Evidence on the prevalence, incidence, mortality and trends of human papilloma virus-associated cancers in sub-Saharan Africa: systematic scoping review

HPV vaccination in Africa in the COVID-19 era: a cross-sectional survey of healthcare providers' knowledge, training, and recommendation practices

Introduction

Although the burden of cervical cancer in Africa is highest, HPV vaccination coverage remains alarmingly low in this region. Providers' knowledge and recommendation are key drivers of HPV vaccination uptake. Yet, evidence about providers' knowledge and recommendation practices about the HPV vaccine against a backdrop of emerging vaccine hesitancy fueled by the COVID-19 pandemic is lacking in Africa.

Methods

A cross-sectional study was conducted in 2021-2022 among healthcare providers involved in cervical cancer prevention activities in Africa. They were invited to report prior training, the availability of the HPV vaccine in their practice, whether they recommended the HPV vaccine, and, if not, the reasons for not recommending it. Their knowledge about the HPV vaccine was assessed through self-reporting (perceived knowledge) and with three pre-tested knowledge questions (measured knowledge).

Results

Of the 153 providers from 23 African countries who responded to the survey (mean age: 38.5 years, SD: 10.1), 75 (54.0%) were female and 97 (63.4%) were based In countries with national HPV immunization programs. Overall, 57 (43.8%) reported having received prior training on HPV vaccine education/counseling, and 40 (37.4%) indicated that the HPV vaccine was available at the facility where they work. Most respondents (109, 83.2%) reported recommending the HPV vaccine in their practice. Vaccine unavailability (57.1%), lack of effective communication tools and informational material (28.6%), and need for adequate training (28.6%) were the most commonly reported reasons for not recommending the HPV vaccine. While 63 providers (52.9%) reported that their knowledge about HPV vaccination was adequate for their practice, only 9.9% responded correctly to the 3 knowledge questions.

Conclusion

To increase HPV vaccination coverage and counter misinformation about this vaccine in Africa, adequate training of providers and culturally appropriate educational materials are needed to improve their knowledge of the HPV vaccine and to facilitate effective communication with their patients and the community.

Factors associated with vulvar cancer from 2005 to 2021 in Togo, sub-Saharan Africa

BACKGROUND

vulvar cancer, once predominantly diagnosed in older women, is increasingly being diagnosed in younger individuals, due to Human Papillomavirus (HPV) infection. Our study aimed to describe the epidemiological and histopathological aspects of vulvar cancer in Togo and its associated factors.

METHODS

This was a cross-sectional study, conducted on vulvar cancer cases histologically diagnosed at the Pathological Laboratory of Lomé over a period of 17-years (2005-2021). Parameters investigated included age, occupation, risk factors, sample nature, macroscopic tumor aspects, histological types, therapeutic intervenions, and prognostic outcomes.

RESULTS

A total of 32 cases of vulvar cancer were collected, yieding an annual frequency of 1.88 cases. The average age of the patients was 48±14.12 years with extremes of 27 years and 82 years. Housewives accounted for the largest proportion of cases (37.5%). Among the 32 cases, 27 had identifiable risk factors, with HPV infection being the most prevalentr (33.3%). The ulcero-budding aspect was most frequently observed, and squamous cell carcinoma was the most common histological type, with the majority being well differentiated (89.3%). Statistically significant associations were found between risk factors and histological types, risk factors and degrees of differentiation, as well as between histological types and good differentiation of vulvar cancers. The 3-year survival was estimated at 78.13%.

CONCLUSION

The incidence of vulvar cancer is increasing in Togo, particularly among young, primarily due to HPV infection.

Female genital schistosomiasis, human papilloma virus infection, and cervical cancer in rural Madagascar: a cross sectional study

BACKGROUND

Women's health in resource-limited settings can benefit from the integrated management of high-burden diseases, such as female genital schistosomiasis (FGS) and human papilloma virus (HPV)-related cervical cancer. In schistosomiasis-endemic countries such as Madagascar, data on FGS and HPV prevalence are lacking as well as preventive measures for both conditions. This study aims to estimate the prevalence of FGS and HPV in rural Madagascar, and to examine associated risk factors to identify opportunities for improving women's health.

