors in Burkina Faso

PURPOSE

Cervical cancer is the most common cancer in women in low income countries. Certain oncogenic types of human papillomaviruses are causally associated with the cervical cancer. To ensure effective primary prevention through the introduction of a national vaccination program in Burkina Faso, information about the disease burden of HPV infection in the country is of great importance.

METHODS

In the present work the prevalence of 54 different HPV types and 18 other sexually transmitted infection as well as the predominant risk factors for the development of cervical cancer were investigated in Ouagadougou. A cross-sectional study on two populations without (n=471) and with known cervical dysplasia (n=39) was carried out between October 2013 and March 2014. Retrospectively, data on possible and secured risk factors of the cervical carcinoma were collected. The participants were examined gynecologically and a vaginal lavage was taken, which was molecular genetically examined for 54 different human papillomavirus genotypes and 18 other STIs.

RESULTS

The prevalence of human papillomavirus was 42.3% (188/444) in the first study population and 87.2% (34/39) in the second study population. The immunization coverage would be 24.5% of the HPV types and 33.9% of the high-risk HPV types with quadrivalent vaccine Gardasil®. The nonavalent vaccine Gardasil®9 (9vHPV) would cover 37.3% of all HPV types and 57.1% of high-risk HPV types.

CONCLUSION

The prevention of infection with human papillomaviruses by vaccination is expected to result in a drastic reduction in the morbidity and mortality of the cervical cancer in Burkina Faso.

Burden of cervical neoplasia in mid-western rural Nepal: a population-based study

Objective

To assess the burden of cervical neoplasia in mid-western rural, Nepal using cytology, visual inspection with acetic acid (VIA) and visual inspection with Lugol's iodine (VILI).

Method

A cross-sectional, population-based study was conducted. Total of 2,279 married, non-pregnant women aged 20–65 years participated in a screening clinic from May 2016 to January 2017. All eligible women completed self-report of socio-demographic and reproductive health data followed by screening tests. Biopsies were obtained from areas on the cervix assessed by VIA and or VILI to be abnormal. Final disease was confirmed by biopsy report.

Results

A total of 96.09% (n=2,190) women were eligible for this study with mean age 32.78±9.33 years. The overall rate of positive cytology, VIA, and VILI were 3.69%, 12.45%, and 16.89%, respectively. Sixty-two cases were biopsy proven cervical neoplasia. Altogether 78 (3.69%) cases were cytologically abnormal: 25 (1.18%) were atypical squamous cells of undetermined significance, 33 (1.56%) were low-grade squamous intraepithelial lesion, 11 (0.52%) were high-grade squamous intraepithelial lesion, and 9 (0.42%) were squamous cell carcinoma. Illiterate women appeared to be at higher risk for cervical neoplasia (p<0.001). Similarly, age ≥46 years (p<0.013), participant's multiple marriages or sexual partners (p<0.005), and positive human immunodeficiency virus status (p<0.001) were significantly associated with abnormal cytology.

Conclusion

Based on cytology report, there is 3.69% prevalence of cervical neoplasia among women in a rural region of mid-western, Nepal. A “screen and treat” approach would be more attractive in low resource settings.

Uptake of Cervical Cancer Screening and Associated Factors Among 15-49-Year-Old Women in Dessie Town, Northeast Ethiopia

Cervical cancer screening is acknowledged as the most effective approach to reduce incidence and mortality rates from the disease. Nevertheless, there are limited data on the rate of uptake of cervical cancer screening and factors that are related to uptake of screening services in Ethiopia. The purpose of this study was to determine the level of uptake of screening and determine associated factors among women of age 15-49 years in Northeast Ethiopia. A community-based cross-sectional survey was conducted among 620 women residing in Dessie town, Northeast Ethiopia. The respondents were selected using a multistage sampling technique. Data were collected using interviewer-administered questionnaires. Binary and multiple logistic regressions were employed to determine factors associated with the uptake of cervical cancer screening service. Overall, 57.7 % of the women had ever heard of cervical cancer, and 51.9 % had sufficient knowledge about the disease. However, only 11 % underwent at least one cervical screening in their lifetime. After adjusting for covariates, knowledge of cervical cancer (adjusted odds ratio (AOR) 11.1; 95 % CI 5.0-24.8) and age (being 25-34 years (AOR 5.0; 95 % CI 1.5-16.7) and being within the age group of 34-49 years (AOR 6.0; 95 % CI 1.74-20.8)) were significantly associated with screening service uptake. In this study, uptake of cervical cancer screening service was found to be low. Increasing women's knowledge about cervical cancer, particularly targeting the younger ones, is crucial to enhance uptake of screening.

