Potential impact of antiretroviral therapy and screening on cervical cancer mortality in HIV-positive women in sub-Saharan Africa: a simulation

Socioeconomic characteristics, cancer mortality, and universal health coverage: A global analysis

BACKGROUND

Achieving universal health coverage (UHC) involves all individuals attaining accessible health interventions at an affordable cost. We examined current patterns and temporal trends of cancer mortality and UHC across sociodemographic index (SDI) settings, and quantified these association.

METHODS

We used data from the Global Burden of Disease Study 2019 and Our World in Data. The UHC effective coverage index was obtained to assess the potential population health gains delivered by health systems. The estimated annual percentage change (EAPC) with a 95% confidence interval (CI) was calculated to quantify the trend of cancer age-standardized mortality rate (ASMR). A generalized linear model was applied to estimate the association between ASMR and UHC.

FINDINGS

The high (EAPC = -0.9% [95% CI, -1.0%, -0.9%]) and high-middle (-0.9% [-1.0%, -0.8%]) SDI regions had the fastest decline in ASMR (per 100,000) for total cancers from 1990 to 2019. The overall UHC effective coverage index increased by 27.9% in the high-SDI quintile to 62.2% in the low-SDI quintile. A negative association was observed between ASMR for all-cancer (adjusted odds ratio [OR] = 0.87 [0.76, 0.99]), stomach (0.73 [0.56, 0.95]), breast (0.64 [0.52, 0.79]), cervical (0.42 [0.30, 0.60]), lip and oral cavity (0.55 [0.40, 0.75]), and nasopharynx (0.42 [0.26, 0.68]) cancers and high UHC level (the lowest as the reference).

CONCLUSIONS

Our findings strengthen the evidence base for achieving UHC to improve cancer outcomes.

FUNDING

This work is funded by the China National Natural Science Foundation and Chinese Academy of Medical Sciences Innovation Fund for Medical Science.

Factors Associated With Precancerous Cervical Lesions in Human Immunodeficiency Virus-Infected Women: A Cross-Sectional Survey in Togo

Background

The burden of human immunodeficiency virus (HIV) in cervical cancer remains a major public health challenge in developing countries, like Togo. Precancerous lesions include all cellular abnormalities that have malignant potential that can develop into cancer. The objective of this study was to determine the prevalence and factors associated with precancerous cervical lesions in HIV-infected women in our context.

Methods

A cross-sectional descriptive study was carried out from November 31, 2022, to January 31, 2023, in an HIV care center in Lomé (Non-Governmental Organization Espoir Vie Togo [NGO EVT] Grand-Lomé-Togo).

Results

A total of 271 women were included with a mean age of 47.0 years and a standard deviation of 10.0 years, among whom 20.7% do not have any scholar education. Only 6.7% of them had previously performed cervical smear examinations. The prevalence of precancerous cervical lesions observed in people living with human immunodeficiency virus (PLHIV) was 11.4% with a 95% confidence interval (CI) of 5.0 to 15.4. Cytological abnormalities were marked by low-grade squamous intraepithelial lesion (LSIL) (5.1%), followed by the presence of atypical squamous cells of undetermined significance (ASCUS) (3.5%). A statistically significant association was found between parity and the presence of precancerous lesions (P = .014).

Conclusions

In this study, more than 1 out of 10 women living with HIV had precancerous cervical lesions, and parity was the factor associated. The implementation of a systematic screening program for precancerous cervical lesions and human papillomavirus (HPV) infection integrated into HIV care is necessary for early treatment.

Cervical cancer screening among female health workers: Evidence from a secondary health facility in Northern Malawi

Cervical cancer is preventable and curable if identified early. Although health workers have a critical role in influencing beliefs and practices of the entire population, some studies have shown paradoxical efforts among female health workers themselves-a threat towards attainment of the triple-intervention strategy as propagated by the World Health Organization (WHO). The study aimed to assess knowledge, attitudes and practices of cervical cancer screening among female health workers. The study used a descriptive cross-sectional design. Data entry and analysis were carried out using IBM Statistical Package for Social Scientists (SPSS) version 20.0 (SPSS, Michigan Avenue, Chicago, IL, USA). The response rate was 65.4 % and mean age of 32 years with standard deviation=±8.397. The majority of participants were nurses n = 31 (43.3). There was poor knowledge on signs/symptoms and risk factors as only 15.7 % were aware of multiple sexual partners, 7.1 % for each early sexual encounter and uncircumcised men as risk factors. Regarding willingness, 77.1 % were willing to have the screening test. Their practices were rated poor as only 35.7 % (n = 25) had ever undergone screening within the past 6 years. There was poor knowledge, fair attitudes and poor practices of cervical cancer screening among female health workers. As part of the efforts to achieve sustainable development goal (SDG) target 3.4 and the attainment of WHO 90-70-90 target by 2030; this study recommends scaling up health education, social mobilization and Human Papillomavirus (HPV) vaccinations to support awareness, detection and treatment of cervical cancer. Acceptability of the current screening methods must be further explored.