METHODS

After initial community outreach activities, interested women aged 18-49 years were recruited consecutively in 2021 at three primary health care centers in the district of Marovoay. FGS was detected by colposcopy. Colposcopy images were double-blind reviewed by two independent specialists. A Luminex bead-based assay was performed on cervical vaginal lavage specimens for HPV typing. Crude (CPR) and adjusted prevalence ratios (APR) of associations between selected factors and FGS and HPV positivity were estimated using univariable and multivariable binary Poisson regression with 95% confidence intervals (CIs).

RESULTS

Among 500 women enrolled, 302 had complete information on FGS and HPV diagnosis, and were thus eligible for analysis. Within the sample, 189 (62.6%, 95% CI: 56.9-68.1) cases of FGS were detected. A total of 129 women (42.7%, 95% CI: 37.1-48.5) tested positive for HPV. In total, 80 women (26.5%, 95% CI: 21.6-31.8]) tested positive for both conditions. No association was observed between FGS and HPV positivity, while previous pregnancy (APR = 0.65, 95% CI: 0.43-0.78) and older age (APR = 0.59, 95% CI: 0.42-0.81) are showing a negative association with HPV infection compared to no previous pregnancy and younger age groups.

CONCLUSIONS

The results of the study show that FGS and HPV are highly prevalent in rural Madagascar. The concurrent prevalence of these two conditions requires urgent adaptations of public health strategies to improve women's health, such as integrated services at primary level of care.

Brief Report: Prevalence and Predictors of Concern About Anal Cancer Among Sexual and Gender Minorites Living With HIV in Abuja, Nigeria

BACKGROUND

Anal cancer rates are rising among sexual and gender minorities (SGM) who live with HIV and engage in anal sex. Given that secondary cancer prevention programs for nonanal cancers are underutilized in sub-Saharan Africa, our objective was to assess concerns for anal cancer and hesitancy with cancer prevention among at-risk Nigerian SGM.

METHODS

Within 4 weeks, SGM living with HIV were surveyed on levels of worry and hesitancy in engaging with a future anal cancer screening and treatment study. Worry was measured on a 5-point Likert scale (0%, 25%, 50%, 75%, 100%) and categorized as low ≤25%, moderate 50%, and high ≥75%. Ordinal logistic regression identified factors associated with worry by estimating unadjusted and adjusted odds ratios (aOR) and 95% confidence intervals (95% CI).

RESULTS

Of 800 enrolled SGM, median age was 32 (interquartile range: 25-38) years, 99.2% were on antiretroviral therapy, of which 78.5% reported ≥95% pill adherence. The prevalence of moderate and high worry was 46.9% and 39.5%, respectively. Increasing worry was associated with reporting as a bottom for sexual position (aOR: 3.12; 95% CI: 2.04 to 4.80), top or bottom for sexual position (aOR: 2.94; 95% CI: 1.92 to 4.52), or knowing anyone with anal cancer (aOR: 2.99; 95% CI: 1.36 to 6.57). Participants aged ≥35 years were less worried (aOR: 0.72; 95% CI: 0.59 to 0.95). Ninety-nine percent of participants provided contact information for a future cancer prevention study.

DISCUSSION

SGM who heard about and engaged in at-risk practices for anal cancer were willing to access secondary prevention. Addressing biopsychosocial factors such as age could foster future engagement.

Malignancy and viral infections in Sub-Saharan Africa: A review

The burden of malignancy related to viral infection is increasing in Sub-Saharan Africa (SSA). In 2018, approximately 2 million new cancer cases worldwide were attributable to infection. Prevention or treatment of these infections could reduce cancer cases by 23% in less developed regions and about 7% in developed regions. Contemporaneous increases in longevity and changes in lifestyle have contributed to the cancer burden in SSA. African hospitals are reporting more cases of cancer related to infection (e.g., cervical cancer in women and stomach and liver cancer in men). SSA populations also have elevated underlying prevalence of viral infections compared to other regions. Of 10 infectious agents identified as carcinogenic by the International Agency for Research on Cancer, six are viruses: hepatitis B and C viruses (HBV and HCV, respectively), Epstein-Barr virus (EBV), high-risk types of human papillomavirus (HPV), Human T-cell lymphotropic virus type 1 (HTLV-1), and Kaposi's sarcoma herpesvirus (KSHV, also known as human herpesvirus type 8, HHV-8). Human immunodeficiency virus type 1 (HIV) also facilitates oncogenesis. EBV is associated with lymphomas and nasopharyngeal carcinoma; HBV and HCV are associated with hepatocellular carcinoma; KSHV causes Kaposi's sarcoma; HTLV-1 causes T-cell leukemia and lymphoma; HPV causes carcinoma of the oropharynx and anogenital squamous cell cancer. HIV-1, for which SSA has the greatest global burden, has been linked to increasing risk of malignancy through immunologic dysregulation and clonal hematopoiesis. Public health approaches to prevent infection, such as vaccination, safer injection techniques, screening of blood products, antimicrobial treatments and safer sexual practices could reduce the burden of cancer in Africa. In SSA, inequalities in access to cancer screening and treatment are exacerbated by the perception of cancer as taboo. National level cancer registries, new screening strategies for detection of viral infection and public health messaging should be prioritized in SSA's battle against malignancy. In this review, we discuss the impact of carcinogenic viruses in SSA with a focus on regional epidemiology.

