Preparing for human papillomavirus vaccine introduction in Kenya: implications from focus-group and interview discussions with caregivers and opinion leaders in Western Kenya

The influence of demographic and socio-economic factors on non-vaccination, under-vaccination and missed opportunities for vaccination amongst children 0-23 months in Kenya for the period 2003-2014

Vaccination is crucial in reducing child mortality and the prevalence of Vaccine-Preventable-Diseases (VPD), especially in low-and-middle-income countries like Kenya. However, non-vaccination, under-vaccination, and missed opportunities for vaccination (MOV) pose significant challenges to these efforts. This study aimed to analyze the impact of demographic and socio-economic factors on non-vaccination, under-vaccination, and MOV among children aged 0-23 months in Kenya from 2003 to 2014. A secondary data analysis of data from the Kenya Demographic Health Surveys (KDHS) conducted during this period was conducted, with a total of 11,997 participants, using a two-stage, multi-stage, and stratified sampling technique. The study examined factors such as child's sex, residence, mother's age, marital status, religion, birth order, maternal education, wealth quintile, province, child's birth order, parity, number of children in the household, place of delivery, and mother's occupation. Binary logistic regression was employed to identify the determinants of non-vaccination, under-vaccination, and MOV, and multivariable logistic regression analysis to report odds ratios (OR) and their corresponding 95% confidence intervals (CI). In 2003, the likelihood of non-vaccination decreased with higher maternal education levels: mothers who did not complete primary education (AOR = 0.55, 95% CI = 0.37-0.81), completed primary education (AOR = 0.34, 95% CI = 0.21-0.56), and had secondary education or higher (AOR = 0.26, 95% CI = 0.14-0.50) exhibited decreasing probabilities. In 2008/09, divorced/separated/widowed mothers (AOR = 0.22, 95% CI = 0.07-0.65) and those with no religion (AOR = 0.37, 95% CI = 0.17-0.81) showed lower odds of non-vaccination, while lower wealth quintiles were associated with higher odds. In 2014, non-vaccination was higher among younger mothers aged 15-19 years (AOR = 12.53, 95% CI = 1.59-98.73), in North Eastern Province (AOR = 7.15, 95% CI = 2.02-25.30), in families with more than 5 children (AOR = 4.19, 95% CI = 1.09-16.18), and in children born at home (AOR = 4.47, 95% CI = 1.32-15.17). Similar patterns were observed for under-vaccination and MOV. This information can inform strategies for bridging the gaps in immunization coverage and promoting equitable vaccination practices in Kenya.

Confronting the human papillomavirus-HIV intersection: Cervical cytology implications for Kenyan women living with HIV

Background

High-risk human papillomavirus (HR-HPV) is the primary cause of cervical cancer, leading to over 311 000 global deaths, mainly in low- and middle-income countries. Kenyan women living with HIV (WLHIV) face a disproportionate burden of HR-HPV.

Objectives

We determined the prevalence of HR-HPV infections and their association with cervical cytology findings among Kenyan WLHIV.

Method

We conducted a cross-sectional study among WLHIV attending the HIV care and treatment clinic at the Kenyatta National Hospital (KNH), Kenya's national referral hospital. Study nurses collected a cervical sample with a cytobrush for HR-HPV genotyping using Gene Xpert® assays and HPV Genotypes 14 Real-TM Quant V67-100FRT. Bivariate analysis explored the associations.

Results

We enrolled 647 WLHIV (mean age of 42.8 years), with 97.2% on antiretroviral therapy (ART) and 79% with a suppressed viral load (< 50 copies/mL plasma). The prevalence of any and vaccine-preventable HR-HPV was 34.6% and 29.4%, respectively, with HPV 52 being the most common genotype (13.4%). Among WLHIV with HR-HPV infections, 21.4% had abnormal cervical cytology. Women with multiple HR-HPV infections were more likely to have abnormal cytology compared to those with single HR-HPV infections (34.9 vs 9.3%, adjusted odds ratio [aOR] = 6.2, 95% confidence interval [CI]: 2.7-14.1, P = 0.001). Women with HR-HPV infection (single or multiple) were more likely to be on the second-line ART regimen compared to those without HR-HPV infections (53.1% vs 46.7%, aOR = 2.3, 95% CI: 1.3-4.1, P = 0.005).

Conclusion

Among WLHIV at KNH, abnormal cytology was common and more frequent among women with multiple HR-HPV infections.

Communication strategies to improve human papillomavirus (HPV) immunisation uptake among adolescents in sub-Saharan Africa: a systematic review and meta-analysis

OBJECTIVES

Developing countries face the greatest cervical cancer disease burden and mortality with suboptimal immunisation uptake. This review explores the communication strategies adopted, successes, challenges and lessons learnt in sub-Saharan countries to enhance human papillomavirus (HPV) immunisation.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Hinari, Cochrane Library, Trip database, CINAHL, Web of Science, Scopus and seven grey resources were searched through May 2022.