Mathematical Models for Evaluating Effectiveness and Cost-Effectiveness of Cervical Cancer Control Policies in Populations Including Women Living With Human Immunodeficiency Virus: A Scoping Review

OBJECTIVES

Mathematical modeling is increasingly used to inform cervical cancer control policies, and model-based evaluations of such policies in women living with human immunodeficiency virus (HIV) are an emerging research area. We did a scoping review of published literature to identify research gaps and inform future work in this field.

METHODS

We systematically searched literature up to April 2022 and included mathematical modeling studies evaluating the effectiveness or cost-effectiveness of cervical cancer prevention strategies in populations including women living with HIV. We extracted information on prevention strategies and modeling approaches.

RESULTS

We screened 1504 records and included 22 studies, almost half of which focused on South Africa. We found substantial between-study heterogeneity in terms of strategies assessed and modeling approaches used. Fourteen studies evaluated cervical cancer screening strategies, 7 studies assessed human papillomavirus vaccination (with or without screening), and 1 study evaluated the impact of HIV control measures on cervical cancer incidence and mortality. Thirteen conducted cost-effectiveness analyses. Markov cohort state-transition models were used most commonly (n = 12). Most studies (n = 17) modeled the effect of HIV by creating HIV-related health states. Thirteen studies performed model calibration, but 11 did not report the calibration methods used. Only 1 study stated that model code was available upon request.

CONCLUSIONS

Few model-based evaluations of cervical cancer control strategies have specifically considered women living with HIV. Improvements in model transparency, by sharing information and making model code publicly available, could facilitate the utility of these evaluations for other high disease-burden countries, where they are needed for assisting policy makers.

СERVICAL CANCER’S EPIDEMIOLOGY IN THE REPUBLIC OF KAZAKHSTAN AND IN THE WORLD. IMPACT OF POPULATION ADHERENCE ON COVERAGE AND SUCCESS OF CERVICAL CANCER SCREENING PROGRAMS

For many years, the problem of the prevalence of cervical cancer has been one of the most pressing for public health in most countries of the world. Despite the increasing number of screening programs, cervical cancer is still one of the most common sites of malignant neoplasms of the female reproductive system. Screening programs are effective if they involve 70% or more of the population in the appropriate age groups. In Kazakhstan, this figure for cervical cancer screening is 48–50%. [1,2,3]

Healthcare worker compliance with cervical cancer screening guidelines. An audit at district and regional level of care in the Pietermaritzburg Metropolitan area of KwaZulu-Natal

Background

In South Africa (SA) there are screening guidelines for cervical cancer in women living with HIV (WLWH). To our knowledge there is lack of data concerning the knowledge of health care workers (HCWs) about cervical cancer screening guidelines before the initiation of antiretroviral therapy (ART) in WLWH.

Objectives

To investigate the knowledge and familiarity of HCWs regarding cervical cancer screening guidelines in WLWH.

Methods

A cross-sectional questionnaire-based study exploring compliance with cervical cancer screening guidelines before initiating ART was conducted with 85 HCWs in the antiretroviral (ARV) clinics of a district and regional hospitals in KwaZulu-Natal, SA. Data were analysed using Stata V13 and a p-value of ≤ 0.05 was considered statistically significant.

Results

Eighty-five HCWs were included in the study. Health care workers’ responses to knowledge about cervical cancer screening in WLWH were suboptimal and revealed significant gaps. Most HCWs did not know the screening intervals of WLWH. Statistically significant associations were found between an HCW’s occupation and responses to the Likert scale questions.

Conclusion

Although the majority of HCWs were familiar with cervical cancer screening guidelines in WLWH, the study highlights that there are deficiencies in both knowledge and practice. Creating awareness among HCWs regarding the current methods of cervical cancer screening is a necessary to reduce morbidity and mortality from cervical cancer in WLWH.

Prevalence and predictors of precancerous cervical lesions among HIV-positive women in Jos, north-central Nigeria

OBJECTIVE

To determine the prevalence and predictors of precancerous cervical lesions among HIV-positive women in Jos, Nigeria.