Knowledge and Attitude towards Human Papilloma Virus Infection, Vaccines, and Cervical Cancer Prevention among School Students in Kano, Nigeria

The rising cases of human papillomavirus (HPV) infection and cervical cancer cases in Nigeria are alarming. Only a few studies have looked at secondary school students in Nigeria's understanding of HPV infection and vaccine acceptance, whereas earlier studies have mostly focused on screening. In this study, 400 students from two secondary schools in Kano State, Nigeria, were engaged with the aim of assessing their level of knowledge and attitudes regarding HPV infection. The study further seeks to understand the respondent's opinion on HPV vaccination and sensitize them to the health effects of HPV infection, thereby communicating the findings to the authorities concerned with policy making. The study revealed that only 128 (32%) and 142 (35.5%) respondents have knowledge about HPV and cervical cancer, respectively. Furthermore, none of the respondents were administered the HPV vaccine, with 81% of them not ready to take the vaccine. It was observed that the majority of the respondents (91%) believed that early hospital visits could help in mitigating HPV or cervical cancer cases. Following their sensitization, the respondents were observed to have different levels of satisfaction, ranging from very satisfied and satisfied to not satisfied. Effective awareness creation amongst students as well as parents is therefore essential in HPV vaccination projects, as well as in reducing the burden of cervical cancer in Nigeria.

Role of Immunity and Vaginal Microbiome in Clearance and Persistence of Human Papillomavirus Infection

Cervical cancer disproportionately affects women of reproductive age, with 80% of cases occurring in low- and middle-income countries. Persistent infection with high-risk human papillomavirus (HPV) genotypes has been described as the most common non-systemic biological risk factor for the development of cervical cancer. The mucosal immune system plays a significant role in controlling HPV infection by acting as the first line of host defense at the mucosal surface. However, the virus can evade host immunity using various mechanisms, including inhibition of the antiviral immune response necessary for HPV clearance. Pro-inflammatory cytokines and the vaginal microbiome coordinate cell-mediated immune responses and play a pivotal role in modulating immunity. Recently, diverse vaginal microbiome (associated with bacterial vaginosis) and genital inflammation have emerged as potential drivers of high-risk HPV positivity and disease severity in women. The potential role of these risk factors on HPV recurrence and persistence remains unclear. This article reviews the role of cellular or cytokine response and vaginal microbiome dysbiosis in the clearance, persistence, and recurrence of HPV infection.

Global Pattern and Trends in Penile Cancer Incidence: Population-Based Study

Background

Penile cancer is a relatively rare genital malignancy whose incidence and mortality are rising in many countries.

Objective

This study aims to assess the recent incidence and mortality patterns and incidence trends of penile cancer.

Methods

The age-standardized incidence and mortality rates (ASIR and ASMR, respectively) of penile cancer in 2020 were estimated from the Global Cancer Registries (GLOBOCAN) database. Incidence trends of penile cancer from 1973 to 2012 were assessed in 44 populations from 43 countries using the Cancer Incidence in Five Continents plus (CI5plus) and the Nordic Cancer Registries (NORDCAN) databases. Average annual percentage change was calculated to quantify trends in ASIR using joinpoint regression.

Results

Globally, the estimated ASIR and ASMR of penile cancer were 0.80 (per 100,000) and 0.29 (per 100,000) in 2020, equating to 36,068 new cases and 13,211 deaths in 2020, respectively. There was no significant correlation between the ASIR (P=.05) or ASMR (P=.90) and Human Development Index. In addition, 15 countries saw increasing ASIR for penile cancer, 13 of which were from Europe (United Kingdom, Lithuania, Norway, Estonia, Finland, Sweden, Cyprus, Netherlands, Italy, Croatia, Slovakia, Russia, and the Czech), and 2 from Asia (China and Israel).