ELIGIBILITY CRITERIA

We included observational studies addressing communication strategies for HPV immunisation uptake.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers used standardised methods to search, screen and code included studies. Data extraction and assessment of risk of bias were done in duplicate to enhance validity of the results. Meta-analysis was conducted using the random-effects model. Findings were summarised and synthesised qualitatively.

RESULTS

Communication intervention to facilitate decision-making achieved uptake rate of 100% (95% CI 0.99% to 1.00%), followed by intervention to enable communication, which achieved 92% (95% CI 0.92% to 0.92%). Communication intervention to inform and educate achieved 90% (95% CI 0.90% to 0.90%).Targeting both healthcare workers and community leaders with the communication intervention achieved 95% (95% CI 0.91% to 0.98%), while teachers and school boards achieved 92% (95% CI 0.84% to 1.01%). Targeting policymakers achieved 86% (95% CI 0.78% to 0.93%).Based on the method of communication intervention delivery, use of training achieved an uptake rate of 85% (95% CI 0.84% to 0.87%); similarly, drama and dance achieved 85% (95% CI 0.84% to 0.86%). However, use of information, education and communication materials achieved 82% (95% CI 0.78% to 0.87%).

CONCLUSION

HPV vaccine communication is critical in ensuring that the community understands the importance of vaccination. The most effective communication strategies included those which educate the population about the HPV vaccine, facilitate decision-making on vaccine uptake and community ownership of the vaccination process immunisation.

PROSPERO REGISTRATION NUMBER

CRD42021243683.

HPV-Vaccine Hesitancy in Colombia: A Mixed-Methods Study

In Colombia, the uptake rate of the HPV vaccine dropped from 96.7% after its introduction in 2013 to 9% in 2020. To identify the behavioural components of HPV-vaccine hesitancy in females aged 15 and under and their families, we conducted a convergent mixed-methods study in which 196 parents/caregivers responded to an online questionnaire and 10 focus groups were held with 13 of these parents/caregivers, and 50 age-eligible girls. The study is novel as it is the first to explore the factors influencing HPV-vaccine hesitancy alongside the COVID vaccine within an integrative model of behaviour change, the capability-opportunity-motivation-behaviour (COM-B) model. We found that COVID-19 has had an impact on the awareness of HPV and HPV vaccination. Lack of information about the vaccination programs, concerns about vaccine safety and the relationship between HPV and sexuality could be related to vaccine hesitancy. Trust in medical recommendations and campaigns focused on the idea that vaccination is a way of protecting daughters from cervical cancer could improve HPV vaccine uptake.

Impact of Parental Knowledge and Beliefs on HPV Vaccine Hesitancy in Kenya-Findings and Implications

Cervical cancer can be prevented by human papillomavirus (HPV) vaccination. However, parents can have concerns about vaccinating their daughters. Consequently, there is a need to identify prevalence and risk factors for HPV vaccine hesitancy among parents in Kenya. A descriptive cross-sectional study was conducted among parents with children aged 9−14 years attending a leading referral hospital in Kenya. Data on sociodemographic traits, HPV knowledge, beliefs and vaccine hesitancy were collected. Out of 195 participants, 183 (93.5%) were aged >30 years. Thirty-four (46.4%) of males and 39 (35.1%) of females did not know that the vaccine is given to prevent HPV infection. Encouragingly, levels of vaccine acceptance were high (90%) although one-third (37.9%) had a negative perception about the effectiveness of the vaccine, with vaccine hesitancy attributed to safety concerns (76%) and feelings that the child was too young (48%). Positive beliefs and knowledge of the vaccine were positively associated with parental willingness to vaccinate their children. Low levels of parenteral education and a younger age among mothers were negatively associated with willingness to vaccinate. Most parents (59%) would consult their daughters before vaccination, and 77% (n = 150) recommended early sex education. Despite low knowledge levels, there was high parental willingness to have their children vaccinated.

Men and infertility in The Gambia: Limited biomedical knowledge and awareness discourage male involvement and exacerbate gender-based impacts of infertility

Introduction

Infertility in Sub-Saharan Africa constitutes an important social and public health problem. Yet, there is a paucity of research on the experiences of men living with infertility, especially in West Africa. This study explored men’s aetiological knowledge, views and experiences of infertility in the West Coast region of The Gambia, West Africa.

Methodology

An explorative qualitative study was conducted among men living in the rural and urban communities of the West Coast region of The Gambia using in-depth interviews. Data collection and analysis were performed concurrently, and thematic data analysis was an iterative process carried out using NVivo 11 Analysis Software.