METHODS

A cross-sectional study was conducted from October 2017 to January 2018 among 326 HIV-positive women. Cervical smears were collected for examination at the AIDS Preventive Initiative of Nigeria clinics of Jos University Teaching Hospital (JUTH) and Bingham University Teaching Hospital (BhUTH), Jos, Nigeria. Demographic characteristics of participants were documented using a structured questionnaire. Data were entered and analyzed using SPSS version 21.

RESULTS

Of the 326 participants, precancerous cervical lesions were present in 40 (12.2%) women: 4 (1.2%) had atypical squamous cells of undetermined significance, 19 (5.8%) had low-grade squamous intraepithelial lesions, 1 (0.3%) had atypical squamous cells cannot exclude high-grade squamous intraepithelial lesions, 13 (4.0%) had high-grade squamous intraepithelial lesions, and 3 (0.9%) had high-grade squamous intraepithelial lesions, suspected for invasion. The multivariate logistics regression model showed that parity (odds ratio 3.4, 95% confidence interval 1.3-9.5, P=0.043) was a significant predictor of precancerous cervical lesions.

CONCLUSION

The prevalence of precancerous cervical lesions among HIV-infected women is relatively low compared to earlier reported prevalence in an HIV population in Jos. Increasing parity was a significant predictor.

The impact of scaling up cervical cancer screening and treatment services among women living with HIV in Kenya: a modelling study

Introduction

We aimed to quantify health outcomes and programmatic implications of scaling up cervical cancer (CC) screening and treatment options for women living with HIV in care aged 18–65 in Kenya.

Methods

Mathematical model comparing from 2020 to 2040: (1) visual inspection with acetic acid (VIA) and cryotherapy (Cryo); (2) VIA and Cryo or loop excision electrical procedure (LEEP), as indicated; (3) human papillomavirus (HPV)-DNA testing and Cryo or LEEP; and (4) enhanced screening technologies (either same-day HPV-DNA testing or digitally enhanced VIA) and Cryo or LEEP. Outcomes measured were annual number of CC cases, deaths, screening and treatment interventions, and engaged in care (numbers screened, treated and cured) and five yearly age-standardised incidence.

Results

All options will reduce CC cases and deaths compared with no scale-up. Options 1–3 will perform similarly, averting approximately 28 000 (33%) CC cases and 7700 (27%) deaths. That is, VIA screening would yield minimal losses to follow-up (LTFU). Conversely, LTFU associated with HPV-DNA testing will yield a lower care engagement, despite better diagnostic performance. In contrast, option 4 would maximise health outcomes, averting 43 200 (50%) CC cases and 11 800 (40%) deaths, given greater care engagement. Yearly rescreening with either option will impose a substantial burden on the health system, which could be reduced by spacing out frequency to three yearly without undermining health gains.

Conclusions

Beyond the specific choice of technologies to scale up, efficiently using available options will drive programmatic success. Addressing practical constraints around diagnostics’ performance and LTFU will be key to effectively avert CC cases and deaths.

Predictors of cervical cancer screening practice among HIV positive women attending adult anti-retroviral treatment clinics in Bishoftu town, Ethiopia: the application of a health belief model

BACKGROUND

Cervical cancer is a global public health problem and the second most common cancer causing morbidity and mortality in Ethiopia. Few available evidences revealed that despite distribution and severity of cervical cancer among HIV-positive women and the ease with which it can be prevented, cervical cancer screening practice in Ethiopia among them is considerably low. Thus, this study aims to assess predictors of cervical cancer screening practice among HIV-positive women by applying health belief model concepts.

METHODS

Facility based cross-sectional study was conducted in Bishoftu. Data was collected from 475 women who visit the health facilities for anti-retroviral services using interviewer-administered questionnaires. Champion's revised Health Belief Model sub-scales were used as data collection tools containing sources of information, knowledge, perception on cervical cancer screening and cervical cancer screening practice as variables. Frequencies, percentage, mean and standard deviation were used to describe findings. Multi-variable logistic regression and 95% confidence intervals were considered to identify predictors of cervical cancer screening practice by controlling possible confounders.

RESULTS

Cervical cancer screening practice among HIV-positive women in this study was 25%. Health proffesionals were the main sources of information about cervical cancer and its screening. There was a difference between the 'ever' and 'never' screened groups in mean scores of their perceived severity, perceived benefit, perceived barrier, perceived self-efficacy, perceived threat and net-benefit towards screening (P < 0.05). Perceived self-efficacy (AOR 1.24, 95%CI 1.13-1.37), perceived threat (AOR 1.08, 95%CI 1.05-1.12) and perceived net-benefit (AOR 1.18, 95% CI 1.12, 1.24) were the predictors of cervical cancer screening practice.