Assessment of drug therapy problems among patients with cervical cancer at Kenyatta National Hospital, Kenya

Background

Although cervical cancer is preventable, it is still the second leading cause of cancer deaths among women in the world. Further, it is estimated that around 5–10% of hospital admissions are due to drug related problems (DRPs), of which 50% are avoidable. In cancer therapy, there is an immense potential for DRPs due to the high toxicity of most chemotherapeutic regimens. Hence, this study sought to assess DRPs among patients with cervical cancer at Kenyatta National Hospital (KNH).

Methods

A cross-sectional study was conducted at the oncology units of KNH. A total of 81 study participants were recruited through simple random sampling. Data were collected from medical records and interviewing patients. The appropriateness of medical therapy was evaluated by comparing with National Compressive Cancer Network and European Society for Medical Oncology practice guideline of cervical cancer treatment protocol. The degree of adherence was determined using eight-item Morisky medication adherence scale. The likelihood of drug interaction was assessed using Medscape, Micromedex and Epocrates drug interaction checkers. The data were entered in Microsoft Excel and analysed using statistical software STATA version 13.0. Descriptive statistics such as mean, percent and frequency were used to summarise patients’ characteristics. Univariable and multivariable binary logistic regression were used to investigate the potential predictors of DRPs.

Result

A total of 215 DRPs were identified from 76 patients, translating to a prevalence of 93.8% and a mean of 2.65 ± 1.22 DRPs. The predominant proportion of DRPs (48.2%) was identified in patients who had been treated with chemoradiation regimens. Adverse drug reactions 56(69.1%) and drug interactions 38(46.9%) were the most prevalent DRPs. Majority (67.9%) of the study population were adherent to their treatment regimens. Forgetfulness 18(69.2%), expensive medications 4(15.4%) and side effects of medications 4(15.4%) were the main reasons for medication non-adherence. Patients with advanced stage cervical cancer were 15.4 times (AOR = 15.4, 95% CI = 1.3–185.87, p = 0.031) more likely to have DRPs as compared to patients with early stage disease.

Conclusion

Adverse drug reactions, drug interactions, and need of additional drug therapy were the most common DRPs identified among cervical cancer patients. Advanced stage cervical cancer was the only predictor of DRPs.

Association between depression in carers and malnutrition in children aged 6 months to 5 years

Background

Childhood malnutrition is an important risk factor for child mortality and underlies close to 50% of child deaths worldwide. Previous studies have found an association between maternal depression and child malnutrition, but it is not known whether this association exists in Botswana. In addition, previous studies excluded non-maternal primary caregivers (PCGs). It is unclear whether the association between primary caregiver depression and child malnutrition remains when non-maternal PCGs are included.

Aim

The aim of this study was to determine if there is an association between PCG depression and malnutrition in children aged between 6 months and 5 years in Mahalapye, Botswana.

Setting

The study was conducted in the child welfare clinics of Xhosa and Airstrip clinics, two primary health care facilities in Mahalapye, Botswana.

Methods

This was a case control study. Cases were malnourished children aged between 6 months and 5 years, and controls were non-malnourished children matched for age and gender. The outcome of interest was depression in the PCGs of the cases and controls, which was assessed using the Patient Health Questionnaire 9 (PHQ 9), a depression screening tool.

Results

From a sample of 171 children, 84 of whom were malnourished, we found that the malnourished children were significantly more likely to have depressed PCGs (odds ratio = 4.33; 95% CI: 1.89, 9.89) than non-malnourished children in the 6-month to 5-year age group; the PCGs of malnourished children also had lower educational status.

Conclusion

This study found a significant association between PCG depression and child malnutrition.

Effect of HIV Infection on Human Papillomavirus Types Causing Invasive Cervical Cancer in Africa

OBJECTIVES

HIV infection is known to worsen the outcome of cervical human papillomavirus (HPV) infection and may do so differentially by HPV type.

DESIGN

Twenty-one studies were included in a meta-analysis of invasive cervical cancers (ICC) among women infected with HIV in Africa.

METHOD

Type-specific HPV DNA prevalence was compared with data from a similar meta-analysis of HIV-negative ICC using prevalence ratios (PR).