Results

Gambian men had generally poor knowledge of infertility, allocating it to God, spiritual powers and bodily (biomedical) factors. While societal norms meant that infertility was generally attributed to women, some men allocated male-factor infertility to poor sperm quality and impotence. Infertility threatened participants’ sense of masculinity and resulted in psychosocial distress, including stigma, feelings of isolation, and low self-esteem.

Conclusion

Normative gendered frameworks of infertility result in high levels of female responsibilisation in the Gambian context. Yet men diagnosed with infertility experience significant, often unrecognized, psychological and social distress. We therefore call for increased attention to male-factor infertility, and the promotion of male engagement with infertility-care and services, both of which are essential for successfully addressing infertility and it’s psychosocial consequences in The Gambia.

Community perceptions of vaccination among influential stakeholders: qualitative research in rural India

Background

In India and other low- and middle-income countries, multiple family and community members are influential in caregivers’ perceptions of vaccination. Existing literature indicates the primary caregiver, typically the mother, is instrumental in vaccine decision-making, but this may vary in contexts. We investigated the role of stakeholders in India who influence caregivers’ vaccination perceptions, as this is essential to developing strategies to promote vaccine acceptance and improve uptake.

Methods

This research was conducted in 2019 in Mewat District in Haryana, an area in India with extremely low vaccination coverage. We conducted six focus group discussions with 60 participants in the following categories: fathers of children under-5 years old, expectant mothers, mothers-in-law, community health workers, and community influencers such as locally elected officials and religious leaders.

Results

Our results highlighted four themes that influence vaccine uptake. First, while caregivers associated vaccination with reductions in specific diseases, they also noted that vaccination services brought broad health gains, including improved nutrition, antenatal guidance, and social support. Second, community health workers critically influenced, positively or negatively, caregivers’ vaccination perceptions. Third, community health workers faced gaps in their education such as limited training on vaccine side-effects, placing them at a disadvantage when dealing with families. Finally, we found that mothers-in-law, fathers, and religious leaders influence caregivers’ perceptions of vaccination.

Conclusions

Communication of broader benefits of vaccines and vaccination services by community health workers could be impactful in increasing vaccine acceptance. Vaccine uptake could potentially be improved by facilitating community health workers’ ownership over vaccine acceptance and uptake by involving them in the design and implementation of interventions to target mothers and mothers-in-law. A ‘bottom-up’ approach, leveraging community health workers’ knowledge to design interventions, and giving a voice to key members of the household and society beyond mothers alone, may sustain health improvement in low vaccine coverage areas.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12188-4.

Postmortem Study of Cause of Death Among Children Hospitalized With Respiratory Illness in Kenya

BACKGROUND

In resource-limited settings, acute respiratory infections continue to be the leading cause of death in young children. We conducted postmortem investigations in children <5 years hospitalized with a clinical diagnosis of respiratory disease at Kenya's largest referral hospital.

METHODS

We collected respiratory and other tissues postmortem to examine pathologic processes using histology, molecular and immunohistochemistry assays. Nasopharyngeal, trachea, bronchi and lung specimens were tested using 21-target respiratory pathogen real-time reverse transcription polymerase chain reaction assays deployed on Taqman Array Cards. Expert panels reviewed all findings to determine causes of death and associated pathogens.

RESULTS

From 2014 to 2015, we investigated 64 pediatric deaths (median age 7 months). Pneumonia was determined as cause of death in 70% (42/52) of cases where death was associated with an infectious disease process. The main etiologies of pneumonia deaths were respiratory syncytial virus (RSV) (n = 7, 19%), Pneumocystis jirovecii (n = 7, 19%), influenza A (n = 5, 14%) and Streptococcus pneumoniae (n = 5, 14%)-10% of cases had multi-pathogen involvement. Among the other 10 deaths associated with a nonpneumonia infectious process, 4 did not have an etiology assigned, the others were associated with miliary tuberculosis (2), cerebral thrombosis due to HIV (1), Enterobacteriaceae (1), rotavirus (1), and 1 case of respiratory infection with severe hypokalemia associated with RSV.

CONCLUSIONS

In spite of well-established vaccination programs in Kenya, some deaths were still vaccine preventable. Accelerated development of RSV monoclonal antibodies and vaccines, introduction of seasonal influenza vaccination, and maintenance or improved uptake of existing vaccines can contribute to further reductions in childhood mortality.