Conclusions

Although the developing countries still bear the higher incidence and mortality of penile cancer, the incidence is on the rise in most European countries. To mitigate the disease burden resulting from penile cancer, measures to lower the risk for penile cancers, including improving penile hygiene and male human papillomavirus vaccination, may be warranted.

Mapping Evidence on the Burden of Breast, Cervical, and Prostate Cancers in Sub-Saharan Africa: A Scoping Review

Background

Cancer remains a major public health problem, especially in Sub-Saharan Africa (SSA) where the provision of health care is poor. This scoping review mapped evidence in the literature regarding the burden of cervical, breast and prostate cancers in SSA.

Methods

We conducted this scoping review using the Arksey and O'Malley framework, with five steps: identifying the research question; searching for relevant studies; selecting studies; charting the data; and collating, summarizing, and reporting the data. We performed all the steps independently and resolved disagreements through discussion. We used Endnote software to manage references and the Rayyan software to screen studies.

Results

We found 138 studies that met our inclusion criteria from 2,751 studies identified through the electronic databases. The majority were retrospective studies of mostly registries and patient files (n = 77, 55.8%), followed by cross-sectional studies (n = 51, 36.9%). We included studies published from 1990 to 2021, with a sharp increase from 2010 to 2021. The quality of studies was overall satisfactory. Most studies were done in South Africa (n = 20) and Nigeria (n = 17). The majority were on cervical cancer (n = 93, 67.4%), followed by breast cancer (67, 48.6%) and the least were on prostate cancer (48, 34.8%). Concerning the burden of cancer, most reported prevalence and incidence. We also found a few studies investigating mortality, disability-adjusted life years (DALYs), and years of life lost (YLL).

Conclusions

We found many retrospective record review cross-sectional studies, mainly in South Africa and Nigeria, reporting the prevalence and incidence of cervical, breast and prostate cancer in SSA. There were a few systematic and scoping reviews. There is a scarcity of cervical, breast and prostate cancer burden studies in several SSA countries. The findings in this study can inform policy on improving the public health systems and therefore reduce cancer incidence and mortality in SSA.

Prevalence of and factors associated with anal high-risk human papillomavirus in urban Tanzanian men who have sex with men, 2011-2012

Background: Anal cancer is primarily caused by high-risk human papillomavirus (hrHPV), is associated with HIV infection, and has a very high incidence among men who have sex with men (MSM). We assessed prevalence of hrHPV, and factors associated with hrHPV in anal canal specimens collected in Dar es Salaam, Tanzania from HIV-positive and HIV-negative MSM. Methods: MSM were recruited using respondent-driven sampling in this cross-sectional study. The primary outcome in this ancillary analysis of 116 MSM was prevalence of HPV-16 and other hrHPV types. Prevalence ratios (PR) estimated the association between hrHPV and HIV-negative participants' demographics, sexual behaviour and sexually transmitted infections. Results: Median age was 23 years and 33.6% of participants were HIV-positive. HrHPV and HPV-16 prevalence was 54.3% and 17.2%, respectively, with HPV-16 prevalence highest among HIV-positive MSM identifying as gay (36.1%) and lowest among HIV-negative MSM identifying as bisexual (2.9%). Having two or more receptive anal sex partners in the past month was associated with hrHPV (PR 3.20, 95%CI 1.69-6.07, vs. 0 partners) among HIV-negative MSM.Conclusions: HrHPV prevalence was high among MSM in Dar es Salaam and highest among HIV-positive MSM identifying as gay. These estimates may be used to support HPV vaccination and screening initiatives.

HPV vaccination uptake among foreign-born Blacks in the US: insights from the National Health Interview Survey 2013-2017

INTRODUCTION

Human papillomavirus (HPV) vaccination uptake is lower among foreign-born than US-born individuals, but HPV-related (e.g., cervical) cancer risks are disproportionately higher among immigrant populations. Although timely vaccination can help reduce these risks, less is known about differences in the low HPV vaccination uptake among foreign-born groups, especially Black immigrants. The purpose of this study was to examine the differences in HPV vaccination initiation among US- and foreign-born Black men and women.

