Evaluation of 'see-see and treat' strategy and role of HIV on cervical cancer prevention in Uganda

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

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

Visual inspection with acetic acid (VIA) positivity among female sex workers: a cross-sectional study highlighting one-year experiences in early detection of pre-cancerous and cancerous cervical lesions in Kampala, Uganda

BACKGROUND

Although cervical cancer is preventable, most women in sub-Saharan Africa (SSA) do not receive routine screening and few treatment options exist. Female Sex Workers (FSWs) are among the Ugandan female population at highest risk of acquiring sexually transmitted infections (STIs) including HIV and human papilloma viruses (HPV), the cause of cervical cancer. We report one-year experiences of visual inspection with acetic acid (VIA) positivity among FSWs in the early detection of pre-cancerous and cancerous cervical lesions in Kampala, Uganda.

METHODS

Between June 2014 and July 2015, we enrolled FSWs into a cross-sectional study at a research clinic. The women were screened using the VIA method (application of 3-5 % acetic acid to the cervix). All VIA positive women were referred to a tertiary hospital for colposcopy, biopsy, and immediate treatment (if indicated) at the same visit according to national guidelines. Data on socio-demographic, sexual behaviour, sexual reproductive health and clinical characteristics were collected. We used logistic regression to identify factors associated with VIA positivity.

RESULTS

Of 842 women assessed for eligibility, 719 (85 %) of median age 30 (IQR 26, 35) were screened, and 40 (6 %) women were VIA positive. Of the 24 histology specimens analysed, 6 showed inflammation, only 1 showed cervical intraepithelial neoplasia (CIN) 1, 13 women showed CIN2/3, while 4 women already had invasive cervical cancer. The overall prevalence of HIV was 43 %, of whom only 35 % were receiving ART. In the age-adjusted analysis, VIA positivity was more likely among women who reported having > 100 life-time partners (aOR = 3.34, 95 %CI: 1.38-8.12), and HIV positive women (aOR = 4.55; 95 %CI: 2.12-9.84).

CONCLUSIONS

We found a relatively low proportion of VIA positivity in this population. The experience from our program implies that the VIA results are poorly reproducible even among a category of trained professional health workers. VIA positivity was more likely among women with a high number of sexual partners and HIV infection. Interventions for improving cervical cancer screening should be recommended as part of HIV care for FSWs to reduce the disease burden in this population.

Cervical Cancer Screening in HIV-Positive Farmers in South Africa: Mixed-Method Assessment

Background:

In 2015, a See and Treat cervical cancer screening program was implemented at a local HIV clinic in Limpopo, South Africa, where infrastructure limited adequate Pap smear usability.

Objectives:

The purpose of this evaluation was to determine the quality and sustainability of the implemented program.

Methods:

A mixed-methods program analysis was conducted at 18-months post implementation. Data collection techniques included in-depth interviews of staff and patients, observation of healthcare workers delivering screening, and review of charts and patient logs.

Findings:

Eighteen in-depth interviews revealed improved cervical cancer screening understanding and awareness. Privacy concerns and negative perceptions of medical care were barriers to screening. Informal observations revealed continued clinical competence among healthcare workers who had been previously trained. Review of charts demonstrated positive correlation between VIA and Pap smear results. In evaluating loss to attrition, about half of the first cohort of patients were lost to follow-up. VIAs and Pap smears were offered on an ongoing basis, and month-over-month change for overlapping four months of programming between 2015 and 2016 showed a 4.4% negative change in number of Pap smears and a 57% negative change in VIAs.

Conclusion:

Our evaluation reveals successful integration of See and Treat into current clinic services in rural South Africa and increased awareness of cervical cancer among health workers and participants. Program sustainability was challenging to assess as many patients were lost to follow-up, given the migrant and transient population attending this clinic. Acceptance by health workers and patients alike is vital for the long-term impact on cervical cancer incidence in this region.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018095702.