Stakeholders' Understandings of Human Papillomavirus (HPV) Vaccination in Sub-Saharan Africa: A Rapid Qualitative Systematic Review

Cervical cancer rates in Sub-Saharan Africa (SSA) are amongst the highest worldwide. All three of the Human Papillomavirus (HPV) vaccines (9-valent, quadrivalent and bivalent HPV vaccine) provide primary protection against the most common cancer-causing strains of HPV (types 16 and 18) that are known to cause 70% of cervical cancers. Over the last five years, there has been an increase in Sub-Saharan African countries that have introduced the HPV vaccine. The majority of research has been conducted on supply-side barriers and facilitators to HPV vaccination uptake in SSA, yet little research has been conducted on demand-side or end-user perspectives of, and decisions around, HPV vaccination. In order to complement existing research, and inform current and future HPV vaccination implementation approaches, this qualitative systematic review explored Stakeholders' understandings of HPV vaccination in SSA. This review searched the following databases: Embase (via Scopus), Scopus, MEDLINE (via PubMed), PubMed, EBSCOhost, Academic Search Premier, Africa-Wide Information, CINAHL, PsycARTICLES, PsycINFO, SocINDEX, Web of Science, and the Cochrane Controlled Register of Trials (CENTRAL) and found a total of 259 articles. Thirty-one studies were found eligible for inclusion and were analyzed thematically using Braun and Clarke's methods for conducting a thematic analysis. The quality of included studies was assessed using the Critical Appraisal Skills Programme (CASP) checklist. Three major themes emerged from this analysis; knowledge of HPV vaccination and cervical cancer is intertwined with misinformation; fear has shaped contradictory perceptions about HPV vaccination and gender dynamics are relevant in how stakeholders understand HPV vaccination in SSA.

Decision-making process for introduction of maternal vaccines in Kenya, 2017-2018

BACKGROUND

Maternal immunization is a key strategy for reducing morbidity and mortality associated with infectious diseases in mothers and their newborns. Recent developments in the science and safety of maternal vaccinations have made possible development of new maternal vaccines ready for introduction in low- and middle-income countries. Decisions at the policy level remain the entry point for maternal immunization programs. We describe the policy and decision-making process in Kenya for the introduction of new vaccines, with particular emphasis on maternal vaccines, and identify opportunities to improve vaccine policy formulation and implementation process.

METHODS

We conducted 29 formal interviews with government officials and policy makers, including high-level officials at the Kenya National Immunization Technical Advisory Group, and Ministry of Health officials at national and county levels. All interviews were recorded and transcribed. We analyzed the qualitative data using NVivo 11.0 software.

RESULTS

All key informants understood the vaccine policy formulation and implementation processes, although national officials appeared more informed compared to county officials. County officials reported feeling left out of policy development. The recent health system decentralization had both positive and negative impacts on the policy process; however, the negative impacts outweighed the positive impacts. Other factors outside vaccine policy environment such as rumours, sociocultural practices, and anti-vaccine campaigns influenced the policy development and implementation process.

CONCLUSIONS

Public policy development process is complex and multifaceted by its nature. As Kenya prepares for introduction of other maternal vaccines, it is important that the identified policy gaps and challenges are addressed.

Perceptions of key informants on the provision of cervical cancer prevention and control programme in Uganda: implication for cervical cancer policy

Background

Uganda has one of the highest burdens of cervical cancer globally. In 2010 the Ugandan Ministry of Health launched the Strategic Plan for Cervical Cancer Prevention and Control with the hope of developing cervical cancer policy in Uganda. This study explored the beliefs of senior key informants in Uganda about cervical cancer prevention, the control programme, and the relevance of cervical cancer policy.

Methods

We conducted 15 key informant interviews with participants from six organisations across Northern and Central Uganda. Participants were drawn from district local government health departments, St. Mary’s Hospital Lacor, Uganda Nurses and Midwifery Council, non-governmental organisations (NGOs) and Ministry of Health in Kampala, Uganda. The interview recordings were transcribed and analysed using thematic analysis.

Results

Seven themes emerged relating to the cervical cancer prevention and control programmes in Uganda: (1) policy frameworks for cervical cancer, (2) operationalising cervical cancer prevention and control, (3) financial allocation and alignment, (4) human resources and capability, (5) essential supplies and vaccines, (6) administrative data and resource distribution, and (7) cervical cancer services.

Conclusions

The key informants perceive that the lack of a cervical cancer policy in Uganda is hindering cervical cancer prevention and control programmes. Therefore, the Ministry of Health and stakeholders need to work together in coming up with an effective policy framework that will accelerate efforts towards cervical cancer prevention and control in Uganda.

Health systems constraints and facilitators of human papillomavirus immunization programmes in sub-Saharan Africa: a systematic review

Given the vast investments made in national immunization programmes (NIPs) and the significance of NIPs to public health, it is important to understand what influences the optimal performance of NIPs. It has been established that well-performing NIPs require enabling health systems. However, systematic evidence on how the performance of health systems impacts on NIPs is lacking, especially from sub-Saharan Africa. We conducted a qualitative systematic review to synthesize the available evidence on health systems constraints and facilitators of NIPs in sub-Saharan Africa, using human papillomavirus immunization programmes as a proxy. Fifty-four articles published between 2008 and 2018 were found to be eligible. Data extraction was guided by an analytical model on the interface between NIPs and health systems. A cross-cutting thematic analysis of the extracted data was performed. This systematic review provides evidence necessary for informing ongoing health systems strengthening initiatives in sub-Saharan Africa. There is evidence to suggest that NIPs in sub-Saharan Africa have surmounted significant health systems constraints and have achieved notable public health success. This success can be attributed to strong political endorsement for vaccines, clear governance structures and effective collaboration with global partners. Despite this, significant health systems constraints persist in service delivery, vaccine communication, community engagement, the capacity of the health workforce and sustainable financing. These constraints could derail further progress if not addressed through health systems strengthening efforts. There is a need to expand the research agenda to include the comprehensive evaluation of health systems constraints and facilitators of NIPs within sub-Saharan Africa.