CONCLUSIONS

Cervical cancer screening practice in this study was lower than that of the recommended coverage of the target group by the national guideline (80%). This finding has an important implication for public health intervention aimed at cervical cancer prevention. Morever, womens' perceptions on cervical cancer screening had a significant influence on the utilization of cervical cancer screening service. Therefore, educational programmes geared towards severity of the case, availability of screeningand helpfulness of being screened can significantly improve the uptake of cervical cancer screening.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Association Between HIV Infection and Cancer Stage at Presentation at the Uganda Cancer Institute

PURPOSE

The HIV epidemic has contributed to the increasing incidence of cancer in sub-Saharan Africa, where most patients with cancer present at an advanced stage. However, improved access to HIV care and treatment centers in sub-Saharan Africa may facilitate earlier diagnosis of cancer among patients who are HIV positive. To test this hypothesis, we characterized the stage of cancer and evaluated the factors associated with advanced stage at presentation among patients in Uganda.

METHODS

We conducted a retrospective analysis of adult patients with any of four specific cancers who presented for care in Kampala, Uganda, between 2003 and 2010. Demographic, clinical, and laboratory data were abstracted from the medical record, together with the outcome measure of advanced stage of disease (clinical stage III or IV). We identified measures for inclusion in a multivariate logistic regression model.

RESULTS

We analyzed 731 patients with both AIDS-defining cancers (cervical [43.1%], and non-Hodgkin lymphoma [18.3%]), and non-AIDS-defining cancers (breast [30.0%] and Hodgkin lymphoma [8.6%]). Nearly 80% of all patients presented at an advanced stage and 37% had HIV infection. More than 90% of patients were symptomatic and the median duration of symptoms before presentation was 5 months. In the multivariate model, HIV-positive patients were less likely to present at an advanced stage as were patients with higher hemoglobin and fewer symptoms.

CONCLUSION

Patients with limited access to primary care may present with advanced cancer because of a delay in diagnosis. However, patients with HIV now have better access to clinical care. Use of this growing infrastructure to increase cancer screening and referral is promising and deserves continued support, because the prognosis of HIV-positive patients with advanced cancer is characterized by poor survival globally.

Socio-demographic characteristics influencing cervical cancer screening intention of HIV-positive women in the central region of Ghana

Background

The burden of HIV and cervical cancer is concentrated in sub-Saharan Africa. Women with HIV are more likely to have persistent HPV infection leading to cervical abnormalities and cancer. Cervical cancer screening seems to be the single most critical intervention in any efforts to prevent cervical cancer. The purpose of this study was to determine the socio-demographic factors influencing intention to seek cervical cancer screening by HIV-positive women in the Central Region of Ghana.

Methods

A descriptive cross-sectional study involving a convenience sample of 660 HIV-positive women aged 20 to 65 years receiving antiretroviral therapy in HIV care centres in the Central Region of Ghana was conducted using an interviewer-administered questionnaire. The data were summarised and analysed using frequencies, percentages and binary logistic regression.

Results

The study revealed that 82.0% of HIV-positive women intended to obtain cervical cancer screening. Level of education was a determinant of cervical cancer screening intention. HIV-positive women with low levels of education were 2.67 times (95% CI, 1.61–4.42) more likely to have intention to screen than those with no formal education. Those with high levels of education were 3.16 times (95% CI, 1.42–7.02) more likely to have intention to screen than those with no formal education. However, age, religion, marital status, employment status, and ability to afford the cost of cervical cancer screening were not determinants of intention to screen.

Conclusions

Education of women of all ages needs to be a priority, as it could enable them to adopt appropriate health behaviours and engage in cervical cancer screening. Additionally, interventions to improve understanding of cervical cancer screening among HIV-positive women are highly recommended. These include health education about the disease and availability of screening options in HIV/AIDS care centres.

Predictors of cervical cancer screening intention of HIV-positive women in the central region of Ghana

BACKGROUND

Cervical cancer affects women, especially those with HIV-positive status. This study hypothesised that more HIV-positive women with high cues about cervical cancer screening, high perceived susceptibility to cervical cancer, high perceived seriousness of cervical cancer, high perceived benefits of cervical cancer screening, and low perceived barriers about cervical cancer screening have intention to seek cervical cancer screening than HIV-positive women with low cues, low perceived susceptibility, low perceived seriousness, low perceived benefits, and high perceived barriers.

METHODS

A descriptive cross-sectional study was conducted with 660 HIV-positive women aged 20 to 65 years using an interviewer administered questionnaire. Data were summarised using frequencies, percentages and binary logistic regression analysis.

