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

Role and knowledge of nurses in the management of non-communicable diseases in Africa: A scoping review

BACKGROUND

31.4 million people in low- and middle-income countries die from chronic diseases annually, particularly in Africa. To address this, strategies such as task-shifting from doctors to nurses have been proposed and have been endorsed by the World Health Organization as a potential solution; however, no comprehensive review exists describing the extent of nurse-led chronic disease management in Africa.

AIMS

This study aimed to provide a thorough description of the current roles of nurses in managing chronic diseases in Africa, identify their levels of knowledge, the challenges, and gaps they encounter in this endeavor.

METHODS

We performed a scoping review following the key points of the Cochrane Handbook, and two researchers independently realized each step. Searches were conducted using five databases: MEDLINE, PyscINFO, CINAHL, Web of Science, and Embase, between October 2021 and April 2023. A descriptive analysis of the included studies was conducted, and the quality of the studies was assessed using the Downs and Black Scale.

RESULTS

Our scoping review included 111 studies from 20 African countries, with South Africa, Nigeria, and Ghana being the most represented. Findings from the included studies revealed varying levels of knowledge. Nurses were found to be actively involved in managing common chronic diseases from diagnosis to treatment. Facilitating factors included comprehensive training, close supervision by physicians, utilization of decision trees, and mentorship. However, several barriers were identified, such as a shortage of nurses, lack of essential materials, and inadequate initial training.

CONCLUSION

There is significant potential for nurses to enhance the screening, diagnosis, and treatment of chronic diseases in Africa. Achieving this requires a combination of rigorous training and effective supervision, supported by robust policies. To address varying levels of knowledge, tailored training programs should be devised. Further research is warranted to establish the effectiveness of nurse-led interventions on population health outcomes.

Human Papillomavirus Types and Cervical Cancer Screening among Female Sex Workers in Cameroon

BACKGROUND

Female sex workers (FSWs) are at high risk for sexually transmitted infections (STIs), including infection with human papillomavirus (HPV) and cervical cancer due to occupational exposure. The objective of this study was to estimate the prevalence of HPV, HPV types, and precancerous lesions of the cervix among FSWs in Cameroon.

MATERIAL AND METHODS

In this cross-sectional study, FSWs in Cameroon aged 30 years and above were screened for cervical cancer using high-risk HPV testing and genotyping and visual inspection with acetic acid and Lugol's iodine (VIA/VILI) enhanced using digital cervicography (DC) simultaneously. Those who were positive for VIA/VILI-DC were provided treatment with thermal ablation (TA) immediately for cryotherapy/TA-eligible lesions while lesions meeting the criteria for large loop excision of the transformation zone (LLETZ) were scheduled at an appropriate facility for the LLETZ procedure. HPV-positive FSWs without any visible lesion on VIA/VILI-DC were administered TA. Bivariate analyses were conducted to compare demographic and clinical characteristics. Crude and adjusted logistic regression models were computed for HPV infection status and treatment uptake as outcomes in separate models and their ORs and 95% confidence intervals (95% CI) were reported.

RESULTS

Among the 599 FSWs aged 30 years and older that were screened for HPV and VIA/VILI-DC, 62.1% (95% CI: (0.58-0.66)) were positive for one or more HPV types. HPV type 51 had the highest prevalence (14%), followed by types 53 (12.4%) and 52 (12.2%). Type 18 had the lowest prevalence of 2.8% followed by type 16 with 5.2%. In the multivariable model, HIV-positive FSWs were 1.65 times more likely to be infected with HPV compared to their HIV-negative counterparts (AOR: 1.65, CI: 1.11-2.45). A total of 9.9% of the 599 FSWs were positive for VIA/VILI-DC.

CONCLUSION

The prevalence of HPV infection among FSWs in Cameroon is higher than the worldwide pooled FSW prevalence. HPV types 51 and 53 were the most prevalent, while types 18 and 16 were the least prevalent. HIV status was the only variable that was significantly associated with infection with HPV.

Training health care providers to administer VIA as a screening test for cervical cancer: a systematic review of essential training components

BACKGROUND

Training health care providers to administer visual inspection after application of acetic acid (VIA) is paramount in improving cervical cancer screening services for women in low- and middle-income countries. The objective of this systematic review was to create a framework of essential VIA training components and provide illustrating examples of how VIA training programs can be carried out in different clinical settings.

METHODS

A systematic review of PubMed, Embase, and Web of Science (from 2006 to 2021) was undertaken. Our inclusion criteria comprised articles reporting on implemented cervical cancer screening programs using VIA in a screen-and-treat approach. Trained health care providers with any level of health education were included, and the outcome of interest was the reporting of training components. Data were extracted by two reviewers, and a narrative synthesis of the training programs was performed. We developed a framework of seven essential training components and applied it to assess how training courses were conducted in different settings.