Uptake of the HPV vaccine among people with and without HIV, cisgender and transgender women and men who have sex with men and with women at two sexual health clinics in Mexico City

Our aim was to better understand Human Papillomavirus (HPV) vaccine acceptance among Mexican adults including people with and without HIV, cisgender men who have sex with men (MSM) or with women (MSW), cisgender and transgender women. A computer-assisted, self-administered questionnaire was completed by healthcare users and participants recruited through community organizations, and the first dose of the quadrivalent HPV vaccine was offered at no cost at a large sexual health clinic in Mexico City, from May to December 2018. Socio-demographic characteristics and factors associated with HPV vaccine acceptance were analyzed using logistic regression.The sample of 1915 participants included 1341 cisgender men (70.9%, 1247 MSM and 94 MSW), 396 (20.7%) cisgender women and 178 (9.3%) transwomen; 615 people (32.1%) were HIV positive. Uptake of the HPV vaccine was higher in men and transwomen (91.5% and 87%, respectively) than among cisgender women (81.8%; p < .001). Cisgender women (OR 0.43, 95%CI 0.30-0.61, p < .05) were less likely to accept HPV vaccination than men. Married/partnered people were less likely to accept HPV vaccination compared to those who were single (OR 0.70, 95%CI 0.51-0.97). People living with HIV were not significantly more likely to accept HPV vaccination (OR 1.7; 95%CI 0.86-1.61).HPV vaccine acceptance was high among adult Mexican study participants; it may be higher than among other Mexican adults given most of these individuals are engaged in care. Modifications will be needed in national and international recommendations on HPV vaccination in adults if healthcare personnel are to recommend the vaccine to the population groups studied.

CDC Activities for Improving Implementation of Human Papillomavirus Vaccination, Cervical Cancer Screening, and Surveillance Worldwide

Cervical cancer incidence and mortality rates are high, particularly in developing countries. Most cervical cancers can be prevented by human papillomavirus (HPV) vaccination, screening, and timely treatment. The US Centers for Disease Control and Prevention (CDC) provides global technical assistance for implementation and evaluation of HPV vaccination pilot projects and programs and laboratory-related HPV activities to assess HPV vaccines. CDC collaborates with global partners to develop global cervical cancer screening recommendations and manuals, implement screening, create standardized evaluation tools, and provide expertise to monitor outcomes. CDC also trains epidemiologists in cancer prevention through its Field Epidemiology Training Program and is working to improve cancer surveillance by supporting efforts of the World Health Organization in developing cancer registry hubs and assisting countries in estimating costs for developing population-based cancer registries. These activities contribute to the Global Health Security Agenda action packages to improve immunization, surveillance, and the public health workforce globally.

Perspectives of Screening-Eligible Women and Male Partners on Benefits of and Barriers to Treatment for Precancerous Lesions and Cervical Cancer in Kenya

BACKGROUND

Cervical cancer is the leading cause of female cancer mortality in Kenya. Kenya's National Cervical Cancer Prevention Program Strategic Plan outlines efforts to reduce the burden; however, treatment services remain limited. This study identified male and female perspectives regarding benefits, facilitators, and barriers to treatment for precancerous lesions and cervical cancer.

MATERIALS AND METHODS

Ten focus groups were conducted in Nairobi and Nyanza in 2014 with females aged 25-49 years (n = 60) and male partners (n = 40). Participants were divided into groups dependent on screening status, sex, language, and geographic location. Qualitative analytic software was used to analyze transcribed and translated data.

RESULTS

Treatment was endorsed as beneficial for the prevention of death and the improvement of wellness, quality of life, symptoms, and family life. Barriers reported by males and females included the following: (a) concerns about side effects; (b) treatment-related fear and stigma; (c) marital discord; (d) financial and access issues; (e) religious and cultural beliefs; and (f) limited knowledge. Male endorsement of wanting to improve knowledge and communication with their partners, in spite of stigmatizing beliefs and misperceptions regarding females with abnormal screening results or those who have been diagnosed with cancer, was novel.