Acceptability of cervical cancer screening using visual inspection among women attending a childhood immunization clinic in Uganda

Objective

To evaluate the acceptability and performance of cervical cancer (CC) screening using visual inspection with acetic acid (VIA) integrated into a rural immunization clinic in Uganda.

Methods/materials

We conducted a cross-sectional pilot study in rural Uganda. We explored associations between women's characteristics and acceptance of VIA testing. We collected samples for Papanicolaou (Pap) smear testing in a random subset of women and used results from this test as a comparator for assessing VIA performance.

Results

We enrolled 625 women of whom 571 (91.4%) accepted and 54 (8.6%) refused CC screening. In the univariate model, age (Odds Ratio (OR)=1.10; p-value<0.001) and employment status (OR 2.00; p-value=0.019) were significantly associated with acceptance of VIA screening. In the multivariate model, no characteristic was independently associated with acceptance of VIA screening after adjusting for other factors. Compared to reference Pap smear, CC screening with VIA had a sensitivity of 50% and a specificity of 97.7%.

Conclusions

CC screening with VIA is highly acceptable in the setting of rural immunization clinics in Uganda. Studies to assess which screening method would be the most effective and cost-effective are needed before stakeholders can consider adopting screening programs at scale.

Public health approach to prevent cervical cancer in HIV-infected women in Kenya: Issues to consider in the design of prevention programs

Women living with HIV in Africa are at increased risk to be co-infected with Human Papilloma Virus (HPV), persistent high risk (HR) HPV infection and bacterial vaginosis (BV), which compounds HPV persistence, thereby increasing the risk for cervical dysplasia. New guidance from WHO in 2014 advocating for a “screen and treat” approach in resource poor settings is becoming a more widely recommended screening tool for cervical cancer prevention programs in such contexts. This review article summarizes the risk factors to be considered when designing a primary and secondary cervical prevention program in a post-vaccination era for HIV-infected women in Kenya.

This review article is based on our prior research on the epidemiology of pHR/HR-HPV genotypes in HIV-infected women and CIN 2 + in Kenya and other sub-Saharan contexts. In order to contextualize the findings, a literature search was carried out in March 2017 by means of four electronic databases: PUBMED, EMBASE, SCOPUS, and PROQUEST.

Risk factors for potential (pHR)/HR HPV acquisition, including CD4 count, HAART initiation, Female Sex Worker status (FSW) and BV need to be considered. Furthermore, there may be risk factors for abnormal cytology, including FSW status, multiple potential (p)HR/HR HPV genotypes, which may require that HIV-infected women be subjected to screening at more frequent intervals than the three year recommended by the WHO. The quadruple synergistic interaction between HIV, HPV and BV and its related cervicitis may need to be reflected within a larger prevention framework at the community level. The opportunities brought forth by the roll out of HAART could lead to task shifting of HIV-HPV-BV care to nurses, which may increase access in poorly-served areas.

•

Bacterial Vaginosis treatment should be an integral component of cervical cancer prevention.

•

A larger cervical cancer prevention framework at the community level is needed.

•

Task shifting to nurses of Bacterial Vaginosis management in HIV-HPV co-infected women should be explored.

Implementing a Fee-for-Service Cervical Cancer Screening and Treatment Program in Cameroon: Challenges and Opportunities

BACKGROUND

Cervical cancer screening is one of the most effective cancer prevention strategies, but most women in Africa have never been screened. In 2007, the Cameroon Baptist Convention Health Services, a large faith-based health care system in Cameroon, initiated the Women's Health Program (WHP) to address this disparity. The WHP provides fee-for-service cervical cancer screening using visual inspection with acetic acid enhanced by digital cervicography (VIA-DC), prioritizing care for women living with HIV/AIDS. They also provide clinical breast examination, family planning (FP) services, and treatment for reproductive tract infection (RTI). Here, we document the strengths and challenges of the WHP screening program and the unique aspects of the WHP model, including a fee-for-service payment system and the provision of other women's health services.