RESULTS

13 primary studies were eligible for inclusion, including 2,722 trained health care providers and 342,889 screened women. Most training courses lasted 5-7 days and included theoretical education, practical skill development, and competence assessment. It was unclear how visual aids and training in client counselling and quality assessment were integrated in the training courses. After the training course, nearly all the VIA training programs made provisions for on-job training at the providers' own clinical settings through supervision, feedback, and refresher training.

CONCLUSIONS

This study demonstrates the feasibility of implementing international training recommendations for cervical cancer screening in real-world settings and provides valuable examples of training program implementation across various clinical settings. The diverse reporting practices of quality indicators in different studies hinder the establishment of direct links between these data and training program effectiveness. To enhance future reporting, authors should emphasize specific training components, delivery methods, and contextual factors. Standardized reporting of quality indicators for effective evaluation of VIA training programs is recommended, fostering comparability, facilitating research, and enhancing reporting quality in this field.

Disparities in cervical cancer screening programs in Cameroon: a scoping review of facilitators and barriers to implementation and uptake of screening

BACKGROUND

Cervical cancer is the fourth most common cancer worldwide. Organized screening has achieved significant reductions in cervical cancer incidence and mortality in many high-income countries (HICs). But the gap between HICs and low-and-middle-income countries (LMICs) is still substantial as the highest burden of the disease is in LMICs. Cameroon is a LMIC, where cervical cancer is the leading cause of cancer-related deaths among women, only 3-5% of eligible women have been screened and there is no effective national cervical cancer prevention program.

OBJECTIVE(S)

Identify facilitators and barriers to the implementation and uptake of existing cervical cancer screening programs in Cameroon to inform the implementation of a comprehensive national program.

METHODS

We conducted a scoping review using the Preferred Reporting Items for Systematic Reviews and Meta-analysis, extension for Scoping Reviews (PRISMA-ScR). Google Scholar and five electronic databases (PubMed, CINAHL, Embase, Cochrane library and Web of Science) were searched systematically from 2012 to 2022. Articles on cervical cancer screening programs in Cameroon were eligible for inclusion. Two reviewers independently screened search results and extracted relevant data.

RESULTS

A total of 182 articles were identified using our search strategy, and 20 were included. There was scarcity of publications from the North, Adamawa, East and South regions of Cameroon. Barriers and facilitators found were presented using the World Health Organisation framework for health systems. Cross-cutting barriers were: (1) the lack of a national training curriculum for screening providers with no elaborate, harmonized screening and treatment algorithm for cervical precancers; and (2) women's lack of information about cervical cancer screening activities. Conversely, provision of screening services at a low or no cost to women in some programs and the feasibility of using novel point of care screening methods like the Human Papillomavirus DNA test were identified as facilitators.

CONCLUSION

This scoping review indicates that there are knowledge and research gaps concerning the state of cervical cancer screening services in some regions of Cameroon. Moreover, it underlines the need for comprehensive cancer control policies and practices integrating all six-health system building blocks to reduce disparities between regions, and rural versus urban areas in Cameroon.

Results from Two HPV-Based Cervical Cancer Screening-Family Planning Integration Models in Malawi: A Cluster Randomized Trial

We conducted a cluster randomized trial of two models for integrating HPV self-collection into family-planning (FP) services at 16 health facilities in Malawi between March 2020-December 2021. Model 1 involved providing only clinic-based HPV self-collection, whereas Model 2 included both clinic-based and community-based HPV self-collection. An endline household survey was performed in sampled villages and households between October-December 2021 in the catchment areas of the health facilities. We analyzed 7664 surveys from 400 villages. Participants from Model 2 areas were more likely to have ever undergone cervical cancer screening (CCS) than participants from Model 1 areas, after adjusting for district, facility location (urban versus rural), and facility size (hospital versus health center) (adjusted odds ratio = 1.73; 95% CI: 1.29, 2.33). Among participants who had ever undergone CCS, participants from Model 2 were more likely to report having undergone HPV self-collection than participants from Model 1 (50.5% versus 22.8%, p = 0.023). Participants from Model 2 were more likely to be using modern FP (adjusted odds ratio = 1.01; 95% CI: 1.41, 1.98) than Model 1 participants. The integration of FP and HPV self-collection in both the clinic and community increases CCS and modern FP uptake more than integration at the clinic-level alone.

Development, Implementation, and Evaluation of a Distance Learning and Telementoring Program for Cervical Cancer Prevention in Cameroon

IMPORTANCE

Although Africa has the highest burden of cervical cancer in the world, educational resources to achieve the 90-70-90 targets set by the World Health Organization in its strategy to eliminate cervical cancer are lacking in the region.

OBJECTIVES

To adapt, implement, and evaluate the Project Extension for Community Health Care Outcomes (ECHO), an innovative learning tool, to build capacity of clinicians to better incorporate new evidence-based guidelines into cervical cancer control policies and clinical practices.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study assessed knowledge and practices of clinicians and support staff regarding cervical cancer prevention and control and compared them among respondents who had attended Project ECHO sessions (prior ECHO attendees) with those who had not but were planning on attending in the near future (newcomers) as part of the Cameroon Cervical Cancer Prevention Project ECHO. Satisfaction of prior ECHO attendees was also evaluated. Data were analyzed from January to March 2022.