METHOD

Data from the 2013-2017 National Health Interview Survey on Black adults, aged 18-37 years, were analyzed in 2019. HPV vaccination initiation prevalence among US- and foreign-born blacks by region of birth were examined. Multivariate binary logistic regression analysis was used to examine the relationship between foreign-birth status and HPV vaccination initiation separately among men and women, after adjusting for sociodemographic and health-related factors.

RESULTS

There were significant differences (p < 0.001) in HPV vaccination initiation among Blacks from the US (22.5%), Africa (14.2%), and Americas/Caribbean Islands (11.4%). Adjusted odds of HPV vaccination initiation were lower among foreign- than US-born Blacks (AOR 0.71, CI 0.52, 0.98) but insignificant after controlling for health-related factors. Being ≤ 17 years versus 18-26 years at age of vaccine eligibility (AOR 3.44, CI 2.90, 4.07) was associated with HPV vaccination, and this relationship remained significant among men and women. Being single was associated with vaccination initiation among men, and some college experience, fair/poor health, obstetric/gynecological visit, and pap test were associated with HPV vaccination. Conclusion Cancer prevention strategies to promote HPV vaccination should consider making age-appropriate, gender-specific, and culturally relevant programs among foreign-born blacks in the US. Health insurance is also a key factor that might help with the lower rates of vaccinated black immigrants.

Precancerous Lesion of the Cervix and Associated Factors Among Women of West Wollega, West Ethiopia, 2022

Background

Precancerous cervical lesion is an abnormality in the cells of the cervix that could eventually develop into cervical cancer. Cervical cancer is a public health problem that contributes to the death of women worldwide. In line with the high burden of the issue, the Ethiopian government had attempted to expand cervical cancer screening centers and recommendation of services to age-eligible as well as high-risk groups of women. Therefore, the study aimed to assess the prevalence of precancerous lesions of cervix cancer among women aged 30-49 years and associated factors in West Wollega.

Method

Facility-based analytic cross-sectional study design was conducted in selected hospitals of West Wollega from January 1- February 20, 2022, among 339 women. A face-to-face interview was conducted and the presence or absence of precancerous cervical lesion was tested by visual inspection with acetic acid. Data were analyzed by SPSS version 25. Variable with P-value <.25 in the bi-variable analysis were entered into multivariable logistic regression. Results with a P-value ≤ .05 at 95% confidence level were considered for statistical significance.

Result

The prevalence of precancerous cervical lesions was 27.4% (95% CI: 22.7%32.1%). The mean standard deviation of participants was 35.22 +6.32 years. More than half (63.4%) and 67.6% of them were regarded as having good knowledge and a favorable attitude towards precancerous cervical lesions respectively. History of menstrual irregularity had two folds higher odds of being diagnosed with the precancerous cervical lesion when compared with counterparts at, [AOR = 2.29(95% CI:1.29-4.04]. Women with a history of STI had 3.5 times higher odds of developing precancerous cervical lesion compared to women with no history of STI [AOR)=3.46(95% CI:1.94-6.18)], history of bleeding after sexual intercourse was 2.88 times more likely to have precancerous cervical lesion compared to those without it at [AOR=2.88(95% CI:1.43-5.78)]. Parity greater than or equal to five had 2.4 times higher odds of developing precancerous cervical lesions compared to women with parity less than five at [AOR=2.41(95% CI: 1.23-4.75)]. History of steroid use had 3.5 times higher odds of developing precancerous cervical lesion compared with opponents at [AOR=3.5(95% CI: 1.32-9.34) and women with an Unfavorable attitude towards screening for Cervical cancer screening, prevention, and control methods had 2.2 times higher odds of developing precancerous cervical lesion compared their counterpart at [AOR=2.15(95% CI: 1.21-3.83)].

Conclusion

The precancerous cervical lesions continue to be a significant public health concern in Ethiopia. It will remain a significant cause of death of women unless effective screening methods like VIA and vaccination against HPV are scaled up. Furthermore, having a history of menstrual irregularities, STI, bleeding after coitus, parity greater than ≥5, steroid use, and having an unfavorable attitude towards screening factors are significantly associated with the occurrence of the precancerous lesion. Therefore, effective prevention approaches have to consider these factors for the control of cervical cancer in the early phase of the lesion.