METHODS

We retrospectively reviewed WHP medical records from women who presented for cervical cancer screening from 2007-2014.

RESULTS

In 8 years, WHP nurses screened 44,979 women for cervical cancer. The number of women screened increased nearly every year. The WHP is sustained primarily on fees-for-service, with external funding totaling about $20,000 annually. In 2014, of 12,191 women screened for cervical cancer, 99% received clinical breast exams, 19% received FP services, and 4.7% received treatment for RTIs. We document successes, challenges, solutions implemented, and recommendations for optimizing this screening model.

CONCLUSION

The WHP's experience using a fee-for-service model for cervical cancer screening demonstrates that in Cameroon VIA-DC is acceptable, feasible, and scalable and can be nearly self-sustaining. Integrating other women's health services enabled women to address additional health care needs.

IMPLICATION FOR PRACTICE

The Cameroon Baptist Convention Health Services Women's Health Program successfully implemented a nurse-led, fee-for-service cervical cancer screening program using visual inspection with acetic acid-enhanced by digital cervicography in the setting of a large faith-based health care system in Cameroon. It is potentially replicable in many African countries, where faith-based organizations provide a large portion of health care. The cost-recovery model and concept of offering multiple services in a single clinic rather than stand-alone "silo" cervical cancer screening could provide a model for other low-and-middle-income countries planning to roll out a new, or make an existing, cervical cancer screening services accessible, comprehensive, and sustainable.

Cross-sectional study to assess the need to commence opportunistic screening of women for cervical cancer presenting with sexually transmitted disease in Western India

This study examines the prevalence of suspected cervical cancer (established through the use of visual inspection with Lugol's Iodine - VILI) among outpatients attending Surat Municipal Institute of Medical Education & Research Hospital, India. A cross-sectional study was conducted on 356 patients; 178 with an established sexually transmitted disease (STD) and 178 patients without. Patients with positive results were investigated with cervical biopsy; out of 356 patients, 21.91% patients with STD and 12.35% patients without STD tested positive for VILI respectively (p = .017). The factors found to be significantly associated with a positive VILI test were STD, marital status, oral contraceptive pill use, a complaint of PV bleeding, white discharge on speculum examination (PS) and cervical erosion on PS. On applying multiple logistic regression, STD, age of patient in years, parity, OC pill use, a complaint of PV bleeding and cervical erosion on PS were found to be significant predictors of VILI positivity among the patients. STD patients are 2.5 times more likely to test positive for VILI than patients without STD. In Indian populations comparable to ours, opportunistic screening should be considered in gynaecology outpatient clinics for women presenting with complaints related to STDs.

The time has come to make cervical cancer prevention an essential part of comprehensive sexual and reproductive health services for HIV-positive women in low-income countries

INTRODUCTION

HIV and cervical cancer are intersecting epidemics that disproportionately affect one of the most vulnerable populations in the world: women in low- and middle-income countries (LMICs). Historically, the disparity in cervical cancer risk for women in LMICs has been due to the lack of organized screening and prevention programmes. In recent years, this risk has been augmented by the severity of the HIV epidemic in LMICs. HIV-positive women are at increased risk for developing cervical precancer and cancer, and while the introduction of antiretroviral therapy has dramatically improved life expectancies among HIV-positive women it has not been shown to improve cancer-related outcomes. Therefore, an increasing number of HIV-positive women are living in LMICs with limited or no access to cervical cancer screening programmes. In this commentary, we describe the gaps in cervical cancer prevention, the state of evidence for integrating cervical cancer prevention into HIV programmes and future directions for programme implementation and research.

DISCUSSION

Despite the biologic, behavioural and demographic overlap between HIV and cervical cancer, cervical cancer prevention has for the most part been left out of sexual and reproductive health (SRH) services for HIV-positive women. Lower cost primary and secondary prevention strategies for cervical cancer are becoming more widely available in LMICs, with increasing evidence for their efficacy and cost-effectiveness. Going forward, cervical cancer prevention must be considered a part of the essential package of SRH services for HIV-positive women. Effective cervical cancer prevention programmes will require a coordinated response from international policymakers and funders, national governments and community leaders. Leveraging the improvements in healthcare infrastructure created by the response to the global HIV epidemic through integration of services may be an effective way to make an impact to prevent cervical cancer among HIV-positive women, but more work remains to determine optimal approaches.