MAIN OUTCOMES AND MEASURES

Main outcomes were practices and knowledge regarding cervical cancer education and prevention and preinvasive management procedures compared among prior ECHO attendees and newcomers.

RESULTS

Of the 75 participants (mean [SD] age, 36.4 [10.0] years; 65.7% [95% CI, 54.3%-77.1%] women) enrolled in this study, 41 (54.7%; 95% CI, 43.1%-66.2%) were prior ECHO attendees, and most were clinicians (55 respondents [78.6%; 95% CI, 68.7%-88.4%]). Overall, 50% (95% CI, 37.8%-62.2%) of respondents reported performing cervical cancer screening with visual inspection of the cervix after application of acetic acid (VIA) and/or visual inspection of the cervix after application of Lugol's iodine (VILI), 46.3% (95% CI, 34.0%-58.5%) of respondents reported performing human papillomavirus (HPV) testing, and 30.3% (95% CI, 18.9%-41.7%) of respondents reported performing cervical cytological examination in their practices, Approximately one-fourth of respondents reported performing cryotherapy (25.4% [95% CI, 14.7%-36.1%]), thermal ablation (27.3% [95% CI, 16.2%-38.3%]) or loop electrosurgical excisional procedure (LEEP, 25.0% [95% CI, 14.4%-35.6%]) for treatment of preinvasive disease. The clinical use of many of these screening and treatment tools was significantly higher among prior ECHO attendees compared with newcomers (VIA/VILI: 63.2% [95% CI, 47.4%-78.9%] vs 33.3% [95% CI, 16.0%-50.6%]; P = .03; cryotherapy: 40.5% [95% CI, 24.3%-56.8%] vs 6.7% [95% CI, 0.0%-15.8%]; P = .002; thermal ablation: 43.2% [95% CI, 26.9%-59.6%] vs 6.9% [95% CI, 0.0%-16.4%]; P = .002). Knowledge about cervical cancer education, prevention, and management procedures was satisfactory in 36.1% (95% CI, 23.7%-48.5%) of respondents; this proportion was significantly higher among prior ECHO attendees (53.8% [95% CI, 37.7%-69.9%]) compared with newcomers (4.5% [95% CI, 0.0%-13.5%]; P < .001). Approximately two-thirds of participants (68.8% [95% CI, 51.8%-85.8%]) reported that they had applied knowledge learned in our ECHO sessions to patient care in their practice or adopted best-practice care through their participation in this ECHO program.

CONCLUSIONS AND RELEVANCE

These findings suggest that the Project ECHO e-learning and telementoring program was associated with improved skills for clinicians and support staff and enhanced quality of care for patients. In the COVID-19 era and beyond, reinforced efforts to strengthen cervical cancer knowledge and best practices through distance learning and collaboration are needed.

"When You Have Gotten Help, That Means You Were Strong": A Qualitative Study of Experiences in a "Screen and Treat" Program for Cervical Cancer Prevention in Malawi

Disproportionate cervical cancer burden falls on women in low-income countries, and there are new efforts to scale up prevention worldwide, including via "screen and treat" for detection and removal of abnormal cervical lesions. This study examines Malawian women's experiences with "screen and treat"; this is an under-explored topic in the literature, which has focused largely on knowledge about and attitudes toward screening, but not on experiences with screening. We interviewed 47 women who have been screened at least once for cervical cancer. The interview guide and analysis approach were informed by the Multi-Level Health Outcomes Framework. Women were recruited at facilities that offer "screen and treat" and asked about their experiences with screening. The average age of respondents was 40 years, and approximately half were HIV-negative. Although women were knowledgeable about the benefits of screening, they articulated many barriers including being turned away because of stock-outs of equipment, far distances to services, discomfort with male providers, and poor communication with providers. Alongside the many health education campaigns to increase awareness and demand for "screen and treat" services, the global public health community must also address implementation barriers in the resource-constrained health systems where burden is greatest. Particular attention should be paid to quality and person-centeredness of "screen and treat" services to optimize uptake and engagement in care.

Association of HIV status and treatment characteristics with VIA screening outcomes in Malawi: A retrospective analysis

Background

Although evidence from high-resource settings indicates that women with HIV are at higher risk of acquiring high-risk HPV and developing cervical cancer, data from cervical cancer “screen and treat” programs using visual inspection with acetic acid (VIA) in lower-income countries have found mixed evidence about the association between HIV status and screening outcomes. Moreover, there is limited evidence regarding the effect of HIV-related characteristics (e.g., viral suppression, treatment factors) on screening outcomes in these high HIV burden settings.