CONCLUSION

Incorporating qualitative data on benefits of and barriers to treatment for precancerous lesions and cervical cancer into Kenya's national priorities and activities is important. These findings can be used to inform the development and successful implementation of targeted, region-specific community outreach and health messaging campaigns focused on alleviating the country's cervical cancer burden.

IMPLICATIONS FOR PRACTICE

This article provides important insight into female and male partner perspectives regarding benefits, facilitators, and barriers to treatment for precancerous lesions and cervical cancer. These novel research findings can inform the development of targeted community health interventions, educational messages, and resources and aid stakeholders in strengthening strategic plans regarding treatment coverage and cervical cancer prevention. Because several treatment barriers identified in this study are similar to barriers associated with cervical cancer screening in low- and middle-resourced countries, effective messaging interventions could address barriers to receipt of both screening and treatment.

Acceptability of multipurpose human papillomavirus vaccines among providers and mothers of adolescent girls: A mixed-methods study in five countries

Introduction

Multipurpose vaccines (MPVs) could be formulated to prevent multiple sexually transmitted infections simultaneously. Little is known about acceptability of MPVs among vaccine health care providers (HCPs) or mothers of adolescent girls.

Methods

151 adolescent vaccine providers and 118 mothers of adolescent girls aged 9–14 were recruited from five geographically-diverse countries: Argentina, Malaysia, South Africa, South Korea, and Spain. We assessed providers’ preferences for single-purpose human papillomavirus (HPV) vaccine versus MPVs (including HPV+herpes simplex virus (HSV)−2, HPV+HIV, or HPV+HSV-2+HIV) via quantitative surveys. Maternal MPV attitudes were assessed in four focus group discussions (FGDs) in each country.

Results

Most providers preferred MPVs over single-purpose HPV vaccination, with preference ranging from 61% in Malaysia to 96% in South Africa. HPV+HSV-2+HIV was the most preferred MPV formulation (56–82%). Overall, 53% of the mothers preferred MPVs over single-purpose HPV vaccines, with strongest support in South Africa (90%) and lowest support in South Korea (29%). Convenience and trust in the health care system were commonly-cited reasons for MPV acceptability. Safety and efficacy concerns were common barriers to accepting MPVs, though specific concerns differed by country. Across FGDs, additional safety and efficacy information on MPVs were requested, particularly from trusted sources like HCPs.

Conclusions

Though maternal acceptability of MPVs varied by country, MPV acceptability would be enhanced by having HCPs provide parents with additional MPV vaccine safety and efficacy information. While most providers preferred MPVs, future health behavior research should identify acceptability barriers, and targeted provider interventions should equip providers to improve vaccination discussions with parents.

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We gauged acceptance of a multipurpose vaccine (MPV) concept to prevent HPV and STIs.

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Most vaccine providers were willing to administer an MPV for HPV, HSV-2, and HIV.

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Mothers of teen girls desired safety and efficacy evidence before accepting MPVs.

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In mothers, MPV acceptability differed by region and daughter's vaccination history.

Environmental and Psychosocial Barriers to and Benefits of Cervical Cancer Screening in Kenya

BACKGROUND

Cervical cancer is the second most commonly diagnosed cancer in females and is a leading cause of cancer-related mortality in Kenya; limited cervical cancer screening services may be a factor. Few studies have examined men's and women's perceptions on environmental and psychosocial barriers and benefits related to screening.

MATERIALS AND METHODS

In 2014, 60 women aged 25-49 years and 40 male partners participated in 10 focus groups (6 female and 4 male), in both rural and urban settings (Nairobi and Nyanza, Kenya), to explore perceptions about barriers to and benefits of cervical cancer screening. Focus groups were segmented by sex, language, geographic location, and screening status. Data were transcribed, translated into English, and analyzed by using qualitative software.

RESULTS

Participants identified screening as beneficial for initiating provider discussions about cancer but did not report it as a beneficial method for detecting precancers. Perceived screening barriers included access (transportation, cost), spousal approval, stigma, embarrassment during screening, concerns about speculum use causing infertility, fear of residual effects of test results, lack of knowledge, and religious or cultural beliefs. All participants reported concerns with having a male doctor perform screening tests; however, men uniquely reported the young age of a doctor as a barrier.

CONCLUSION

Identifying perceived barriers and benefits among people in low- and middle-income countries is important to successfully implementing emerging screening programs. The novel findings on barriers and benefits from this study can inform the development of targeted community outreach activities, communication strategies, and educational messages for patients, families, and providers. The Oncologist 2017;22: 173-181Implications for Practice: This article provides important information for stakeholders in clinical practice and research when assessing knowledge, beliefs, and acceptability of cervical cancer screening and treatment services in low- and middle-resourced countries. Formative research findings provide information that could be used in the development of health interventions, community education messages, and materials. Additionally, this study illuminates the importance of understanding psychosocial barriers and facilitators to cervical cancer screening, community education, and reduction of stigma as important methods of improving prevention programs and increasing rates of screening among women.