RESULTS

The findings showed that 82% (n = 540) of the respondents had intention to seek cervical cancer screening. The determinants of cervical cancer screening intention by HIV-positive women were cues, perceived seriousness and perceived benefits. Specifically, HIV-positive women with high cues were 3.48 times more likely to have intention to screen than those with low cues (95% CI, 1.43-8.49). Those with high perceived seriousness were 2.02 times more likely to have intention to screen than those with low perceived seriousness (95% CI, 1.24-3.30). Similarly, those with high perceived benefits were 1.7 times more likely to have intention to screen than those with low perceived benefits (95% CI, 1.05-2.71). However, perceived susceptibility (p = 0.063, OR 2.57, [95% CI, 0.95-6.93]) and perceived barriers (p = 0.969, OR = 1.01, [95% CI, 0.54-1.88]) were not statistically significant predictors of intention to seek cervical cancer screening in the sample studied.

CONCLUSIONS

Cervical cancer screening interventions for HIV-positive women need to have a strong focus on explaining the seriousness of the disease, benefits of screening, and increase cues about screening, as these factors could improve attitude towards cervical cancer screening and promote the health of high risk women.

Impact of screening and antiretroviral therapy on anal cancer incidence in HIV-positive MSM

BACKGROUND

The incidence of anal cancer is high in HIV-positive MSM. We modeled the impact of screening strategies and combination antiretroviral therapy (cART) coverage on anal cancer incidence in Switzerland.

METHODS

Individual-based, dynamic simulation model parameterized with Swiss HIV Cohort Study and literature data. We assumed all men to be human papillomavirus infected. CD4 cell count trajectories were the main predictors of anal cancer. From 2016 we modeled cART coverage either as below 100% (corresponding to 2010-2015) or as 100%, and the following four screening strategies: no screening, yearly anal cytology (Papanicolaou smears), yearly anoscopy and targeted anoscopy 5 years after CD4 count dropped below 200 cells/μl.

RESULTS

Median nadir CD4 cell count of 6411 MSM increased from 229 cells/μl during 1980-1989 to 394 cells/μl during 2010-2015; cART coverage increased from 0 to 83.4%. Modeled anal cancer incidence peaked at 81.7/100 000 in 2009, plateaued 2010-2015 and will decrease to 58.7 by 2030 with stable cART coverage, and to 52.0 with 100% cART coverage. With yearly cytology, incidence declined to 38.2/100 000 by 2030, with yearly anoscopy to 32.8 and with CD4 cell count guided anoscopy to 51.3. The numbers needed to screen over 15 years to prevent one anal cancer case were 384 for yearly cytology, 313 for yearly anoscopy and 242 for CD4 cell count-dependent screening.

CONCLUSION

Yearly screening of HIV-positive MSM may reduce anal cancer incidence substantially, with a number needed to screen that is comparable with other screening interventions to prevent cancer.

The Global Health Service Partnership: An Academic-Clinical Partnership to Build Nursing and Medical Capacity in Africa

The World Health Organization estimates a global deficit of about 12.9 million skilled health professionals (midwives, nurses, and physicians) by 2035. These shortages limit the ability of countries, particularly resource-constrained countries, to deliver basic health care, to respond to emerging and more complex needs, and to teach, graduate, and retain their future health professionals—a vicious cycle that is perpetuated and has profound implications for health security. The Global Health Service Partnership (GHSP) is a unique collaboration between the Peace Corps, President’s Emergency Plan for AIDS Relief, Seed and host-country institutions, which aims to strengthen the breadth and quality of medical and nursing education and care delivery in places with dire shortages of health professionals. Nurse and physician educators are seconded to host institutions to serve as visiting faculty alongside their local colleagues. They serve for 1 year with many staying longer. Educational and clinical best practices are shared, emphasis is placed on integration of theory and practice across the academic–clinical domains and the teaching and learning environment is expanded to include implementation science and dissemination of locally tailored and sustainable practice innovations. In the first 3 years (2013–2016) GHSP placed 97 nurse and physician educators in three countries (Malawi, Tanzania, and Uganda). These educators have taught 454 courses and workshops to 8,321 trainees, faculty members, and practicing health professionals across the curriculum and in myriad specialties. Mixed-methods evaluation included key stakeholder interviews with host institution faculty and students who indicate that the addition of GHSP enhanced clinical teaching (quality and breadth) resulting in improved clinical skills, confidence, and ability to connect theory to practice and critical thinking. The outputs and outcomes from four exemplars which focus on the translation of evidence to practice through implementation science are included. Findings from the first 3 years of GHSP suggest that an innovative, locally tailored and culturally appropriate multi-country academic–clinical partnership program that addresses national health priorities is feasible and generated new knowledge and best practices relevant to capacity building for nursing and medical education. This in turn has implications for improving the health of populations who suffer a disproportionate burden of global disease.