Methods

This study aimed to evaluate the relationship between HIV status, HIV treatment, and viral suppression with cervical cancer screening outcomes. Data from a “screen and treat” program based at a large, free antiretroviral therapy (ART) clinic in Lilongwe, Malawi was retrospectively analyzed to determine rates of abnormal VIA results and suspected cancer, and coverage of same-day treatment. Multivariate logistic regression assessed associations between screening outcomes and HIV status, and among women living with HIV, viremia, ART treatment duration and BMI.

Results

Of 1405 women receiving first-time VIA screening between 2017–2019, 13 (0.9%) had suspected cancer and 68 (4.8%) had pre-cancerous lesions, of whom 50 (73.5%) received same-day lesion treatment. There was no significant association found between HIV status and screening outcomes. Among HIV+ women, abnormal VIA was positively associated with viral load ≥ 1000 copies/mL (aOR 3.02, 95% CI: 1.22, 7.49) and negatively associated with ART treatment duration (aOR 0.88 per additional year, 95% CI: 0.80, 0.98).

Conclusion

In this population of women living with HIV with high rates of ART coverage and viral suppression, HIV status was not significantly associated with abnormal cervical cancer screening results. We hypothesize that ART treatment and viral suppression may mitigate the elevated risk of cervical cancer for women living with HIV, and we encourage further study on this relationship in high HIV burden settings.

Financing of surgery and anaesthesia in sub-Saharan Africa: a scoping review

OBJECTIVE

This study aimed to provide an overview of current knowledge and situational analysis of financing of surgery and anaesthesia across sub-Saharan Africa (SSA).

SETTING

Surgical and anaesthesia services across all levels of care-primary, secondary and tertiary.

DESIGN

We performed a scoping review of scientific databases (PubMed, EMBASE, Global Health and African Index Medicus), grey literature and websites of development organisations. Screening and data extraction were conducted by two independent reviewers and abstracted data were summarised using thematic narrative synthesis per the financing domains: mobilisation, pooling and purchasing.

RESULTS

The search resulted in 5533 unique articles among which 149 met the inclusion criteria: 132 were related to mobilisation, 17 to pooling and 5 to purchasing. Neglect of surgery in national health priorities is widespread in SSA, and no report was found on national level surgical expenditures or budgetary allocations. Financial protection mechanisms are weak or non-existent; poor patients often forego care or face financial catastrophes in seeking care, even in the context of universal public financing (free care) initiatives.

CONCLUSION

Financing of surgical and anaesthesia care in SSA is as poor as it is underinvestigated, calling for increased national prioritisation and tracking of surgical funding. Improving availability, accessibility and affordability of surgical and anaesthesia care require comprehensive and inclusive policy formulations.

Cervical cancer screening prevalence and its correlates in Cameroon: secondary data analysis of the 2018 demographic and health surveys

Background

Cervical cancer, although preventable, is the fourth most common cancer among women globally, and the second most common and deadliest gynaecological cancer in low-and-middle-income countries. Screening is key to the prevention and early detection of the disease for treatment. A few studies estimated the prevalence of cervical cancer screening and its correlates in Cameroon but relied on data that were limited to certain regions of the country. Therefore, this study sought to examine the prevalence and correlates of cervical cancer screening among Cameroonian women using current data that is nationally representative of reproductive-age women.

Methods

We used secondary data from the 2018 Cameroon Demographic and Health Survey. Summary statistics were used for the sample description. We employed the Firth logistic regression using the “firthlogit” command in STATA-14 to perform the bivariate analyses between the outcome variable and each of the explanatory variables. Given that all the explanatory variables were statistically significant correlates, they were all adjusted for in a multivariable analysis. All analyses were performed in STATA version 14.

Results

The proportion of Cameroonian women who have ever screened for cervical cancer continue to remain low at approximately 4%. In the adjusted model, women with the following sociodemographic characteristics have a higher likelihood of undergoing cervical cancer screening: ever undergone HIV screening (AOR = 4.446, 95% CI: 2.475, 7.986), being 24–34 years (AOR = 2.233, 95% CI: 1.606, 3.103) or 35–44 years (AOR = 4.008, 95% CI: 2.840, 5.657) or at least 45 years old (AOR = 5.895, 95% CI: 3.957, 8.784), having attained a post-secondary education (AOR = 1.849, 95% CI: 1.032, 3.315), currently (AOR = 1.551, 95% CI: 1.177, 2.043) or previously married (AOR = 1.572, 95% CI: 1.073, 2.302), dwelling in the richest household (AOR = 4.139, 95% CI: 1.769, 9.682), and residing in an urban area (AOR = 1.403, 95% CI: 1.004,1.960). Except for the North-West region, residing in some five regions, compared to Yaounde, was negatively associated with cervical cancer screening.

Conclusion

Cervical cancer screening programs and policies should target Cameroonian women who are younger, less educated, and those in poor households and rural areas.