RESULTS

HPV detection was similar in 770 HIV-positive (91.2%) and 3846 HIV-negative (89.6%) ICC, but HIV-positive ICC harbored significantly more multiple HPV infections (PR = 1.75, 95% confidence intervals: 1.18 to 2.58), which were significantly more prevalent in ICC tested from cells than from biopsies. HPV16 was the most frequently detected type in HIV-positive ICC (42.5%), followed by HPV18 (22.2%), HPV45 (14.4%), and HPV35 (7.1%). Nevertheless, HIV-positive ICC were significantly less frequently infected with HPV16 than HIV-negative ICC (PR = 0.88, 95% confidence intervals: 0.79 to 0.99). Other high-risk types were significantly more prevalent in HIV-positive ICC, but only for HPV18 was there a significantly higher prevalence of both single and multiple infections in HIV-positive ICC. Increases for other high-risk types were primarily accounted for by multiple infections. The proportion of HPV-positive ICC estimated attributable to HPV16/18 (71.8% in HIV positive, 73.4% in HIV negative) or HPV16/18/31/33/45/52/58 (88.8%, 89.5%) was not affected by HIV.

CONCLUSIONS

HIV alters the relative carcinogenicity of HPV types, but prophylactic HPV16/18 vaccines may nevertheless prevent a similar proportion of ICC, irrespective of HIV infection.

Prevalence of human papillomavirus genotypes among women with cervical cancer in Ghana

BACKGROUND

Human Papillomavirus (HPV) infections have been shown to be a necessary risk factor for the development of cervical cancer. However, HPV genotype distribution varies geographically, both in type and relative prevalence. In order to ensure a successful introduction of available vaccines, there is the need to identify pre-vaccination HPV genotype prevalence in Ghana and the extent of single and multiple-infections.

METHODS

Paraffin-embedded cervical tissues of 256 confirmed cervical cancer cases diagnosed at the Korle-Bu Teaching Hospital during the period January 2004 to December 2006 were selected after hematoxylin and eosin staining and confirmation. Following a heat-proteinase K-based tissue lysis, HPV was detected and typed by a nested-multiplex PCR assay using an E6/E7 consensus primer and type-specific primers.

RESULTS

Of the 256 cases, 230 (89.8 %, 95 % CI 85.7-93.4 %) were positive for HPV DNA. HPV18 (47.4 %), HPV59 (42.2 %), HPV45 (37.4 %) and HPV16 (9.0 %) were the four common HPV genotypes detected. A total of 110 (47.8 %) of the 230 HPV DNA positive tissues, were infected by a single HPV genotype while the other 120 (52.2 %) were infected by multiple HPV genotypes. A significant association was determined between each of the following HPV genotypes and multiple-infection; HPV18 (OR = 6.97; 95 % CI, 3.89-12.50), HPV59 (OR = 9.56; 95 % CI, 5.57-20.02) and HPV45 (OR = 1.94; 95 % CI, 1.12-3.35).

CONCLUSION

The prevalence of the following high risk HPV genotypes (HPV18, HPV59, HPV45) were relatively high among the cases of cervical cancers reported at this hospital in Ghana during the study period. Additionally, there was a high frequency of HPV multiple-infections among these cases.

Evaluation of Cervical Cancer Screening Programs in Côte d'Ivoire, Guyana, and Tanzania: Effect of HIV Status

Background

HIV infection increases a woman’s risk for cervical cancer, and cervical cancer incidence and mortality rates are higher in countries with high HIV prevalence and limited resources for screening. Visual inspection with acetic acid (VIA) allows screening and treatment of cervical lesions in a single-visit approach (SVA), but data on its performance in HIV-infected women are limited. This study’s objective was to examine cervical cancer screening using VIA/SVA in programs serving HIV-infected women.

Methods

A VIA/SVA program with cryotherapy for VIA-positive lesions was implemented in Côte d’Ivoire, Guyana, and Tanzania from 2009 to 2012. The effect of HIV status on VIA positivity and on presence of cryotherapy-eligible lesions was examined using a cross-sectional study design, with Chi-square tests for comparisons and constructed multivariate logistic regression models. A P-value of < 0.05 was significant.