Cervical Cancer Prevention in Low- and Middle-Income Countries

Cervical cancer is one of the commonest cancers afflicting women in low and middle income countries, however, both primary prevention with human papillomavirus vaccination, and secondary prevention with screening programs and treatment of preinvasive disease are possible. A coordinated approach to eliminating cervical cancer, as has been called for by the World Health Organization, requires a complex series of steps at all levels of a health system. This article outlines the current state of cervical cancer prevention in low and middle income countries, the innovations being employed to improve outcomes, and consideration of the next steps needed as we move towards global elimination.

Vaccine hesitancy in migrant communities: a rapid review of latest evidence

By refusing or delaying vaccination, vaccine hesitant individuals and communities undermine the prevention, and ultimately, elimination of communicable diseases against which safe and effective vaccines are available. We reviewed recent evidence of vaccine hesitancy within migrant communities in the context of increased human mobility and widespread anti-immigrant sentiment and manifest xenophobia. Among many immigrant parents and families, vaccine hesitancy is largely associated with fears and misinformation about vaccine harms, limited knowledge of both preventable diseases and vaccines, distrust of host countries' health systems and their attendant intentions, language barriers, and perceived incompatibility between vaccine uptake and migrants' religion. Hesitancy toward measles, influenza, and human papillomavirus vaccines are most discernible, and main migrant populations involved include Somalis and Poles.

Feasibility of a socio-spiritual intervention to improve quality of life of adult Nigerians with cancer and their family caregivers: Protocol for a randomised controlled trial

BACKGROUND

Despite high psychosocial needs that negatively affect the quality of life of adults living with cancer and their family caregivers, there is a lack of interventions that are culturally sensitive to low-income countries. This protocol tests the feasibility of a randomised controlled trial on the efficacy of a socio-spiritual intervention to improve the quality of life of adult Nigerians living with cancer and their family caregivers.

METHODS/DESIGN

This two-arm trial will recruit 152 adults with cancer and their family caregivers (76 dyads). Participants will be recruited from a clinical facility in Zaria, Kaduna State, Nigeria. Eligible participants will be randomly assigned to either the intervention or control group at a 1:1 ratio. The intervention consists of four weekly face-to-face sessions with a focus on spirituality, social support, and information needs. Control participants will receive usual care. Outcome measures include feasibility, spiritual need, social need, information, cancer health literacy, and quality of life collected at baseline and immediate post-intervention.

DISCUSSION

Nigeria has the highest rate of extreme poverty globally with high rates of cancer mortality. Testing the feasibility of social-spiritual interventions in resource poor settings is important to establish preliminary efficacy and sustainability. Family-centred interventions for adults living with cancer and their family caregivers can strengthen their coping capabilities. If this intervention is feasible and effective, it could be implemented both in clinical practice and communities in other low and middle income countries.

Eliminating Cervical Cancer in Mali and Senegal, Two Sub-Saharan Countries: Insights and Optimizing Solutions

BACKGROUND

The number of cases with cervical cancer is rapidly increasing in Sub-Saharan Africa driven by inadequate rates of human papilloma virus (HPV) vaccination and screening programs and accompanied by poor health delivery systems. There are other factors to contend with such as lack of awareness, social myths, reluctance to vaccine acceptance and stigma with sexually transmitted diseases. Here, we formulate strategies to implement intervention programs against HPV infections and other risk factors for cervical cancer in these countries.

METHODS

We searched PubMed, Web of Science, and African Journals Online for this review. The current status of anti-HPV vaccination and precancerous screening programs in Mali and Senegal has been assessed by onsite visits. Collaborators from Mali and Senegal collected data and information concerning HPV vaccination and screening programs in these countries.

FINDINGS

We found that anti-HPV vaccination and cervical cancer screening have been conducted sporadically mainly in urban areas of Mali and Senegal. No known population-based programs are in progress in either of the two countries. We highlighted the advantages and drawbacks of currently available screening tests and proposed that screening by visual inspection with acetic acid (VIA) accompanied by self-sampling is the most cost-effective, culturally acceptable and most feasible strategy to implement in primary care settings. In addition, HPV DNA testing would be affordable, if local laboratory facilities could be established. We found that many of the factors that increase HPV acquisition and promote the oncogenic effect of the virus are largely widespread in both Senegal and Mali. These include infections with HIV and other sexually transmitted infections (STIs), immunosuppression, polygamous marriages, high parity, early sexual activities, early pregnancies, and multiple sexual partners.