Health care workers' experiences with implementation of "screen and treat" for cervical cancer prevention in Malawi: A qualitative study

BACKGROUND

Cervical cancer remains a major cause of mortality and morbidity in low- and middle-income countries, despite the availability of effective prevention approaches. "Screen and treat" (a single-visit strategy to identify and remove abnormal cervical cells) is the recommended secondary prevention approach in low-resource settings, but there has been relatively scarce robust implementation science evidence on barriers and facilitators to providing "screen and treat" from the provider perspective, or about thermocoagulation as a lesion removal technique.

METHODS

Informed by the Consolidated Framework for Implementation Research (CFIR), we conducted interviews with ten experienced "screen and treat" providers in Malawi. We asked questions based on the CFIR Guide, used the CFIR Guide codebook for a descriptive analysis in NVivo, and added recommended modifications for studies in low-income settings.

RESULTS

Seven CFIR constructs were identified as positively influencing implementation, and six as negatively influencing implementation. The two strong positive influences were the relative advantage of thermocoagulation versus cryotherapy (Innovation Characteristics) and respondents' knowledge and beliefs about providing "screen and treat" (Individual Characteristics). The two strong negative influences were the availability of ongoing refresher trainings to stay up-to-date on skills (Inner Setting, Implementation Climate) and insufficient resources (staffing, infrastructure, supplies) to provide "screen and treat" to all women who need it (Inner Setting, Readiness for Implementation). Weak positive factors included perceived scalability and access to knowledge/information, as well as compatibility, leadership engagement, and team characteristics, but these latter three were mixed in valence. Weak negative influences were structural characteristics and donor priorities; and mixed but weakly negative influences were relative priority and engaging clients. Cross-cutting themes included the importance of broad buy-in (including different cadres of health workers and leadership at the facility and in the government) and the opportunities and challenges of offering integrated care (screening plus other services).

CONCLUSIONS

Although "screen and treat" is viewed as effective and important, many implementation barriers remain. Our findings suggest that implementation strategies will need to be multi-level, include a diverse set of stakeholders, and explicitly address both screening and treatment.

Characterization and analysis of the basic elements of health payment mechanisms and their most frequent types

Introduction Healthcare systems are developed in imperfect scenarios, in which there are constant failures (uncertainty, information asymmetry, agency relationship problem, and supply-induced demand). These failures, based on the imperfection of the sector, determine the relationships and incentives between the actors. It is within this context that payment mechanisms regulate aspects of the system behavior and incentives, acting as instruments for the purchasing of health care from providers, mediated by health insurance on behalf of users. Objective To characterize the basic elements of most frequent payment mechanisms to help providers in their relationship with payers. Methods A review of the evidence was conducted in PubMed, Google, Google Scholar, and strategic snowball selection. Payment mechanisms consist of three classical microeconomics variables, fixed or variable: price, quantity, and expense. Time dimensions are used to analyze their attributes and effects. Different mechanisms emerge from the combination of these variables. Results Among the most used are: Fee-For-Service, Global Budget, Bundled Payments, Diagnosis-Related Groups, Per-capita, Performance Pay, and Risk-Sharing Agreements. A fourth has also gained importance: Financial Risk. Conclusions Payment mechanisms are essential to link health efforts with clinical practice. They make it possible to regulate relationships between insurers, providers, and users, which, depending on the architecture of the mechanism, can become beneficial or hinder the fulfillment of the objectives of the health system.

<p>Factors Associated with Treatment Uptake Among Women with Acetic Acid/Lugol’s Iodine Positive Lesions of the Cervix in Cameroon</p>

Purpose

Treatment of cervical precancer is the primary aim in secondary prevention of cervical cancer. The purpose of this study was to examine factors associated with treatment uptake among women with acetic acid/Lugol’s iodine positive lesions identified by digital cervicography (DC) in a cervical cancer prevention program in Cameroon.

Patients and Methods

We conducted a cross-sectional survey of medical records from 2013 to 2018 of 755 women in Cameroon who screened positive with acetic acid/Lugol’s iodine in 2013.

Results

Of the 755 women, 422 (55.9%) had treatment/biopsy on the same day or followed up later, but only 344 (45.6%) received treatment/biopsy and 333 (44.1%) were lost to follow-up. Overall, 180 (52.3%) of the 344 women were treated/biopsied the same day they were screened, and 164 (47.7%) were treated/biopsied after the initial visit. Women aged 30–49 and HIV-positive women were significantly more likely to have received treatment or returned for treatment than women less than 30 and HIV-negative women. Of the 266 women who followed up at a later date, the lesions of 78 (29.3%) women regressed spontaneously without treatment. Women with low-grade lesions, HIV-negative women and women who had follow-up more than a year after the initial exam were significantly more likely to have spontaneous regression with regression rates of 30.6%, 32.1% and 62.2%, respectively (p<0.001). Age was not a significant determinant of spontaneous regression (p=0.149).

Conclusion

Efforts to increase treatment uptake are needed in this population, including adherence to same day “See and treat” policies.