Findings

VIA was performed on 34,921 women, 10% (3,580) were VIA positive; 2,508 (85%) eligible women received cryotherapy during the same visit; only 234 (52%) of those who postponed returned for treatment; 622 (17%) VIA-positive women had lesions too large to be treated with cryotherapy and were referred for excisional treatment. In multivariate analysis—controlling for HIV status, location of the screening clinic, facility location, facility type, and country—compared to HIV-uninfected/unknown women, HIV-infected women had higher odds of being VIA positive (OR 1.95, 95% CI 1.76, 2.16, P<0.0001) and of having large lesions requiring referral (OR 1.93, 95% CI 1.49, 2.51, P< 0.0001). Minor treatment complications occurred in 19 of 3,032 (0.63%) women; none required further intervention.

Conclusions

This study found that compared to HIV-uninfected/unknown women, HIV-infected women had nearly twice the odds of being VIA-positive and to require referral for large lesions. SVA was safe and resulted in significant reductions in loss to follow-up. There is increased need for excisional treatment in countries with high HIV prevalence.

Cancer and HIV infection in referral hospitals from four West African countries

The consequences of the HIV epidemic on cancer epidemiology are sparsely documented in Africa. We aimed to estimate the association between HIV infection and selected types of cancers among patients hospitalized for cancer in four West African countries. A case-referent study was conducted in referral hospitals of Benin, Côte d'Ivoire, Nigeria and Togo. Each participating clinical ward included all adult patients seeking care with a confirmed diagnosis of cancer. All patients were systematically screened for HIV infection. HIV prevalence of AIDS-defining and some non-AIDS defining cancers (Hodgkin lymphoma, leukemia, liver, lung, skin, pharynx, larynx, oral cavity and anogenital cancers) were compared to a referent group of cancers reported in the literature as not associated with HIV. Odds ratios adjusted on age, gender and lifetime number of sexual partners (aOR) and their 95% confidence intervals (CI) were estimated. Among the 1644 cancer patients enrolled, 184 (11.2%) were identified as HIV-infected. The HIV prevalence in the referent group (n=792) was 4.4% [CI 3.0-5.8]. HIV infection was associated with Kaposi sarcoma (aOR 34.6 [CI: 17.3-69.0]), non-Hodgkin lymphoma (aOR 3.6 [CI 1.9-6.8]), cervical cancer (aOR 4.3 [CI 2.2-8.3]), anogenital cancer (aOR 17.7 [CI 6.9-45.2]) and squamous cell skin carcinoma (aOR 5.2 [CI 2.0-14.4]). A strong association is now reported between HIV infection and Human Papillomavirus (HPV)-related cancers including cervical cancer and anogenital cancer. As these cancers are amenable to prevention strategies, screening of HPV-related cancers among HIV-infected persons is of paramount importance in this African context.

Prevalence of human papillomavirus genotypes among African women with normal cervical cytology and neoplasia: a systematic review and meta-analysis

BACKGROUND

Several meta-analyses confirmed the five most prevalent human papillomavirus (HPV) strains in women with and without cervical neoplastic diseases are HPV16, 18, 31, 52, and 58. HPV16/18 are the predominant oncogenic genotypes, causing approximately 70% of global cervical cancer cases. The vast majority of the women studied in previous analyses were from Europe, North America, Asia, and most recently Latin America and the Caribbean. Despite the high burden of cervical cancer morbidity and mortality in Africa, a robust meta-analysis of HPV genotype prevalence and distribution in African women is lacking.

METHODS AND FINDINGS

We systematically searched 14 major databases from inception to August 2013 without language restriction, following the Meta-Analysis of Observational Studies in Epidemiology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Seventy-one studies from 23 African countries were identified after screening 1162 citations and data abstracted and study quality appraised from 195 articles. HPV type-specific prevalence and distribution was estimated from 17,273 cases of women with normal cervical cytology; 1019 women with atypical squamous cells of undetermined significance (ASCUS); 1444 women with low-grade squamous intraepithelial lesion (LSIL); 1571 women with high-grade squamous intraepithelial lesion (HSIL); and 4,067 cases of invasive cervical carcinoma (ICC). Overall prevalence of HPV16/18 were 4.4% and 2.8% of women with normal cytology, 12.0% and 4.4% with ASCUS, 14.5% and 10.0% with LSIL, 31.2% and 13.9% with HSIL, and 49.7% and 18.0% with ICC, respectively. Study limitations include the lack of adequate data from Middle and Northern African regions, and variations in the HPV type-specific sensitivity of different genotyping protocols.