INTERPRETATION

Neither vaccines nor screening tests are within the reach of the population in Mali and Senegal because of the high cost. The effective intervention measure would be to integrate anti-HPV vaccines into the Extended Program for Immunization (EPI), which has saved 3 million young lives per year in Africa with the support of GAVI, to implement cost control mechanisms for HPV vaccinations via price negotiations with manufacturing companies, as has recently been done by Rwanda. The collective efforts by local governments, researchers, private sector, and donors may lead to the introduction of affordable screening tests. A robust awareness campaign coupled with sustained and regular engagement of local communities about the prevention and risk factors is extremely important. The projected solutions may be well applicable to other Sub-Saharan countries that face similar challenges containing cervical cancer.

Satisfaction with high-resolution anoscopy for anal cancer screening among men who have sex with men: a cross-sectional survey in Abuja, Nigeria

Background

Men who have sex with men (MSM) living with HIV are at increased risk for anal cancer. We evaluated satisfaction with first-time anal cancer screening using high resolution anoscopy (HRA) as a cross sectional survey among men who have sex with men (MSM) attending a community-engaged clinic in Abuja, Nigeria.

Methods

Between March and August 2017, 342 MSM underwent screening and 307 (89%) completed a satisfaction survey that evaluated 8 domains related to expectations, convenience, staff interpersonal skills, physical surroundings, technical competence, pain/discomfort, general satisfaction, and intention to re-screen if symptomatic. The 22-item questionnaire used 5-point Likert scales ranging from 1 (strongly disagree) to 5 (strongly agree). For each domain, responses to specific items were averaged, aggregated, and converted to a 100-point scaled score (SS) with 25 and 75 corresponding to disagree and agree, respectively.

Results

Median age was 24 years (interquartile range [IQR]: 22–28), median years since anal coital debut was 7 (IQR: 4–12), and 58% (95% confidence interval [CI]: 52–64%) were living with HIV. Despite respondents reporting pre-procedure anxiety (SS:73), most were comfortable with the setting and procedure and reported overall satisfaction (SS:74–76). Willingness to undergo future screening had the lowest score (SS:69) within the general satisfaction domain. The lowest scoring domains were pain/discomfort (SS:57) and agreement to re-screen if symptomatic (SS:59), which correlated with lower overall satisfaction (p < 0.001). Domain responses did not differ by HIV infection after adjusting for multiple comparisons (p > 0.006) or number of anal biopsies (all p > 0.05).

Conclusions

Overall, HRA was satisfactory for those naïve to screening but moving forward necessitates monitoring levels of discomfort with pain scales and normalizing dialogue around clinical symptoms of anal cancer and overall anal health to sustain future screening.

A Systematic Review of Patient-Facing Visualizations of Personal Health Data

OBJECTIVES

As personal health data are being returned to patients with increasing frequency and volume, visualizations are garnering excitement for their potential to facilitate patient interpretation. Evaluating these visualizations is important to ensure that patients are able to understand and, when appropriate, act upon health data in a safe and effective manner. The objective of this systematic review was to review and evaluate the state of the science of patient-facing visualizations of personal health data.

METHODS

We searched five scholarly databases (PubMed, Embase, Scopus, ACM Digital Library [Association for Computing Machinery Digital Library], and IEEE Computational Index [Institute of Electrical and Electronics Engineers Computational Index]) through December 1, 2018 for relevant articles. We included English-language articles that developed or tested one or more patient-facing visualizations for personal health data. Three reviewers independently assessed quality of included articles using the Mixed methods Appraisal Tool. Characteristics of included articles and visualizations were extracted and synthesized.

RESULTS

In 39 articles included in the review, there was heterogeneity in the sample sizes and methods for evaluation but not sample demographics. Few articles measured health literacy, numeracy, or graph literacy. Line graphs were the most common visualization, especially for longitudinal data, but number lines were used more frequently in included articles over past 5 years. Article findings suggested more patients understand the number lines and bar graphs compared with line graphs, and that color is effective at communicating risk, improving comprehension, and increasing confidence in interpretation.

CONCLUSION

In this review, we summarize types and components of patient-facing visualizations and methodologies for development and evaluation in the reviewed articles. We also identify recommendations for future work relating to collecting and reporting data, examining clinically actionable boundaries for diverse data types, and leveraging data science. This work will be critically important as patient access of their personal health data through portals and mobile devices continues to rise.