CONCLUSIONS

Cervical cancer prevention is an essential part of comprehensive HIV care. In order to ensure maximal impact and cost-effectiveness, implementation strategies for screening programmes must be adapted and rigorously evaluated through a framework that includes equal participation with policymakers, programme planners and key stakeholders in the target communities.

Implementation and Operational Research: Age Distribution and Determinants of Invasive Cervical Cancer in a "Screen-and-Treat" Program Integrated With HIV/AIDS Care in Zambia

BACKGROUND

Cervical cancer screening efforts linked to HIV/AIDS care programs are being expanded across sub-Saharan Africa. Evidence on the age distribution and determinants of invasive cervical cancer (ICC) cases detected in such programs is limited.

METHODS

We analyzed program operations data from the Cervical Cancer Prevention Program in Zambia, the largest public sector programs of its kind in sub-Saharan Africa. We examined age distribution patterns by HIV serostatus of histologically confirmed ICC cases and used multivariable logistic regression to evaluate independent risk factors for ICC among younger (≤35 years) and older (>35 years) women.

RESULTS

Between January 2006 and April 2010, of 48,626 women undergoing screening, 571 (1.2%) were diagnosed with ICC, including 262 (46%) HIV seropositive (median age: 35 years), 131 (23%) HIV seronegative (median age: 40 years), and 178 (31%) of unknown HIV serostatus (median age: 38 years). Among younger (≤35 years) women, being HIV seropositive was associated with a 4-fold higher risk of ICC [adjusted odds ratio = 4.1 (95% confidence interval: 2.8, 5.9)] than being HIV seronegative. The risk of ICC increased with increasing age among HIV-seronegative women and women with unknown HIV serostatus, but among HIV-seropositive women, the risk peaked around age 35 and nonsignificantly declined with increasing ages. Other factors related to ICC included being married (vs. being unmarried/widowed) in both younger and older women, and with having 2+ (vs. ≤1) lifetime sexual partners among younger women.

CONCLUSIONS

HIV infection seems to have increased the risk of cervical cancer among younger women in Zambia, pointing to the urgent need for expanding targeted screening interventions.

Willingness and acceptability of cervical cancer screening among women living with HIV/AIDS in Addis Ababa, Ethiopia: a cross sectional study

Background

In Ethiopia, cervical cancer (CC) ranks the 2nd most frequent cancer and the country had 27.19 million women at risk of developing the disease though only 0.6 % women age 18-69 years was screened every 3 years. Nearly a quarter (22.1 %) of southern Ethiopia HIV (Human Immunodeficiency Virus) infected Women were positive for precancerous cervical cancer. Doing regular screening can prevent the disease by around half (45 %) of the cases in age of 30s and three quarter (75 %) cases in 50s and 60s.In the presence of high risk for acquiring cervical cancer among HIV patients, willingness and acceptance of the screening is low in Addis Ababa, Ethiopia thus the current study was aimed to assess willingness and acceptability of cervical cancer screening and its determinants among women living with HIV/AIDS in Addis Ababa, Ethiopia.

Method

A facility based cross sectional study was conducted among HIV positive women attending HIV treatment centers in Addis Ababa. The respondents were identified using systematic random sampling method. Data was collected using pretested questionnaire and were entered in to Epi-info version 3.5.1 software and exported in to SPSS version 20 statistical package for analysis. The criterias for entering independent variables into multivariate analysis were having p-value 0.05 or less at bivariate analysis and not co-linear.

Result

One third (34.2 %) of participants knew cervical cancer and two third (62.7 %) were willing for the test though only a quarter (24.8 %) were accepted the test. The independent variables significantly associated with acceptance of screening were educational level, source of information, awareness for the test and preventability of the disease.