CONCLUSIONS

To our knowledge, this study is the most comprehensive assessment of the overall prevalence and distribution of HPV genotypes in African women with and without different cervical neoplasias. We have established that HPV16/18 account for 67.7% of ICC cases among African women. Based on our findings, we highly recommend the administration of existing prophylactic vaccines to younger women not infected with HPV16/18 and an increase in HPV screening efforts for high-risk genotypes to prevent cervical cancer.

REVIEW REGISTRATION

International Prospective Register of Systematic Reviews CRD42013006558.

Combination antiretroviral therapy reduces the detection risk of cervical human papilloma virus infection in women living with HIV

OBJECTIVE

Data on the effect of combination antiretroviral therapy (cART) on cervical human papilloma virus (HPV) infection are both limited and conflicting. We aimed to determine the effect of the initiation of cART for HPV genotype detection on cervical samples in HIV-infected South African women.

DESIGN

Prospective cohort study.

METHODS

Generalized estimating equation was performed to estimate parameters of mixed-effects logistic regression models of cART on HPV cervical detection risk, adjusting for time-dependent covariates CD4 T-cell count, sexual activity and excision treatment. Ratio of odds ratios (ORs) was computed to compare the pooled cART effect on lower vs. high-risk HPV genotype groups, to the effect of cART on the risk of HPV-16 detection.

RESULTS

Of the 300 patients, 204 (68%) were commenced on ART during follow-up, as they met the criteria for cART initiation. cART significantly reduced the risk for detection of HPV by 77% [OR 0.23, 95% confidence interval (CI) 0.15-0.37]. cART significantly reduced the risk of HPV-16 detection (OR 0.50, 95% CI 0.37-0.67). Every month on cART significantly reduced the detection risk of any HPV type by 9% (OR 0.91, 95% CI 0.89-0.94). The protective effect of cART on the detection risk for the low-risk HPV genotype group was significantly less than the protective effect of cART on the detection risk of HPV-16 (ratio of ORs 1.35, 95% CI 1.22-1.50).

CONCLUSION

cART significantly reduced cervical HPV infection. This effect was dependent on the duration of exposure to cART and is the mechanism by which cART may improve the outcome of dysplasia in HIV-infected women.

The burden of human papillomavirus infections and related diseases in sub-saharan Africa

Despite the scarcity of high quality cancer registries and lack of reliable mortality data, it is clear that human papillomavirus (HPV)-associated diseases, particularly cervical cancer, are major causes of morbidity and mortality in sub-Saharan Africa (SSA). Cervical cancer incidence rates in SSA are the highest in the world and the disease is the most common cause of cancer death among women in the region. The high incidence of cervical cancer is a consequence of the inability of most countries to either initiate or sustain cervical cancer prevention services. In addition, it appears that the prevalence of HPV in women with normal cytology is higher than in more developed areas of the world, at an average of 24%. There is, however, significant regional variation in SSA, with the highest incidence of HPV infection and cervical cancer found in Eastern and Western Africa. It is expected that, due to aging and growth of the population, but also to lack of access to appropriate prevention services and the concomitant human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) epidemic, cervical cancer incidence and mortality rates in SSA will rise over the next 20 years. HPV16 and 18 are the most common genotypes in cervical cancer in SSA, although other carcinogenic HPV types, such as HPV45 and 35, are also relatively more frequent compared with other world regions. Data on other HPV-related anogenital cancers including those of the vulva, vagina, anus, and penis, are limited. Genital warts are common and associated with HPV types 6 and 11. HIV infection increases incidence and prevalence of all HPV-associated diseases. Sociocultural determinants of HPV-related disease, as well as the impact of forces that result in social destabilization, demand further study. Strategies to reduce the excessive burden of HPV-related diseases in SSA include age-appropriate prophylactic HPV vaccination, cervical cancer prevention services for women of the reproductive ages, and control of HIV/AIDS. This article forms part of a regional report entitled "Comprehensive Control of HPV Infections and Related Diseases in the Sub-Saharan Africa Region" Vaccine Volume 31, Supplement 5, 2013. Updates of the progress in the field are presented in a separate monograph entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.

Risk factors for cervical intraepithelial neoplasia in HIV-infected women on antiretroviral treatment in Côte d'Ivoire, West Africa

Background

Facing the dual burden of invasive cervical cancer and HIV in sub-Saharan Africa, the identification of preventable determinants of Cervical Intraepithelial Neoplasia (CIN) in HIV-infected women is of paramount importance.