Cost-effectiveness of cervical cancer screening and preventative cryotherapy at an HIV treatment clinic in Kenya

Objective

This study evaluated the potential cost-effectiveness of cervical cancer screening in HIV treatment clinics in Nairobi, Kenya.

Methods

A Markov model was used to project health outcomes and costs of cervical cancer screening and cryotherapy at an HIV clinic in Kenya using cryotherapy without screening, visual inspection with acetic acid (VIA), Papanicolaou smear (Pap), and testing for human papillomavirus (HPV). Direct and indirect medical and non-medical costs were examined from societal and clinic perspectives.

Results

Costs of cryotherapy, VIA, Pap, and HPV for women with CD4 200–500 cells/mL were $99, $196, $219, and $223 from a societal perspective and $19, $94, $124, and $113 from a clinic perspective, with 17.3, 17.1, 17.1, and 17.1 years of life expectancy, respectively. Women at higher CD4 counts (>500 cells/mL) given cryotherapy VIA, Pap, and HPV resulted in better life expectancies (19.9+ years) and lower cost (societal: $49, $99, $115, and $102; clinic: $13, $51, $71, and $56). VIA was less expensive than HPV unless HPV screening could be reduced to a single visit.

Conclusions

Preventative cryotherapy was the least expensive strategy and resulted in highest projected life expectancy, while VIA was most cost-effective unless HPV could be reduced to a single visit.

A Comparison of the Natural History of HPV Infection and Cervical Abnormalities among HIV-Positive and HIV-Negative Women in Senegal, Africa

Background: There is evidence of an interaction between HIV and human papillomavirus (HPV) resulting in increased HPV-associated morbidity and cancer mortality among HIV-positive women. This study aims to determine how the natural history of cervical HPV infection differs by HIV status.Methods: A total of 1,320 women (47% were positive for HIV-1 and/or HIV-2) were followed for an average of two years in Senegal, West Africa between 1994 and 2010. Cytology (with a sub-sample of histology) and HPV DNA testing were performed at approximately 4-month intervals yielding data from over 7,900 clinic visits. Competing risk modeling was used to estimate rates for transitioning between three clinically relevant natural history stages: Normal, HPV, and HSIL (high-grade squamous intraepithelial lesions). Among HIV-positive women, exploratory univariate analyses were conducted examining the impact of HPV type, infection with multiple HPV types, HIV type, CD4⁺ count, and age.Results: HIV-positive women had higher rates of progression and lower rates of regression compared with HIV-negative women (i.e., adverse transitions). HIV-positive women had a 2.55 [95% confidence interval (CI), 1.69-3.86; P < 0.0001] times higher rate of progression from HPV to HSIL than HIV-negative women (with 24-month absolute risks of 0.18 and 0.07, respectively). Among HIV-positive women, HPV-16/18 infection and CD4⁺ count <200/mm³ were associated with adverse transitions.Conclusions: Adverse HIV effects persist throughout HPV natural history stages.Impact: In the limited-resource setting of sub-Saharan Africa where cervical cancer screening is not widely available, the high-risk population of HIV-positive women may be ideal for targeted screening. Cancer Epidemiol Biomarkers Prev; 26(6); 886-94. ©2017 AACR.

Cervical cancer screening uptake and challenges in Malawi from 2011 to 2015: retrospective cohort study

BACKGROUND

Malawi has the highest cervical cancer incidence and mortality in the world with age-standardized rate (ASR) of 75.9 and 49.8 per 100,000 population respectively. In response, Ministry of Health established a cervical cancer screening programme using visual inspection with acetic acid (VIA) and treatment of precancerous lesions with cryotherapy. This paper highlights the roll out, integration with family planning services and HIV ART Programme, uptake and challenges of VIA and Cryotherapy programme.

METHODS

We analyzed program data, supportive supervision, quarterly and annual reports from the National Cervical Cancer Control Program. We evaluated the uptake and challenges of screening services by age, HIV serostatus and trends over a five year period (2011-2015).