Conclusion

In current study willingness and acceptance of CC (cervical cancer) were low thus organizations working on cancer and HIV/AIDS should establish cervical cancer screening program and further enhance awareness creation.

Predictors of default from follow-up care in a cervical cancer screening program using direct visual inspection in south-western Nigeria

Background

Increasingly evidence is emerging from south East Asia, southern and east Africa on the burden of default to follow up care after a positive cervical cancer screening/diagnosis, which impacts negatively on cervical cancer prevention and control. Unfortunately little or no information exists on the subject in the West Africa sub region. This study was designed to determine the proportion of and predictors and reasons for default from follow up care after positive cervical cancer screen.

Method

Women who screen positive at community cervical cancer screening using direct visual inspection were followed up to determine the proportion of default and associated factors. Multivariate logistic regression was used to determine independent predictors of default.

Results

One hundred and eight (16.1%) women who screened positive to direct visual inspection out of 673 were enrolled into the study. Fifty one (47.2%) out of the 108 women that screened positive defaulted from follow-up appointment. Women who were poorly educated (OR: 3.1, CI: 2.0 – 5.2), or lived more than 10 km from the clinic (OR: 2.0, CI: 1.0 – 4.1), or never screened for cervical cancer before (OR: 3.5, CI:3:1–8.4) were more likely to default from follow-up after screening positive for precancerous lesion of cervix . The main reasons for default were cost of transportation (48.6%) and time constraints (25.7%).

Conclusion

The rate of default was high (47.2%) as a result of unaffordable transportation cost and limited time to keep the scheduled appointment. A change from the present strategy that involves multiple visits to a “see and treat” strategy in which both testing and treatment are performed at a single visit is recommended.

Trends in the incidence of cancer in Kampala, Uganda 1991-2010

The Kampala cancer registry is the longest established in Africa. Trends in incidence rates for a 20-year period (1991-2010) for Kyadondo County (Kampala city and a rural hinterland) illustrate the effects of changing lifestyles in urban Africa, and the effects of the epidemic of HIV-AIDS. There has been an overall increase in the risk of cancer during the period in both sexes, with incidence rates of major cancers such as breast and prostate showing particularly marked increases (3.7% and 5.2% annually, respectively). In the 1960s cancer of the oesophagus was the most common cancer of men (and second in women), and incidence in the last 20 years has not declined. Cancer of the cervix, always the most frequent cancer of women, has shown an increase over the period (1.8% per year), although the rates appear to have declined in the last 4 years. HIV prevalence in adults in Uganda fell from a maximum in 1992 to a minimum (about 6%) in 2004, and has risen a little subsequently, while availability of antiretroviral drugs has risen sharply in recent years. Incidence of Kaposi sarcoma in men fell until about 2002, and has been relatively constant since then, while in women there has been a continuing decline since 2000. Other HIV related cancers-non-Hodgkin lymphoma of younger adults, and squamous cell carcinoma of conjunctiva-have shown major increases in incidence, although the former (NHL) has shown a small decline in incidence in the most recent 2 years.

Screening for Cervical Cancer in Low-Resource Settings in 2011

Context.—Cervical cancer remains the most common malignancy in women living in low- and middle-income countries, despite the decline of the disease in countries where cervical cytology screening programs have been implemented.

Objectives.—To review the current incidence of cervical cancer in low-resource countries, the availability and types of screening programs, and the treatment options.

Data Sources.—Literature review through PubMed, Internet search, and personal communication.

Conclusions.—Although data are incomplete, available figures confirm that the rate of cervical cancer deaths and the availability of cervical cancer screening programs are inversely proportional and vary, in general, by the wealth of the nation. Despite the success of cervical cytology screening, many major health care organizations have abandoned screening by cytology in favor of direct visualization methods with immediate treatment of lesions by cryotherapy provided by trained, nonmedical personnel.