Methods

A cervical cancer screening based on visual inspection methods was proposed to HIV-infected women in care in Abidjan, Côte d'Ivoire. Positively screened women were referred for a colposcopy to a gynaecologist who performed directed biopsies.

Results

Of the 2,998 HIV-infected women enrolled, 132 (4.4%) CIN of any grade (CIN+) were identified. Women had been followed-up for a median duration of three years [IQR: 1–5] and 76% were on antiretroviral treatment (ART). Their median most recent CD4 count was 452 [IQR: 301–621] cells/mm³. In multivariate analysis, CIN+ was associated with a most recent CD4 count >350 cells/mm³ (OR: 0.3; 95% CI: 0.2–0.6) or ≥200–350 cells/mm³ (OR 0.6; 95% CI 0.4–1.0) (Ref: <200 cells/mm³ CD4) (p<10⁻⁴).

Conclusions

The presence of CIN+ is less common among HIV-infected women with limited or no immune deficiency. Despite the potential impact of immunological recovery on the reduction of premalignant cervical lesions through the use of ART, cervical cancer prevention, including screening and vaccination remains a priority in West Africa while ART is rolled-out.

Safety and immunogenicity of the HPV-16/18 AS04-adjuvanted vaccine in HIV-positive women in South Africa: a partially-blind randomised placebo-controlled study

In developing countries, risk of human papillomavirus (HPV) infection may be increased by the high prevalence of human immunodeficiency virus (HIV) infection. We evaluated the safety and immunogenicity of the HPV-16/18 AS04-adjuvanted vaccine in HIV-infected women in South Africa. Asymptomatic HIV-positive women aged 18-25 years (N=120) were stratified by CD4⁺ T-cell count and randomised (1:1) to receive HPV-16/18 vaccine (Cervarix®; GlaxoSmithKline Vaccines) or placebo (Al[OH]3) at 0, 1 and 6 months (double-blind). HIV-negative women (N=30) received HPV-16/18 vaccine (open label). Anti-HPV-16/18 antibody and CD4⁺ T-cell responses, CD4⁺ T-cell count, HIV viral load, HIV clinical stage and safety were evaluated for 12 months. The safety and reactogenicity profile of the HPV-16/18 vaccine was comparable in HIV-positive and HIV-negative women. Irrespective of baseline HPV status, all HIV-positive and HIV-negative women who received the HPV-16/18 vaccine were seropositive for both HPV-16 and HPV-18 after the second vaccine dose (month 2) and remained seropositive for both antigens at month 12. Anti-HPV-16/18 antibody titres at month 12 remained substantially above levels associated with natural infection. The HPV-16/18 vaccine induced sustained anti-HPV-16/18 CD4⁺ T-cell responses in both HIV-positive and HIV-negative women. No impact of baseline CD4⁺ T-cell count or HIV viral load was observed on the magnitude of the immune response in HIV-positive women. In HIV-positive women, CD4⁺ T-cell count, HIV viral load and HIV clinical stage were unaffected by HPV-16/18 vaccine administration. In conclusion, the HPV-16/18 AS04-adjuvanted vaccine appears immunogenic and well-tolerated in women with HIV infection. Study ID: 107863/NCT00586339.

Cervical cancer treatment in Africa

PURPOSE OF REVIEW

This review is to inform the reader about the current situation with regard to treatment of cervical cancer in Africa and the barriers and complexities faced in most African countries. It also reviews the natural history of cervical cancer, the new 2009 International Federation of Gynecology and Obstetrics staging, and current treatment guidelines for cervical cancer.

RECENT FINDINGS

There have been no dramatic new findings in the treatment of cervical cancer other than newer approaches to fertility-sparing surgery and the addition of concomitant chemotherapy to radiation for advanced cervical cancer and the data from randomized trials that have shown an improved overall and disease-free survival. The most important new findings in cervical cancer pertain to cervical cancer prevention strategies, which included using alternative approaches to cytology and the introduction of human papillomavirus (HPV) vaccination.

SUMMARY

Cervical cancer is the commonest cancer cause of death among women in developing countries and efforts to prevent the disease using newer approaches and HPV vaccination should be implemented. Detection of cervical cancer at an early stage is associated with excellent survival but most women in developing countries present with advanced and often untreatable disease. The ratio between incidence and mortality from cervical cancer remains very high, largely due to lack of access to appropriate anticancer therapies in African countries.