RESULTS

Between 2011 and 2015, number of cervical cancer screening sites, number of women screened and coverage per annum increased from 75 to 130, 15,331 to 49,301 and 9.3 % to 26.5 % respectively. In this five year period, a total of 145,015 women were screened. Of these, 7,349 (5.1 %) and 6,289 (4.3 %) were VIA positive and suspect cancer respectively. Overall 13,638 (9.4 %) were detected to be VIA positive or had suspect cancer. Of the 48,588 women with known age screened in 2015; 13,642 (28.1 %), 27,275 (56.1 %) and 7,671 (15.8 %) were aged 29 or less, 30-45, 46 years or more. Among 39,101 women with data on HIV serostatus; 21,546 (55.1 %) were HIV negative, 6,209 (15.9 %) were HIV positive and 11, 346 (29.0 %) status was unknown. VIA positivity rate and prevalence of suspect cancer were significantly higher in HIV positive than HIV negative women (8.8 % vs 5.0 %, 6.4 % vs 3.0 %); in women aged 30-45 years than women aged 29 years or less (5.6 % vs 2.3 %, 2.6 % vs 1.2 %) respectively, all p <0.05). The main challenge of the programme was failure to treat VIA positive women eligible for cryotherapy. Over the five year period, the programme only treated 1,001 (43.3 %) out of 2,311 eligible women and only 266 (31.8 %) of the 836 women with large lesion or suspect cancer who were referred, received the health care at the referral centre. The reasons for failure to provide cryotherapy treatment were stock out of gas, faulty/broken cryotherapy machine (usually connectors or probes) or no cryotherapy machine at all in the whole district. For women with large lesion or suspect cancer; lack of loop electrosurgical excision procedure (LEEP) machine or inadequate gynaecologists at the referral centre, were the major reasons. Cancer radiotherapy services were not available in Malawi.

CONCLUSIONS

This study provided data on VIA positivity rate, prevalence of suspect cancer, failure rate of cryotherapy and challenges in the provision of cryotherapy and LEEP treatment in Malawi. These data could be used as baseline for monitoring and evaluation of Human Papillomavirus (HPV) vaccination programme which the country introduced in 2013, the linkage of cervical cancer screening and women on HIV ART and the long term effect of ART, voluntary male medical circumcision on the prevalence and incidence of cervical cancer.

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.

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

Background

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

Methods

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

Findings

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

Conclusions

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

Integrating cervical cancer prevention initiatives with HIV care in resource-constrained settings: A formative study in Durban, South Africa

Cervical cancer screening rates remain suboptimal among women in South Africa (SA), where cervical cancer prevalence is high. The rollout of HIV-related services across SA may provide a means to deliver cervical cancer screening to populations with limited access to health care systems. In this mixed methods study, psychosocial factors influencing cervical cancer prevention and perceptions of the provision of Pap smears in HIV care settings were examined. Structured interviews were conducted with women (n = 67) from a municipal housing estate in Durban, SA. Key informants (n = 12) also participated in semi-structured interviews. Findings revealed that participants had low cervical cancer knowledge, but desired more information. Relevant themes included the normalisation of HIV and beliefs that cervical cancer might be worse than HIV. A comprehensive community clinic was desired by most, even if HIV-positive patients were treated there. This study provides important insight into integrating cervical cancer screening with HIV clinics, which may increase cancer screening among South African women.

Integrating HIV testing into cervical cancer screening in Tanzania: an analysis of routine service delivery statistics

BACKGROUND

While the lifetime risk of developing cervical cancer (CaCx) and acquiring HIV is high for women in Tanzania, most women have not tested for HIV in the past year and most have never been screened for CaCx. Good management of both diseases, which have a synergistic relationship, requires integrated screening, prevention, and treatment services. The aim of this analysis is to assess the acceptability, feasibility and effectiveness of integrating HIV testing into CaCx prevention services in Tanzania, so as to inform scale-up strategies.

METHODS

We analysed 2010-2013 service delivery data from 21 government health facilities in four regions of the country, to examine integration of HIV testing within newly introduced CaCx screening and treatment services, located in the reproductive and child health (RCH) section of the facility. Analysis included the proportion of clients offered and accepting the HIV test, reasons why testing was not offered or was declined, and HIV status of CaCx screening clients.

RESULTS

A total of 24,966 women were screened for CaCx; of these, approximately one-quarter (26%) were referred in from HIV care and treatment clinics. Among the women of unknown HIV status (n = 18,539), 60% were offered an HIV test. The proportion of women offered an HIV test varied over time, but showed a trend of decline as the program expanded. Unavailability of HIV test kits at the facility was the most common reason for a CaCx screening client not to be offered an HIV test (71% of 6,321 cases). Almost all women offered (94%) accepted testing, and 5% of those tested (582 women) learned for the first time that they were HIV-positive.

CONCLUSION

Integrating HIV testing into CaCx screening services was highly acceptable to clients and was an effective means of reaching HIV-positive women who did not know their status; effectiveness was limited, however, by shortages of HIV test kits at facilities. Integration of HIV testing into CaCx screening services should be prioritized in HIV-endemic settings, but more work is needed to eliminate logistical barriers. The coverage of CaCx screening among HIV care and treatment-enrolled women in Tanzania may be low and should be examined.