Multiple HPV infections in female sex workers in Western Kenya: implications for prophylactic vaccines within this sub population

Background

Whilst the imputed role of High Risk (HR) HPV infection in the development of cervical lesions and cancer has been established, the high number of HPV genotypes that Female Sex workers (FSW) harbour warrants that the synergistic effects of potential HR (pHR) and HR HPV genotypes be elucidated to assess the potential impact of prophylactic vaccines. This population in Kenya also harbours a number of other vaginal infections and STIs, including bacterial vaginosis (BV), trichomonas vaginalis (TV) and candida spp.

The aims of this cross-sectional analysis in Kenya are to explore the epidemiology of abnormal cytology and the pairing of pHR/HPV genotypes in HIV-negative and HIV-infected FSW.

Methods

A cross-sectional study design of 616 FSW from Western Kenya aged between 18 and 61 years during 2009–2015 using a peer recruitment sampling strategy.

Results

Of the 599 FSW who underwent cytological examination, 87 had abnormal cytology (14.5%; 95% CI: 12.0–17.6%). A combined prevalence of HPV16 and 18 (29.6%; 95% CI: 22.2–37.8%) was observed in abnormal cytology. HPV 53 and 51 were the most observed pairing in FSW with abnormal cytology. Significant adjusted associations were found between abnormal cytology and TV (aOR: 30; 95% CI: 14.1–62.9), multiple HR HPV (aOR: 3.7; 95% CI: 1.9–7.3), HPV 51 (aOR 3.7; 95% CI 1.6–8.6) and HPV 52 (aOR 6.1; 95% CI: 2.8–13.3).

Conclusion

HPV 51 and 52 were independently associated with abnormal cervical cytology in both HIV negative/positive FSW. The strong association between TV and cervical dysplasia and the high percentage of FSW harbouring more than one STI underscore the need for enhanced STI management within the framework of cervical cancer prevention.

Associations Between Vaginal Infections and Potential High-risk and High-risk Human Papillomavirus Genotypes in Female Sex Workers in Western Kenya

PURPOSE

Infection with and persistence of high-risk human papillomavirus (HR HPV) are the strongest risk factors for cervical cancer. Little is known about the prevalence and role of concurrent sexually transmitted infections (STIs) found in HPV-infected female sex workers (FSW) in Africa. This study purports to test our a priori hypotheses that STIs are associated with genotypes pertaining to the α-group species 9. The objectives were to determine the prevalence of bacterial vaginosis (BV), Trichomonas vaginalis, and Candida spp in FSW, the association between these STIs and the prevalence of any potential HR and HR HPV genotypes in FSWs.

METHODS

A cross-sectional study design of 616 FSW from Western Kenya aged between 18 and 61 years during 2009-2015 using a peer recruitment sampling strategy. Inclusion criteria for the study entailed female sex and >18 years of age and having engaged in transactional sex in exchange for money, goods, services, or drugs in the last 3 months. Women were excluded if they were pregnant, <18 years of age, had a history of cervical dysplasia or cancer, had current abnormal bleeding, or had a hysterectomy.

FINDINGS

Of the FSW, 33.3% had HIV and 57.7% harbored a potential HR and HR HPV genotype. The 2 most prevalent potential HR and HR genotypes were HPV 16 (16.10%) and HPV 59 (12.20%). BV was the most common infection (48.3%), followed by Trichomonas vaginalis (31.4%) and Candida spp (19.9%). A multivariate regression revealed significant associations with both α-group 9 and 6; BV and HPV 58 (adjusted odds ratio [aOR] = 2.3; 95% CI, 1.0-5.2; P = 0.05), Trichomonas vaginalis and HPV 31 and HPV 35 (aOR = 2.0; 95% CI, 1.0-3.8; P = 0.04 and aOR = 1.8; 95% CI, 1.0-3.3, P = 0.05 respectively); and between Candida spp and HPV 53 (aOR = 2.0; 95% CI, 1.1-4.0; P = 0.03) and 16 (aOR = 1.9; 95% CI, 1.1-3.3; P = 0.03).

IMPLICATIONS

Snowball sampling may have inadvertently excluded FSW less likely to benefit from a social network. Significant associations between BV and HPV 58 and between Candida spp and HPV 16 and 53 suggest the need for sexually transmitted disease management within a cervical cancer prevention program. The probable synergistic effects of the vaginal microbiota should be elucidated, especially within this vulnerable population. Given the potential for FSW to transmit STIs, robust epidemiologic sampling methods are urgently required that account for the heterogeneity of the FSW population.