HIV Status and Contraceptive Utilization among Women in Cameroon

Objective:

We examined patterns of contraceptive utilization by HIV status among women in Cameroon, hypothesizing that women living with HIV would utilize contraception at higher rates than their HIV-negative peers.

Methods:

Deidentified, clinical data from the Cameroon Baptist Convention Health Services (2007-2013) were analyzed (N = 8995). Frequencies compared outcomes between women living with HIV (15.1%) and uninfected women. Multivariate analyses examined associates of contraceptive utilization and desire to become pregnant.

Results:

Contraceptive utilization was associated with higher education, living with HIV, monogamy, and higher parity (P < .001). Women living with HIV had 66% higher odds of using contraceptives than their negative peers (odds ratio [OR]: 1.66, confidence interval [CI]: 1.45-1.91, P < .001). Polygamous women had 37% lower odds of using contraceptives compared to monogamous women (OR: 0.63, 95% CI: 0.52-0.75, P < .001).

Conclusion:

Increasing contraceptive utilization in resource-constrained settings should be a priority for clinicians and researchers. Doing so could improve population health by reducing HIV transmission between partners and from mother to child.

Evaluating the Effectiveness of Interventions on Increasing Participation in Cervical Cancer Screening

Background:

Although cervical cancer is highly preventable through regular screenings using Pap smear or human papillomavirus–deoxyribonucleic acid tests, cervical cancer remains a prevalent women's health issue across the world. Therefore, encouraging women to screen for cervical cancer is very important for the early detection of cervical cancer.

Purpose:

The purposes of this study were to (1) assess the effectiveness of three interventions that are typically used to increase the uptake of cervical cancer screening during home visits and (2) determine the participation rate in cervical cancer screenings after invitation, the health promotion perceptions, and the cervical cancer and screening-related knowledge of women. The three interventions noted in Purpose 1 were one-on-one training accompanied by an educational brochure, providing the educational brochure only, and giving an invitation without any relevant information.

Methods:

This interventional study was conducted on women who were between the ages of 30 and 65 years in three Turkish provinces (Ankara, Malatya, and Trabzon). Five hundred twenty home visits were made, and 356 women who did not have a Pap smear test within the previous year were invited for cervical cancer screening. Women were randomized into one of three intervention groups, and the participants in each group were invited to attend a national cervical cancer screening program and to undergo a cervical cancer screening using the related intervention type.

Results:

The results showed that the interventions used during home visits and knowledge were effective in encouraging women to participate in cervical cancer screening. It was determined that the participants who had received one-on-one training accompanied by an educational brochure had a higher cervical cancer screening rate than their peers who were offered a brochure only or a verbal invitation only.

Conclusions:

Invitations to screenings that are made by providing training accompanied with a brochure were found to be effective in increasing the participation of women in cervical cancer screening.

Evaluation of portable colposcopy and human papillomavirus testing for screening of cervical cancer in rural China

OBJECTIVE

To evaluate the use of a portable, rechargeable colposcope combined with human papillomavirus (HPV) testing, as compared with HPV testing alone, for screening of cervical cancer and pre-cancerous lesions.

METHODS

This was a cross-sectional study among 488 women in Baoshan County, Yunnan. The women underwent HPV testing followed by Gynocular portable colposcopy with visual inspection with acetic acid. Obvious lesions were biopsied. If portable colposcopy testing was negative but HPV testing was positive, the women underwent follow-up testing with thin-prep cytology and traditional colposcopy. Cervical biopsies were performed for any abnormalities. Histopathology was followed up with diagnosis and treatment.

RESULTS

Among 488 women screened with portable colposcopy, 24 women underwent biopsy based on positive colposcopy screening. Of these 24 women, three were HPV positive and 21 were HPV negative. Five women had cervical intra-epithelial neoplasia (CIN) I and one had advanced cervical cancer. Forty-six women tested positive for HPV. Three of these women had screened positive on preliminary colposcopy, with one positive for CIN III/squamous cell carcinoma and one woman with CIN I. Forty-three women underwent follow-up testing with thin-prep cytology. Two women had atypical squamous cells of undetermined significance and five had low-grade squamous intra-epithelial lesions and were biopsied; three women had CIN I, one had CIN II and one had CIN III. HPV testing and portable colposcopy was more sensitive but slightly less specific than portable colposcopy or HPV testing alone.

CONCLUSION

While HPV testing has high sensitivity and specificity for the detection of pre-cancerous and cancerous lesions and portable colposcopy has lower specificity, both methods of detection have low positive predictive value and high negative predictive value. In tandem, HPV testing and portable colposcopy had higher sensitivity for detection among women who underwent biopsies. In clinical practice, portable colposcopy was an effective, easy and affordable tool to transport to villages where cytology is not currently feasible.