HIV, tuberculosis, and noncommunicable diseases: what is known about the costs, effects, and cost-effectiveness of integrated care?

Unprecedented investments in health systems in low- and middle-income countries (LMICs) have resulted in more than 8 million individuals on antiretroviral therapy. Such individuals experience dramatically increased survival but are increasingly at risk of developing common noncommunicable diseases (NCDs). Integrating clinical care for HIV, other infectious diseases, and NCDs could make health services more effective and provide greater value. Cost-effectiveness analysis is a method to evaluate the clinical benefits and costs associated with different health care interventions and offers guidance for prioritization of investments and scale-up, especially as resources are increasingly constrained. We first examine tuberculosis and HIV as 1 example of integrated care already successfully implemented in several LMICs; we then review the published literature regarding cervical cancer and depression as 2 examples of NCDs for which integrating care with HIV services could offer excellent value. Direct evidence of the benefits of integrated services generally remains scarce; however, data suggest that improved effectiveness and reduced costs may be attained by integrating additional services with existing HIV clinical care. Further investigation into clinical outcomes and costs of care for NCDs among people living with HIV in LMICs will help to prioritize specific health care services by contributing to an understanding of the affordability and implementation of an integrated approach.

Awareness, knowledge and beliefs about HPV, cervical cancer and HPV vaccines among nurses in Cameroon: an exploratory study

BACKGROUND

While it is known that sub-Saharan African countries face multiple obstacles such as cost in adopting vaccination against human papillomavirus (HPV), the crucial role nurses can play in implementing such programs has not been adequately examined.

OBJECTIVES

To investigate the knowledge and awareness of HPV, primary cause of cervical cancer and HPV vaccine among nurses working at four Cameroon Baptist Convention Health Services facilities, and to explore what factors influence nurses' willingness to inform and recommend HPV vaccine to adolescents and parents attending clinics.

DESIGN AND SETTING

A structured questionnaire survey was administered to a convenience sample of nursing staff working at the four health facilities.

RESULTS

Of 192 eligible nurses 76 (39.6%) participated in the study. There were moderately low levels of knowledge about HPV infection and prevention of cervical cancer, but a moderately high level of knowledge about HPV vaccine. Although 90.8% acknowledged that cervical cancer is directly linked to HPV infection, nearly 32% failed to identify it as a sexually transmitted infection (STI), while 43.4% believed it is an uncommon infection. Willingness to recommend the HPV vaccine was moderate, with 69.7% intentionally initiating discussions with patients about the subject. The most important factors considered when deciding to recommend the vaccine included effectiveness (56.6%) and side effects/safety (11.8%). Cost was less of a concern (6.6%), likely due to the availability of donated vaccine.

CONCLUSION

Despite high awareness about HPV, more education about the virus, cervical cancer and the vaccine are required to further increase nurses' willingness to recommend the vaccine and strengthen strategies for reaching adolescents through nurses in Cameroon.

Infection-related cancers in sub-saharan Africa: a paradigm for cancer prevention and control

There is much commonality between chronic noncommunicable and communicable diseases which is best exemplified by cancers of infectious origin. It provides the perfect opportunity for harnessing the advances that have been made in the control of communicable diseases to attempt the control of noncommunicable diseases. There are possibilities at various levels of intervention, at primary, secondary and tertiary levels, which fit well within a well-planned national cancer control strategy. Prevention should proceed through steps of disruption of transmission, improvement in disease recognition and diagnosis, as well as through prompt effective treatment. This principle should work for both infection and the resultant cancer. Research is very important in understanding how best to use the available knowledge and how best to sequentially implement strategies. Finally, policies that acknowledge infection-related cancers as a major problem in the region should be in place.

Cancer burden in Africa and opportunities for prevention

Cancer is an emerging public health problem in Africa. About 715,000 new cancer cases and 542,000 cancer deaths occurred in 2008 on the continent, with these numbers expected to double in the next 20 years simply because of the aging and growth of the population. Furthermore, cancers such as lung, female breast, and prostate cancers are diagnosed at much higher frequencies than in the past because of changes in lifestyle factors and detection practices associated with urbanization and economic development. Breast cancer in women and prostate cancer in men have now become the most commonly diagnosed cancers in many Sub-Saharan African countries, replacing cervical and liver cancers. In most African countries, cancer control programs and the provision of early detection and treatment services are limited despite this increasing burden. This paper reviews the current patterns of cancer in Africa and the opportunities for reducing the burden through the application of resource level interventions, including implementation of vaccinations for liver and cervical cancers, tobacco control policies for smoking-related cancers, and low-tech early detection methods for cervical cancer, as well as pain relief at the palliative stage of cancer.