Acceptability of cervical cancer screening via visual inspection with acetic acid or Lugol's iodine at Mulago Hospital, Uganda

OBJECTIVE

To assess acceptability of cervical cancer screening via visual inspection with acetic acid or Lugol's iodine (VIA/VILI) at Mulago Hospital, Uganda.

METHODS

Exit interviews were conducted among women who had undergone opportunistic screening by VIA/VILI at 2 family planning clinics based within the hospital. Measures of acceptability were willingness to undergo the procedure in future if required and willingness to recommend the procedure to others. Focus group discussions were conducted to determine reasons for declining VIA/VILI.

RESULTS

A total of 384 participants were recruited into the study. Of the 229 women who agreed to undergo screening by VIA/VILI, 209 (91.3%) were willing to recommend the service to other women, while 223 (97.4%) stated that they would undergo VIA/VILI again if the need arose. Education level showed a significant association with screening uptake (P=0.007). In all, 155 women declined screening. Reasons for refusal included fears about privacy, fear of pain or discomfort, and worry about the test results.

CONCLUSION

Cervical cancer screening by VIA/VILI was rated highly acceptable among women who underwent the procedure. Women with a positive attitude toward screening could be trained as peer educators and community champions to improve uptake.

Acceptability of cervical cancer screening in rural Mozambique

In Zambézia province, Mozambique, cervical cancer (CC) screening was introduced to rural communities in 2010. Our study sought to determine whether women would accept screening via pelvic examination and visual inspection with acetic acid (VIA) at two clinical sites near the onset of a new CC screening program. A cross-sectional descriptive study of 101 women was undertaken in two rural communities in north-central Mozambique. We assessed a woman's willingness to be screened, knowledge about CC symptoms and treatment, and her recommendations for best methods to deliver information to other women. After the interview, we offered CC screening. Fully 86% of women accepted VIA screening when it was offered, but uptake was 100% at one clinic and only 68% at another. The cause of CC was thought to be associated with promiscuous activity (49%) and curses placed on the woman (42%). All women in one rural Mozambique clinic and two-thirds at a second clinic underwent CC screening. Knowledge about CC screening was significantly associated with uptake, suggesting educational campaigns need to be undertaken. However, educators need to be cautious about linking screening with high-risk behaviors, as women who understood the link trended toward refusing screening.

Cervical cancer screening in primary health care setting in Sudan: a comparative study of visual inspection with acetic acid and Pap smear

OBJECTIVE

To determine the feasibility of visual inspection with the use of acetic acid (VIA) as a screening method for cervical cancer, an alternative to the Pap smear used in primary health care setting in Sudan, and to compare sensitivity, specificity, positive and negative predictive values, and histological diagnosis of positive cases of both tests.

METHODS

A cross-sectional study of 934 asymptomatic women living in Khartoum, Sudan, was conducted during 2009-2010. A semi-structured questionnaire containing socio-economic and reproductive variables was used to collect data from each participant. Methods of screening used were VIA and conventional Pap smear, followed by colposcopy and biopsy for confirmation of the positive results of both screening tests.

RESULTS

The tests identified altogether 119 (12.7%) positive women. VIA detected significantly more positive women than Pap smear (7.6% versus 5.1%; P = 0.004), with an overlap between the two screening tests in 19% of positive results. There was no significant difference between VIA and Pap smear findings and sociodemographic and reproductive factors among screened women. Use of colposcopy and biopsy for positive women confirmed that 88/119 (73.9%) were positive for cervical intraepithelial neoplasia. VIA had higher sensitivity than Pap smear (74.2% versus 72.9%; P = 0.05) respectively. Out of 88 confirmed positive cases, 22 (25.0%) cases were invasive cervical cancer in stage 1, of which 19 versus three were detected by VIA and Pap smear respectively (P = 0.001). VIA had higher sensitivity and lower specificity than Pap smear (60.2% versus 47.7%) and (41.9% versus 83.8%) respectively. The combination of VIA/Pap has better sensitivity and specificity than each independent test (82.6% and 92.2%).