HIV Infection Alters the Spectrum of HPV Subtypes Found in Cervical Smears and Carcinomas from Kenyan Women

Infection with high risk HPV is implicated in pre-cancerous squamous intraepithelial lesions and their progression to cervical cancer. In the developed countries, infection with HPV 16 and 18 accounts for ~70% of cervical cancers, but it has been established that HPV type prevalence differs according to worldwide geographical location. In sub Saharan Africa infection with HPV is known to be augmented by HIV, which is endemic in this region. It is not yet clear, however, whether this ultimately influences progression to cervical cancer. Papillocheck^TM and multiplex PCR were used to determine the range of HPV genotypes found in cervical smears and carcinomas from HIV positive and negative Kenyan women. Smear samples from HIV-positive women had a higher prevalence of: multiple HPV infections; high-risk HPVs 52, 58, 68, potential high risk 53/70, low-risk 44/55 and abnormal cytology compared to HIV-negative women. A low overall prevalence (~8%) of types 16/18 was found in all smear samples tested (n = 224) although this increased in invasive cervical carcinoma tissues to ~80% for HIV-negative and ~46% for HIV-positive women. Furthermore, HPV45 was more common in cervical carcinoma tissues from HIV-positive women.

In summary HIV infection appears to alter the spectrum of HPV types found in both cervical smears and invasive cervical carcinomas. It is hypothesised there could be a complex interplay between these viruses which could either positively or negatively influence the rate of progression to cervical cancer.

Human papillomavirus distribution in invasive cervical carcinoma in sub-Saharan Africa: could HIV explain the differences?

OBJECTIVES

To describe human papillomavirus (HPV) distribution in invasive cervical carcinoma (ICC) from Mali and Senegal and to compare type-specific relative contribution among sub-Saharan African (SSA) countries.

METHODS

A multicentric study was conducted to collect paraffin-embedded blocks of ICC. Polymerase chain reaction, DNA enzyme immunoassay and line probe assay were performed for HPV detection and genotyping. Data from SSA (Mozambique, Nigeria and Uganda) and 35 other countries were compared.

RESULTS

One hundred and sixty-four ICC cases from Mali and Senegal were tested from which 138 were positive (adjusted prevalence = 86.8%; 95% CI = 79.7-91.7%). HPV16 and HPV18 accounted for 57.2% of infections and HPV45 for 16.7%. In SSA countries, HPV16 was less frequent than in the rest of the world (49.4%vs. 62.6%; P < 0.0001) but HPV18 and HPV45 were two times more frequent (19.3%vs. 9.4%; P < 0.0001 and 10.3%vs. 5.6%; P < 0.0001, respectively). There was an ecological correlation between HIV prevalence and the increase of HPV18 and the decrease of HPV45 in ICC in SSA (P = 0.037 for both).

CONCLUSION

HPV16/18/45 accounted for two-thirds of the HPV types found in invasive cervical cancer in Mali and Senegal. Our results suggest that HIV may play a role in the underlying HPV18 and HPV45 contribution to cervical cancer, but further studies are needed to confirm this correlation.

The spectrum of cancers in West Africa: associations with human immunodeficiency virus

Background

Cancer is a growing co-morbidity among HIV-infected patients worldwide. With the scale-up of antiretroviral therapy (ART) in developing countries, cancer will contribute more and more to the HIV/AIDS disease burden. Our objective was to estimate the association between HIV infection and selected types of cancers among patients hospitalized for diagnosis or treatment of cancer in West Africa.

Methods

A case-referent study was conducted in referral hospitals in Côte d’Ivoire and Benin. Each participating clinical ward enrolled all adult patients seeking care for a confirmed diagnosis of cancer and clinicians systematically proposed an HIV test. HIV prevalence was compared between AIDS-defining cancers and a subset of selected non-AIDS defining cancers to a referent group of non-AIDS defining cancers not reported in the literature to be positively or inversely associated with HIV. An unconditional logistic model was used to estimate odds ratios (OR) and their 95% confidence intervals (CI) of the risk of being HIV-infected for selected cancers sites compared to a referent group of other cancers.

