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Basu P, Mwanahamuntu M, Pinder LF, Muwonge R, Lucas E, Nyambe N, Chisele S, Shibemba AL, Sauvaget C, Sankaranarayanan R, Prendiville W, Parham GP. A portable thermal ablation device for cervical cancer prevention in a screen-and-treat setting: a randomized, noninferiority trial. Nat Med 2024; 30:2596-2604. [PMID: 38918630 PMCID: PMC11405263 DOI: 10.1038/s41591-024-03080-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 05/17/2024] [Indexed: 06/27/2024]
Abstract
Implementing standard-of-care cryotherapy or electrosurgical excision to treat cervical precancers is challenging in resource-limited settings. An affordable technological alternative that is as effective as standard-of-care techniques would greatly improve access to treatment. This randomized controlled trial aims to demonstrate the noninferiority efficacy of a portable, battery-driven thermal ablation (TA) device compared to cryotherapy and electrosurgical excision (large loop excision of transformation zone (LLETZ)) to treat cervical precancer in a screen-and-treat program in Zambia. A total of 3,124 women positive on visual inspection with acetic acid and eligible for ablative therapy were randomized to one of the treatment arms. Human papillomavirus (HPV) testing was performed at baseline and at the follow-up. The primary outcome was treatment success, defined as either type-specific HPV clearance at the follow-up in participants positive for HPV at baseline, or a negative visual inspection with acetic acid test for those who had a negative HPV test at baseline. After a median follow-up of 12 months, treatment success rates were 74.0%, 71.1% and 71.4% for the TA, cryotherapy and LLETZ arms, respectively, thus demonstrating noninferiority (P = 0.83). TA was a safe and well-accepted procedure. Only 3.6% of those randomized to TA reported moderate-to-severe pain, compared to 6.5% and 1.9% for the cryotherapy and LLETZ arms, respectively. Thus, our randomized controlled trial demonstrates the safety and efficacy of TA, which is not inferior to cryotherapy or surgical excision.ClinicalTrials.gov registration: NCT02956239 .
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Affiliation(s)
- Partha Basu
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France.
| | - Mulindi Mwanahamuntu
- Department of Obstetrics and Gynecology, University Teaching Hospital, Lusaka, Zambia
| | - Leeya F Pinder
- Department of Obstetrics and Gynecology, University Teaching Hospital, Lusaka, Zambia
| | - Richard Muwonge
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Eric Lucas
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Namakau Nyambe
- Department of Obstetrics and Gynecology, University Teaching Hospital, Lusaka, Zambia
| | - Samson Chisele
- Department of Obstetrics and Gynecology, University Teaching Hospital, Lusaka, Zambia
| | | | - Catherine Sauvaget
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France
| | | | - Walter Prendiville
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Groesbeck P Parham
- Department of Obstetrics and Gynecology, University Teaching Hospital, Lusaka, Zambia
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2
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Mengesha MB, Chekole TT, Hidru HD. Uptake and barriers to cervical cancer screening among human immunodeficiency virus-positive women in Sub Saharan Africa: a systematic review and meta-analysis. BMC Womens Health 2023; 23:338. [PMID: 37370091 DOI: 10.1186/s12905-023-02479-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Cervical cancer is the leading cause of disability and mortality among women in Africa. Despite a significant correlation between HIV/AIDS and cervical cancer, there is unacceptably low coverage of the uptake of cervical cancer screening among human immunodeficiency virus-positive women in Sub-Saharan Africa. Individual primary studies are limited in explaining the patterns of uptake of cervical cancer screening. This review therefore considers the uptake of cervical cancer screening and its barriers among human immunodeficiency virus-positive women in Sub-Saharan Africa. METHODS We systematically searched articles published until December 31, 2019, from the PubMed, Cochrane Library, POP LINE, Google Scholar, African Journals Online and JURN databases. The quality of the included articles was assessed by using the Newcastle‒Ottawa Scale, and the coverage of uptake of cervical cancer screening was pooled after checking for heterogeneity and publication bias. The random effect model was used, and subgroup analysis estimates were performed by country. RESULTS Twenty-one studies comprising 20,672 human immunodeficiency virus-positive women were included. Applying a random effect model, the overall cervical cancer screening uptake among this group of women in Sub-Saharan Africa was estimated to be 30% (95% CI: 19, 41, I2 = 100%). The main barriers to uptake of cervical screening include poor knowledge about cervical cancer and screening, low risk perception of cervical cancer, fear of test result and fear of screening as painful, lack of access to screening services, high cost of screening service, and poor partner attitude and acceptance of the service. The perception of an additional burden of having a cervical cancer diagnosis was found to be a unique barrier among this population of women. CONCLUSION The unacceptably low coverage of uptake of cervical cancer screening would indicate that the need to scale up the opportunities to these groups of women as well. This review revealed that in addition to structural and health care system barriers, sociocultural and personal barriers are powerful barriers in HIV-positive women. For these cohorts of population, a particular obstacle was discovered to be perception of an additional burden of having cervical cancer.