Experiences and lessons learned from 29 HPV vaccination programs implemented in 19 low and middle-income countries, 2009-2014

BACKGROUND

Cervical cancer is the greatest cause of age-weighted years of life lost in the developing world. Human papillomavirus (HPV) infection is associated with a high proportion of cervical cancers, and HPV vaccination may help to reduce the incidence of cancer. The aim of the study was to identify barriers, obstacles, and strategies and to analyze key concerns and lessons learned with respect to the implementation of HPV vaccination program in low- and middle-income countries.

METHODS

The Gardasil Access Program (GAP) is a donation program established to enable organizations and institutions in eligible low-resource countries to gain operational experience designing and implementing HPV vaccination programs. This study used an online survey to capture the experiences and insights of program managers participating in the GAP. Different factors related to HPV vaccination program management were collected. A mixed-method approach enabled the presentation of both quantitative measurements and qualitative insights.

RESULTS

Twenty-nine programs implemented by 23 institutions in 19 low- and middle-income countries were included. Twenty programs managers (97.7 %) reported that their institution implemented sensitization strategies about vaccination prior to the launch of vaccination campaign. The most frequently reported obstacles to HPV vaccination by the program managers were erroneous perceptions of population related to the vaccine's safety and efficacy. Reaching and maintaining follow-up with target populations were identified as challenges. Insufficient infrastructure and human resources financing and the vaccine delivery method were identified as significant health system barriers. Coupling HPV vaccination with other health interventions for mothers of targeted girls helped to increase vaccination and cervical cancer screening. The majority of program managers reported that their programs had a positive impact on national HPV vaccination policy. The majority of institutions had national and international partners that provided support for human resources, technical assistance, and training and financial support for health professionals.

CONCLUSION

Local organizations and institutions can implement successful HPV vaccination campaigns. Adequate and adapted planning and resources that support information sharing, sensitization, and mobilization are essential for such success. These results can inform the development of programs and policies related to HPV vaccination in low- and middle-income countries.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Distribution of human papillomaviruses and bacterial vaginosis in HIV positive women with abnormal cytology in Mombasa, Kenya

BACKGROUND

HPV is the major etiological factor in the causal pathway for cervical cancer, which is the leading cancer among women in sub-Saharan Africa. HIV is associated with a higher prevalence and a broader range of high-risk HPV genotypes. Studies have shown a positive association between Bacterial vaginosis (BV) and HPV and HIV. Also, in African women, BV was found to be significantly associated with vaginal inflammation. The high prevalence of BV, HIV and HPV infections in the African continent makes elucidation of the interactions with one another of utmost public health interest. The aims of the current study are to examine the frequency of HPV genotypes and BV as well as their respective risk factors within an HIV infected population with abnormal cytology in the resource-constrained setting of Mombasa, Kenya and, secondly, highlight issues to consider for triple co-infection clinical management.

METHOD

Cross-sectional analysis with a sample drawn from an ongoing cohort study. All consenting, non-pregnant HIV infected women, between 18 and 50 years of age, without a history of cervical cancer or hysterectomy, between November 2005 and April 2006 were screened for HR HPV DNA in Mombasa, Kenya. 1 out of 4 HIV positive women fulfilled the criteria by having SIL (24.9 %). 600 HIV infected women were tested to reach a cohort of 74 HIV women with abnormal cytology. To assess which factors were associated with HR HPV, crude statistical analysis was performed through logistic regression.

RESULTS

Bacterial vaginosis (BV) was found in 46 women out of 74 (62.2 %). Cervicitis was diagnosed in 15 % of women (n = 11), of which 8 had BV. The most prevalent HPV genotypes were HPV 16 (33.8), HPV 53 (24.3) and HPV 18 (17.6 %), while 65 % of the participants had multiple genotype infection. Statistically significant associations between CD4 counts <200 cells/μl and multiple HPV prevalence, adjusted for age were also noted (OR = 3.7; 95 CI: 1.2-12.1; p = 0.03) and HPV53 (OR = 4.4, 95 % CI: 1.4-13.6; p = 0.01). A statistically significant association was found between CD4 count ≥ 350 μl and HPV 16 adjusted for age (OR = 2.9; 95 % CI: 1.0- 8.3; p = 0.05). A borderline statistically significant association was observed between BV and HPV58 (crude OR = 4.1, 95 % CI: 0.8-21.0; p = 0.07).

CONCLUSION

The most prevalent HPV genotypes observed were HPV 16, HPV 53, and HPV 18, which have a combined prevalence of 76 %. Our results show that a triage based on CD4 count should start at CD4 count ≥ 350 μl as our study suggests that HPV 16 are more prevalent when women are moderately immunosuppressed. Given the high prevalence of HPV 53 in a HIV infected population with abnormal cytology, its cervical carcinoma genesis potential as a stand-alone genotype and as well as its synergism with multiple infections should be investigated. The new WHO guideline in resource-poor settings to rescreen women for HPV within ten years may be more effective if BV and cervicitis management become a major component for HIV-HPV management.