Results

The HIV overall prevalence was 12.3% (CI 10.3–14.4) among the 1,017 cancer cases included. A total of 442 patients constituted the referent group with an HIV prevalence of 4.7% (CI 2.8–6.7). In multivariate analysis, Kaposi sarcoma (OR 62.2 [CI 22.1–175.5]), non-Hodgkin lymphoma (4.0 [CI 2.0–8.0]), cervical cancer (OR 7.9 [CI 3.8–16.7]), anogenital cancer (OR 11.6 [CI 2.9–46.3]) and liver cancer (OR 2.7 [CI 1.1–7.7]) were all associated with HIV infection.

Conclusions

In a time of expanding access to ART, AIDS-defining cancers remain highly associated with HIV infection. This is to our knowledge, the first study reporting a significant association between HIV infection and liver cancer in sub-Saharan Africa.

Cervical human papillomavirus infection among young women engaged in sex work in Phnom Penh, Cambodia: prevalence, genotypes, risk factors and association with HIV infection

Background

Although cervical cancer is the leading cancer in Cambodia, most women receive no routine screening for cervical cancer and few treatment options exist. Moreover, nothing is known regarding the prevalence of cervical HPV or the genotypes present among women in the country. Young sexually active women, especially those with multiple sex partners are at highest risk of HPV infection. We examine the prevalence and genotypes of cervical HPV, as well as the associated risk factors among young women engaged in sex work in Phnom Penh, Cambodia.

Methods

We conducted a cross-sectional study among 220 young women (15–29 years) engaged in sex work in different venues including brothels or entertainment establishments, and on a freelance basis in streets, parks and private apartments. Cervical specimens were collected using standard cytobrush technique. HPV DNA was tested for by polymerase chain reaction (PCR) and genotyping using type-specific probes for 29 individual HPV types, as well as for a mixture of 10 less common HPV types. All participants were also screened for HIV status using blood samples. Multivariate logistic regression analyses were conducted to assess risk factors for any or multiple HPV infection.

Results

The prevalence of cervical HPV 41.1%. HPV 51 and 70 were the most common (5.0%), followed by 16 (4.6%), 71 (4.1%) and 81 (3.7%). Thirty-six women (16.4%) were infected with multiple genotypes and 23.3% were infected with at least one oncogenic HPV type. In multivariate analyses, having HIV infection and a higher number of sexual partners were associated with cervical HPV infection. Risk factors for infection with multiple genotypes included working as freelance female sex workers (FSW) or in brothels, recent binge use of drugs, high number of sexual partners, and HIV infection.

Conclusions

This is the first Cambodian study on cervical HPV prevalence and genotypes. We found that HPV infection was common among young FSW, especially among women infected with HIV. These results underscore the urgent need for accessible cervical cancer screening and treatment, as well as for a prophylactic vaccine that covers the HPV subtypes present in Cambodia.

Demographic, knowledge, attitudinal, and accessibility factors associated with uptake of cervical cancer screening among women in a rural district of Tanzania: three public policy implications

Background

Cervical cancer is an important public health problem worldwide, which comprises approximately 12% of all cancers in women. In Tanzania, the estimated incidence rate is 30 to 40 per 100,000 women, indicating a high disease burden. Cervical cancer screening is acknowledged as currently the most effective approach for cervical cancer control, and it is associated with reduced incidence and mortality from the disease. The aim of the study was to identify the most important factors related to the uptake of cervical cancer screening among women in a rural district of Tanzania.

Methods

A cross sectional study was conducted with a sample of 354 women aged 18 to 69 years residing in Moshi Rural District. A multistage sampling technique was used to randomly select eligible women. A one-hour interview was conducted with each woman in her home. The 17 questions were modified from similar questions used in previous research.

Results

Less than one quarter (22.6%) of the participants had obtained cervical cancer screening. The following characteristics, when examined separately in relation to the uptake of cervical cancer screening service, were significant: husband approval of cervical cancer screening, women's level of education, women's knowledge of cervical cancer and its prevention, women's concerns about embarrassment and pain of screening, women's preference for the sex of health provider, and women's awareness of and distance to cervical cancer screening services. When examined simultaneously in a logistic regression, we found that only knowledge of cervical cancer and its prevention (OR = 8.90, 95%CI = 2.14-16.03) and distance to the facility which provides cervical cancer screening (OR = 3.98, 95%CI = 0.18-5.10) were significantly associated with screening uptake.

Conclusions

Based on the study findings, three recommendations are made. First, information about cervical cancer must be presented to women. Second, public education of the disease must include specific information on how to prevent it as well as screening services available. Third, it is important to provide cervical cancer screening services within 5 km of where women reside.