Human papillomavirus genotype distribution among women with and without cervical cancer: Implication for vaccination and screening in Ghana

Tritesting in Battor, Ghana: an integrated cervical precancer screening strategy to mitigate the challenges of multiple screening visits and loss to follow-up

Background

Human papillomavirus (HPV) DNA testing is more sensitive than cytology for detecting cervical precancer; however, increasing reports of high-risk HPV (hr-HPV)-negative cases of cervical intraepithelial neoplasia (CIN) and even malignancy motivate the use of combined testing. We present our experience with 'tritesting', defined as the performance of HPV DNA testing, cytology and visual inspection in a single session at the Cervical Cancer Prevention and Training Centre, Ghana. We further determined the prevalence rates of hr-HPV infection, abnormal cytology and cervical lesions among women screened using tritesting.

Methods

This descriptive retrospective cross-sectional study assessed all women screened via tritesting between April 2019 to April 2023. HPV DNA testing was performed using the Sansure MA-6000, GeneXpert or AmpFire platforms. Visual inspection was performed using enhanced visual assessment mobile colposcopy or visual inspection with acetic acid. Liquid-based cytology was performed using cervical samples taken with a Cervex-Brush® and fixed in PreservCyt, while samples for conventional cytology were taken using an Ayre spatula and cytobrush.

Results

Among 236 women screened (mean age, 39.1 years (standard deviation, 10.9)), the overall prevalence rates of hr-HPV infection and cervical lesions were 17.8% (95% confidence interval (CI), 13.1-23.3) and 11.9% (95% CI, 8.0-16.7), respectively. Cytology yielded findings of atypical squamous cells of undetermined significance or worse in 2.5% (95% CI, 0.9-5.5) of women. Histopathology following loop electrosurgical excision procedure revealed CIN I (tritest positive) and CIN III (hr-HPV-positive, visual inspection 'positive', cytology-negative) in one woman each. Factors independently associated with hr-HPV infection among 'tritested' women were age ≥ 39 years, tertiary level of education and current contraceptive use. Twenty-seven out of 39 hr-HPV-positive women (69.2%; 95% CI, 52.4-83.0) showed a type 3 transformation zone and would have needed to be recalled for a cytologic sample to be taken in a 'see and triage' approach with HPV DNA testing and a visual inspection method.

Conclusion

This study brings tritesting into the spotlight, as an alternative to other methods, particularly for women who prefer this due to the advantage of a single visit to a health facility and being more cost-effective, if they have to travel long distances to access cervical screening services.

Distribution of high- and low-risk human papillomavirus genotypes and their prophylactic vaccination coverage among West African women: systematic review

INTRODUCTION

The second most deadly gynecological cancer worldwide, cervical cancer is steadily on the rise in sub-Saharan Africa, while vaccination programs are struggling to get off the ground. This systematic review's aim was to assess the prevalence and distribution of high- and low-risk HPV genotypes in West African women.

METHODS

Original studies were retrieved from PubMed/Medline, Embase, Scopus, Google Scholar, and Science Direct. In these studies, Human papillomavirus (HPV) DNA was assessed in cervical samples by polymerase chain reaction (PCR), Hybrid capture, and sequencing. The quality of the articles was assessed and the results were extracted and reviewed.

RESULTS

Thirty-nine studies from 10 West African countries were included for the systematic review including 30 for the pooled analysis. From an overall of 17358 participants, 5126 of whom were infected with at least one HPV genotype, the systematic review showed a prevalence varying from 8.9% to 81.8% in the general population. In contrast, the pooled prevalence of infection was 28.6% (n = 3890; 95% CI 27.85-29.38), and HPV-52 (13.3%), HPV-56 (9.3%), and HPV-35 (8.2) were the most frequent. Quadrivalent and nonavalent vaccines covered 18.2% and 55.8% of identified genotypes respectively.

CONCLUSION

Faced with this growing public health challenge in West Africa, it would be necessary for all its countries to have reliable data on HPV infection and to introduce the nonavalent vaccine. A study of the genotypic distribution of HPV in high-grade precancerous lesions and cervical cancer would be very useful in West Africa.

HPV18 L1 and long control region sequences variation and E6/E7 differential expression in nasopharyngeal and cervical cancers: a comparative study

BACKGROUND

The role of high-risk human papillomaviruses (hr-HPVs) in cervical cancer (CC) pathogenesis has long been established. Knowledge about the involvement of hr-HPVs in the etiology of nasopharyngeal cancers (NPC) was not well appreciated until the early 2000s when a clear link began to emerge. However, it is not clear whether HPV oncogenesis in the different epithelial cancers is associated with L1 gene and long-control region (LCR) sequences variation. This study aimed to investigate the HPV18 L1 gene and LCR sequences variation in cervical and nasopharyngeal biopsies, and assessed E6 and E7 genes expression level in both cancers.