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Affiliation(s)
- Meresa Berwo Mengesha
- Department of Midwifery, College of Medicine and Health Science, Adigrat University, Adigrat, Tigray, Ethiopia.
| | | | - Hagos Degefa Hidru
- Department of Public Health, College of Medicine and Health Science, Adigrat University, Adigrat, Tigray, Ethiopia
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Mulongo M, Chibwesha CJ. Prevention of Cervical Cancer in Low-Resource African Settings. Obstet Gynecol Clin North Am 2022; 49:771-781. [PMID: 36328679 DOI: 10.1016/j.ogc.2022.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cervical cancer is a leading cause of cancer among women. Approximately 350,000 women die from cervical needlessly from cancer each year, and 85% of the global burden occurs in low- and middle-income countries (LMICs). Disparities in the incidence and mortality between LMICs and industrialized countries can be attributed to differences in access to human papillomavirus (HPV) vaccination and cervical cancer screening and treatment. The World Health Organization (WHO) is leading a renewed international effort to reduce the global burden of cervical cancer. In this article, we discuss recommendations for HPV vaccination, primary HPV screening, and treatment of precancerous lesions.
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Mumba JM, Kasonka L, Owiti OB, Andrew J, Lubeya MK, Lukama L, Kasempa C, Msadabwe SC, Kalinda C. Cervical cancer diagnosis and treatment delays in the developing world: Evidence from a hospital-based study in Zambia. Gynecol Oncol Rep 2021; 37:100784. [PMID: 34095422 PMCID: PMC8165546 DOI: 10.1016/j.gore.2021.100784] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/18/2021] [Accepted: 04/30/2021] [Indexed: 01/07/2023] Open
Abstract
Expedited diagnostic processes for all suspected cervical cancer cases remain essential in the effort to improve clinical outcomes of the disease. However, in some developing countries like Zambia, there is paucity of data that assesses factors influencing diagnostic and treatment turnaround time (TAT) and other metrics vital for quality cancer care. We conducted a retrospective hospital-based study at the Cancer Diseases Hospital (CDH) for cervical cancer cases presenting to the facility between January 2014 and December 2018. Descriptive statistics were used to summarize demographic characteristics while a generalized linear model of the negative binomial was used to assess determinants of overall TAT. Our study included 2121 patient case files. The median age was 49 years (IQR: ±17) and most patients (n = 634, 31%) were aged between 41 and 50 years. The International Federation of Gynaecology and Obstetrics (FIGO) Cancer stage II (n = 941, 48%) was the most prevalent while stage IV (n = 103, 5.2%) was the least. The average diagnostic TAT in public laboratories was 1.48 (95%CI: 1.21-1.81) times longer than in private laboratories. Furthermore, referral delay was 55 days (IQR: 24-152) and the overall TAT (oTAT) was 110 days (IQR: 62-204). The age of the patient, HIV status, stage of cancer and histological subtype did not influence oTAT while marital status influenced oTAT. The observed longer oTAT may increase irreversible adverse health outcomes among cervical cancer patients. There is a need to improve cancer care in Zambia through improved health expenditure especially in public health facilities.