Impact of antiviral AV2 in the topical treatment of HPV-associated lesions of the cervix: Results of a phase III randomized placebo-controlled trial

Background

Non-surgical topical therapies have been assessed in the treatment of precancerous lesions of the cervix. Their use can offer logistical and feasibility advantages in low-resource settings. Antiviral AV2^® is a mixture of natural essential oils (eugenol, carvone, nerolidol, geraniol) in olive oil, and has a broad spectrum anti-viral activity. In a phase II randomized controlled trial (RCT), AV2^® proved effective in reducing the size of cervical lesions associated with human papillomavirus (HPV). The purpose of the present study was to further evaluate the efficacy of AV2 over placebo in the topical treatment of HPV-associated cervical lesions.

Methods

Women aged 25 years and older were included in this phase 3 RCT. Cytology screening, HPV testing and visual inspection of the cervix with 5% acetic acid (VIA) were performed on all participants. VIA-positive women were randomized to one of two groups to receive treatment by either AV2® or placebo. The treatment consisted of 2 puffs of spray of the investigational drug directed to the cervix. Participants were subjected to repeat examinations two months and six months later for assessment of outcomes. The primary outcome was the change of lesions on VIA at 2 months after application of the investigational drug. Secondary outcomes were: HPV clearance and cytologic regression at 2 months and 6 months, and number of participants with AEs.

Results

A total 327 VIA positive women were randomized in two groups (168 in AV2 group and 159 in placebo group). Women in the 2 groups were similar with respect to baseline demographics and clinical characteristics. At 2 months, regression of lesions on VIA was observed in 127 (89.4%) out of 142 women in AV2 group compared to 120 (91.6%) out of 131 women in placebo group (P = 0.7). On cytology, regression of lesions occurred in 14 (56%) out of 25 women in the AV2 arm and in 13 (48.1) out of 27 women in the placebo arm (p = 0.7), and HPV clearance rates were 34.1% and 35% in AV2 group and placebo group respectively (p = 0.8). At 6 months cytologic regression was observed in 64.7% of women in AV2 group and 45.8% in placebo group (p = 0.2), while HPV clearance occurred in 11 (51.9%) out of 17 women in AV2 arm versus 11 (34.4%) in placebo arm (p = 0.3).

Some local side effects (burning, itching, irritation) were similarly noted in the 2 groups (p-values = 0.169, 0.623 and 0.172 respectively) but they were mild and transitory.

Conclusion

A topical application of AV2 onto the cervix can induce the regression of cervical precancerous lesions, but its efficacy does not significantly differ with that of placebo. The discrepancy between the expected and the recorded sample size as well as the huge number of lost to follow-up probably impeded the power of analyses, which could be one of the reasons for the lack of difference seen between AV2 and placebo. Further evaluation of the effects of AV2 with different diagnostic methods and treatment regimen and arms is warranted.

Clinical trial registration

NCT02346227 registered on November 8, 2014;

Secular trend in interobserver agreement of VIA diagnosis for cervical cancer screening in Nigeria

OBJECTIVE

In low resource settings, visual inspection with acetic acid (VIA) by allied health workers, has been suggested as an alternative for cervical cancer screening. However, there are concerns about the objectivity and time to diagnostic concordance with specialists. We evaluated the secular trend in interobserver agreement between nurse providers and a gynecologist/colposcopist over a five-year period.

METHODS

Nurses provided VIA screening with digital cervivography to 4,961 participants in five screening clinics from October 2010 to May 2014 in Nigeria in this observational study. Cervigraphs were reviewed at meetings where a gynaecologist/colposcopist made an assessment from the cervigraphs. We used weighted kappa statistics to calculate agreement in diagnosis between nurse providers and the gynecologist/colposcopist; linear regression models to examine overall trend and investigate potential clinic characteristics that may influence agreement; and time series models to characterize month to month variations.

RESULTS

Mean age of participants was 37±8 years. Overall agreement was 0.89 at Site D, 0.78 and 0.73 at Sites A and C respectively, 0.50 for Site E and 0.34 for Site C. The number of trainings attended by nurse providers(β = 0.47,95%CI:0.02-0.93, p = 0.04), high level of engagement by site gynecologists(β = 0.11,95%CI:0.01-0.21,p = 0.04) were associated with increased agreement; while increasing distance from the coordinating site(β = -0.47,95%CI:-0.92-0.02,p = 0.04) was associated with decreased agreement. There were no associations between number of years screening clinics were operational(β = 0.01,95%CI: -0.01-0.03,p = 0.29), cumulative experience of nurse providers(β = 0.04,95%CI:-0.03-0.12,p = 0.19) and agreement. There were no significant increases in weighted kappa statistics over time for all sites considered. Monthly variations were significant for only one of two sites considered in time series models (AR1 term = -0.40, 95%CI:-0.71-0.09,p = 0.01).

CONCLUSION

Our results showed a lack of objectivity, persistent variation and lack of convergence of diagnostic capabilities of nurse led VIA cervical cancer screening with the diagnostic capabilities of a specialist in a cervical cancer screening program in Nigeria.