CONCLUSION

The findings of this study showed that VIA has higher sensitivity and lower specificity compared to Pap smear, but a combination of both tests has greater sensitivity and specificity than each test independently. It indicates that VIA is useful for screening of cervical cancer in the primary health care setting in Sudan, but positive results need to be confirmed by colposcopy and biopsy.

Cervical cancer prevention in low- and middle-income countries: feasible, affordable, essential

The annual worldwide burden of the preventable disease cervical cancer is more than 530,000 new cases and 275,000 deaths, with the majority occurring in low- and middle-income countries (LMIC), where cervical cancer screening and early treatment are uncommon. Widely used in high-income countries, Pap smear (cytology based) screening is expensive and challenging for implementation in LMICs, where lower-cost, effective alternatives such as visual inspection with acetic acid (VIA) and rapid human papillomavirus (HPV)-based screening tests offer promise for scaling up prevention services. Integrating HPV screening with VIA in "screen-and-treat-or-refer" programs offers the dual benefits of HPV screening to maximize detection and using VIA to triage for advanced lesions/cancer, as well as a pelvic exam to address other gynecologic issues. A major issue in LMICs is coinfection with human immunodeficiency virus (HIV) and HPV, which further increases the risk for cervical cancer and marks a population with perhaps the greatest need of cervical cancer prevention. Public-private partnerships to enhance the availability of cervical cancer prevention services within HIV/AIDS care delivery platforms through initiatives such as Pink Ribbon Red Ribbon present an historic opportunity to expand cervical cancer screening in LMICs.

Cervical cancer prevention in low- and middle-income countries: feasible, affordable, essential

The annual worldwide burden of the preventable disease cervical cancer is more than 530,000 new cases and 275,000 deaths, with the majority occurring in low- and middle-income countries (LMIC), where cervical cancer screening and early treatment are uncommon. Widely used in high-income countries, Pap smear (cytology based) screening is expensive and challenging for implementation in LMICs, where lower-cost, effective alternatives such as visual inspection with acetic acid (VIA) and rapid human papillomavirus (HPV)-based screening tests offer promise for scaling up prevention services. Integrating HPV screening with VIA in "screen-and-treat-or-refer" programs offers the dual benefits of HPV screening to maximize detection and using VIA to triage for advanced lesions/cancer, as well as a pelvic exam to address other gynecologic issues. A major issue in LMICs is coinfection with human immunodeficiency virus (HIV) and HPV, which further increases the risk for cervical cancer and marks a population with perhaps the greatest need of cervical cancer prevention. Public-private partnerships to enhance the availability of cervical cancer prevention services within HIV/AIDS care delivery platforms through initiatives such as Pink Ribbon Red Ribbon present an historic opportunity to expand cervical cancer screening in LMICs.

The Prevention of Cervical Cancer in Africa

In this article we aim to draw attention to the burden of cervical cancer in Africa for reproductive health and review strategies for prevention, including appropriate noncytology-based cervical screening and prophylactic human papillomavirus vaccination. We consider the heavy burden of disease attributable to human papillomavirus infection borne by developing countries, particularly in Africa. Following identification of the human papillomavirus as the infectious etiological agent and elucidation of the long natural history of cervical neoplasia, cervical cancer is now one of the most preventable of all cancers. Opportunities for primary prevention by prophylactic vaccination and secondary prevention by appropriate cervical screening are discussed, together with the importance of population coverage. Qualitative work on attitudes towards cervical cancer prevention, education needs, the creation of an environment for informed choice and uptake are essential aspects of effective prevention programs. Cervical cancer poses a huge health burden in Africa. It is a disease that is eminently preventable given political will, the availability of affordable vaccines, appropriate cervical screening and access to cheap, point-of-care human papillomavirus testing. There are a number of unanswered questions for the prevention of cervical cancer and a need for demonstration projects to address these and further develop prevention strategies.