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Affiliation(s)
- Jane Mwamba Mumba
- The University of Zambia, School of Medicine, Department of Obstetrics and Gynaecology, Nationalist Road, P/Box RWX1 50110, Ridgeway, Lusaka, Zambia
- Ndola Teaching Hospital, Department of Obstetrics and Gynaecology, Broadway Road, Postal Agency Ndola, Ndola, Zambia
| | - Lackson Kasonka
- The University of Zambia, School of Medicine, Department of Obstetrics and Gynaecology, Nationalist Road, P/Box RWX1 50110, Ridgeway, Lusaka, Zambia
- Women and Newborn Hospital-University Teaching Hospitals, Nationalist Road, P/Bag RWX1 Ridgeway, Lusaka, Zambia
| | - Okola Basil Owiti
- Hasselt University, Faculty of Science, Campus Diepenbeek, Agoralaan Building D, 3590 Diepenbeek, Belgium
| | - John Andrew
- Hasselt University, Faculty of Science, Campus Diepenbeek, Agoralaan Building D, 3590 Diepenbeek, Belgium
| | - Mwansa Ketty Lubeya
- The University of Zambia, School of Medicine, Department of Obstetrics and Gynaecology, Nationalist Road, P/Box RWX1 50110, Ridgeway, Lusaka, Zambia
- Women and Newborn Hospital-University Teaching Hospitals, Nationalist Road, P/Bag RWX1 Ridgeway, Lusaka, Zambia
| | - Lufunda Lukama
- Ndola Teaching Hospital, Department of Otorhinolaryngology, Head and Neck Surgery, Broadway Road, Postal Agency Ndola, Ndola, Zambia
- University of KwaZulu-Natal, College of Health Sciences., Nelson R Mandela School of Medicine, Durban 4001, South Africa
| | - Charlotte Kasempa
- Cancer Diseases Hospital, Nationalist Road, Nationalist Road, P/Box RWX1 50110 Ridgeway, Lusaka, Zambia
| | - Susan C. Msadabwe
- Cancer Diseases Hospital, Nationalist Road, Nationalist Road, P/Box RWX1 50110 Ridgeway, Lusaka, Zambia
- Zambia College of Medicine and Surgery, Levy Mwanawasa Medical University, Great East Campus, Box 33991, Lusaka, Lusaka
| | - Chester Kalinda
- University of Namibia, Faculty of Agriculture, Engineering and Science, School of Science, Katima Mulilo Campus, Winele Road, Private Bag 1096, Ngweze, Katima Mulilo, Namibia
- University of KwaZulu-Natal, Howard College Campus, College of Health Sciences, School of Public Health and Nursing, Desmond Clarence Building, Durban 4001, South Africa
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5
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Rafferty H, Sturt AS, Phiri CR, Webb EL, Mudenda M, Mapani J, Corstjens PLAM, van Dam GJ, Schaap A, Ayles H, Hayes RJ, van Lieshout L, Hansingo I, Bustinduy AL. Association between cervical dysplasia and female genital schistosomiasis diagnosed by genital PCR in Zambian women. BMC Infect Dis 2021; 21:691. [PMID: 34273957 PMCID: PMC8286581 DOI: 10.1186/s12879-021-06380-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 05/27/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Female genital schistosomiasis (FGS) is a neglected tropical gynaecological disease that affects millions of women in sub-Saharan Africa (SSA). FGS is caused by Schistosoma haematobium, a parasitic carcinogen involved in the pathogenesis of squamous cell carcinoma of the bladder. Cervical cancer incidence and mortality are highest in SSA, where pre-cancerous cervical dysplasia is often detected on screening with visual inspection with acetic acid (VIA). There are no studies evaluating the association between VIA positivity and FGS diagnosed by genital PCR. METHODS Women were recruited from the Bilharzia and HIV (BILHIV) study in Zambia a community-based study comparing genital self-sampling to provider obtained cervicovaginal-lavage for the diagnosis of FGS in women aged 18-31. FGS was defined as positive Schistosoma DNA from any genital PCR. Urogenital schistosomiasis diagnostics included urine circulating anodic antigen, urine microscopy and portable colposcopy. Participants were offered cervical cancer screening using VIA at Livingstone Central Hospital. Associations of PCR confirmed FGS and other diagnostics