Implementation strategies to improve cervical cancer prevention in sub-Saharan Africa: a systematic review

Background

Developed countries, such as the USA, have achieved significant decreases in cervical cancer burden since the introduction of Pap smear-based programs in the 1960s. Due to implementation barriers and limited resources, many countries in sub-Saharan Africa (SSA) have been unable to attain such reductions. The purpose of this review is to evaluate implementation strategies used to improve the uptake and sustainability of cervical cancer prevention programs in SSA.

Methods

A reviewer (LJ) independently searched PubMed, Ovid/MEDLINE, Scopus, and Web of Science databases for relevant articles with the following search limits: English language, peer reviewed, and published between 1996 and 2017. The 4575 search results were screened for eligibility (CJ, LJ) to identify original research that empirically evaluated or tested implementation strategies to improve cervical cancer prevention in SSA. Fifty-three articles met criteria for inclusion in the final review. AA, CJ, and LJ abstracted the included articles for implementation-related content and evaluated them for risk of bias according to study design with the National Heart, Lung, and Blood Institute’s (NHLBI) Quality Assessment Tools. Results were reported according to PRISMA guidelines.

Results

The 53 included studies are well represented among all sub-Saharan regions: South (n = 16, 30.2%), West (n = 16, 30.2%), East (n = 14, 26.4%), and Middle (n = 7, 13.2%). There are 34 cross-sectional studies (64.2%), 10 pre-posttests (18.9%), 8 randomized control trials (15.1%), and one nonrandomized control trial (1.9%). Most studies are “fair” quality (n = 22, 41.5%). Visual inspection with acetic acid (VIA) (n = 19, 35.8%) was used as the main prevention method more frequently than HPV DNA/mRNA testing (n = 15, 28.3%), Pap smear (n = 13, 24.5%), and HPV vaccine (n = 9, 17.0%). Effectiveness of strategies to improve program implementation was measured using implementation outcomes of penetration (n = 33, 62.3%), acceptability (n = 15, 28.3%), fidelity (n = 14, 26.4%), feasibility (n = 8, 15.1%), adoption (n = 6, 11.3%), sustainability (n = 2, 3.8%), and cost (n = 1, 1.9%). Education strategies (n = 38, 71.7%) were used most often but have shown limited effectiveness.

Conclusion

This systematic review highlights the need to diversify strategies that are used to improve implementation for cervical cancer prevention programs. While education is important, implementation science literature reveals that education is not as effective in generating change. There is a need for additional organizational support to further incentivize and sustain improvements in implementation.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0718-9) contains supplementary material, which is available to authorized users.

Screening for cervical cancer among HIV-positive and HIV-negative women in Cameroon using simultaneous co-testing with careHPV DNA testing and visual inspection enhanced by digital cervicography: Findings of initial screening and one-year follow-up

OBJECTIVE

The World Health Organization (WHO)'s cervical cancer screening guidelines for limited-resource settings recommend sequential screening followed by same-day treatment under a "screen-and-treat" approach. We aimed to (1) assess feasibility and clinical outcomes of screening HIV-positive and HIV-negative Cameroonian women by pairing visual inspection with acetic acid and Lugol's iodine enhanced by digital cervicography (VIA/VILI-DC) with careHPV, a high-risk human papillomavirus (HR-HPV) nucleic acid test designed for low-resource settings; and (2) determine persistence of HR-HPV infection after one-year follow-up to inform optimal screening, treatment, and follow-up algorithms.

METHODS

We co-tested 913 previously unscreened women aged ≥30years and applied WHO-recommended treatment for all VIA/VILI-DC-positive women. Baseline prevalence of HR-HPV and HIV were 24% and 42%, respectively.

RESULTS

On initial screen, 44 (5%) women were VIA/VILI-DC-positive, of whom 22 had HR-HPV infection, indicating 50% of women screened false-positive and would have been triaged for unnecessary same-day treatment. VIA/VILI-DC-positive women with HIV infection were three times more likely to be HR-HPV-positive than HIV-negative women (65% vs. 20%). All women positive for either VIA/VILI-DC or HR-HPV (n=245) were invited for repeat co-testing after one year, of which 136 (56%) returned for follow-up. Of 122 women who were HR-HPV-positive on initial screen, 60 (49%) re-tested negative, of whom 6 had received treatment after initial screen, indicating that 44% of initially HR-HPV-positive women spontaneously cleared infection after one year without treatment. Women with HIV were more likely to remain HR-HPV-positive on follow-up than HIV-negative women (61% vs. 22%, p<0.001). Treatment was offered to all VIA/VILI-DC positive women on initial screen, and to all women screening VIA/VILI-DC or HR-HPV positive on follow-up.

CONCLUSIONS

We found careHPV co-testing with VIA/VILI-DC to be feasible and valuable in identifying false-positives, but careHPV screening-to-result time was too long to inform same-day treatment.