METHOD

Four-hundred and three (403) formalin-fixed paraffin-embedded tissues originating from nasopharyngeal (NPC) (279) and cervical (CC) (124) sites were collected from a pathology laboratory, Pathologist Without Borders, Accra, Ghana. Haematoxylin and eosin staining was carried out to confirm the presence of cancer on prepared biopsy sections. DNA was extracted from the confirmed cancer biopsies, followed by PCR using MY09/GP5+ /6+ primers to detect the presence of HPV and specific primers for the amplification of L1 gene and LCR. Sanger sequencing was carried out to determine HPV genotypes, and L1 and LCR sequences variant of HPV18s in CC and NPC biopsies. The HPV18 E6/E7 mRNA expression pattern in both cancers was determined using RT-qPCR.

RESULTS

Most of the NPC (45%) and CC (55%) biopsies were HPV18 positive. Comparison of HPV18 L1 sequences obtained from cervical and nasopharyngeal cancer tissues, the L1 sequences from the NPC were highly dissimilar with a 59-100% variation among themselves, and in relation to the reference strains. However, the L1 sequences from the CC were more similar with a 91.0-100% variation among the amplified sequences. Also, the LCR sequences from CC were quite different relative to that of NPC. Results for the differential expression of E6/E7 in the two cancers showed a higher fold change in E6 expression in the CC tissues than the NPC tissues while a reverse expression pattern was found for E7 gene.

CONCLUSION

The current study reports for the first-time variations in HPV18 L1 and LCR sequences, and differential expression of E6/E7 genes in NPC compared to CC, suggesting a possible adaptation mechanism of the virus at different cancer sites.

Self-sampling and HPV DNA testing for cervical precancer screening in a cohort of nuns in Ghana: a cross-sectional cohort study

Background

The need for cervical cancer screening has been emphasised in at-risk cohorts of women to reduce their risk of cervical cancer. Some women with decreased risk of acquiring human papillomavirus (HPV) infections, such as Catholic nuns, receive less attention and on occasion are missed in cervical cancer screening programmes. This study aimed to determine the high-risk HPV (hr-HPV) prevalence in such a cohort to emphasise the need for cervical precancer screening among all women. To improve compliance, we employed self-sampling.

Methods

This descriptive cross-sectional cohort study involved the data of 105 Catholic nuns subjected to cervical screening using self-samples in the Greater Accra, Volta, and Central regions of Ghana between June 4, 2022 and June 30, 2022. hr-HPV testing was performed on self-samples using the MA-6000 HPV DNA platform. Screen-positive nuns underwent follow-up pap smears and EVA colposcopy. In addition to descriptive analysis, univariate and multivariable nominal logistic regression was used to explore the relationship between hr-HPV positivity and selected continuous and categorical factors.

Findings

105 nuns from three convents were screened with hr-HPV DNA testing (MA-6000). Twenty-five tested positive for hr-HPV (prevalence of 23.8% (95% CI, 15.7-32.0) [HPV 18 only (n = 2, 1.9%), non-HPV 16/18 genotypes (others) (n = 22, 21.0%), and mixed infection with HPV 16 and other genotype(s) (n = 1, 1.0%)]. Pap smears for all 25 hr-HPV-positives came in as negative for intraepithelial lesions or malignancy, whereas EVA mobile colposcopy showed minor abnormal findings in two (8.0%; 95% CI, 1.0-26.0), both of whom were managed conservatively.

Interpretation

Our findings suggest that the hr-HPV prevalence in this cohort of nuns is similar to that of the general population. To meet the World Health Organization's target for cervical cancer elimination, it is important that all women are given access to cervical cancer screening and preventative services. Further, increasing 'anonymity' and privacy among nuns through self-sampling may be crucial to expanding choice, coverage, and uptake of screening in support of their health rights.

Funding

None.

Female students' perspectives on cervical cancer screening inclusion in pre-admission university requirements in Ghana

Cervical cancer is a huge contributor to cancer-related deaths and the commonest gynecological cancerous growth among women globally. Nevertheless, evidence suggests that cervical cancer incidence and mortality could be reduced through early diagnosis. Regardless of the accessibility of cervical cancer screening in Ghana, low reports of cervical screening had been recorded among female students and women in Ghana. The study objectives were to explore.Female students' opinions on the inclusion of cervical cancer screening in the pre-university admission screening requirement in Ghana. The facilitators and barriers to cervical cancer screening among female University students.Qualitative exploratory-descriptive design was employed for the purpose of this study. The target population was female students in a public university in Ghana who were purposively selected. Content analysis was employed for the data analysis. In all, 30 female students were selected to engage in face-face interviews using a semi-structured interview guide. Two categories and seven sub-categories were generated from the study analysis. It was interesting to know that majority 20 (66.66%) of the students supported adding CCS to the preadmission screening requirement with few refuting it. Others also recommended compulsory screening as a means of enhancing screening practices. The reasons for refusing this proposal by a few 10 (33.3%) of the participants were it being burdensome, time-consuming, and capital intensive. Other reasons for refusing it were sexual inactiveness following the screening, fear of discomfort, and the screening results. In conclusion, the study found that students were willing to undergo CCS if made mandatory for admission and suggested it be included in pre-admission screening requirements to encourage more Ghanaian women to participate. As CCS is effective in reducing cervical cancer incidence and burden, the proposal of including it in pre-university screening should be considered to increase uptake.