with VIA positivity were assessed using multivariable logistic regression. RESULTS VIA results were available from 237 BILHIV participants. A positive Schistosoma PCR in any genital specimen was detected in 14 women (5.9%), 28.6% (4/14) of these women had positive VIA compared to 9.0% without PCR evidence of schistosome infection (20/223). Schistosoma PCR positivity in any genital specimen was strongly associated with VIA positivity (OR: 6.08, 95% CI: 1.58-23.37, P = 0.02). CONCLUSIONS This is the first study to find an association between FGS and positive VIA, a relationship that may be causal. Further longitudinal studies are needed.
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Affiliation(s)
- H Rafferty
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - A S Sturt
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | | | - E L Webb
- MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - M Mudenda
- Livingstone Central Hospital, Livingstone, Zambia
| | - J Mapani
- Livingstone Central Hospital, Livingstone, Zambia
| | - P L A M Corstjens
- Department of Cell and Chemical Biology, Leiden University Medical Center, Leiden, The Netherlands
| | - G J van Dam
- Department of Parasitology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - H Ayles
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Zambart, Lusaka, Zambia
| | - R J Hayes
- MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - L van Lieshout
- Department of Parasitology, Leiden University Medical Center, Leiden, The Netherlands
| | - I Hansingo
- Livingstone Central Hospital, Livingstone, Zambia
| | - A L Bustinduy
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
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6
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Lee F, Bula A, Chapola J, Mapanje C, Phiri B, Kamtuwange N, Tsidya M, Tang J, Chinula L. Women's experiences in a community-based screen-and-treat cervical cancer prevention program in rural Malawi: a qualitative study. BMC Cancer 2021; 21:428. [PMID: 33882885 PMCID: PMC8061221 DOI: 10.1186/s12885-021-08109-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 03/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malawi has the world's highest cervical cancer incidence and mortality due to high rate of HIV coupled with inadequate screening and treatment services. The country's cervical cancer control program uses visual inspection with acetic acid (VIA) and cryotherapy, but screening is largely limited by poor access to facilities, high cost of cryotherapy gas, and high loss-to-follow-up. To overcome these limitations, we implemented a community-based screen-and-treat pilot program with VIA and thermocoagulation. Through a qualitative study, we explore the experiences of women who underwent this community-based pilot screening program. METHODS We implemented our pilot program in rural Malawi and conducted an exploratory qualitative sub-study. We conducted in-depth interviews with women who were treated with thermocoagulation during the program. We used semi-structured interviews to explore screen-and-treat experience, acceptability of the program and attitudes towards self-sampling for HPV testing as an alternative screening method. Content analysis was conducted using NVIVO v12. RESULTS Between July - August 2017, 408 participants eligible for screening underwent VIA screening. Thirty participants had VIA positive results, of whom 28 underwent same day thermocoagulation. We interviewed 17 of the 28 women who received thermocoagulation. Thematic saturation was reached at 17 interviews. All participants reported an overall positive experience with the community-based screen-and-treat program. Common themes were appreciation for bringing screening directly to their villages, surprise at the lack of discomfort, and the benefits of access to same day treatment immediately following abnormal screening. Negative experiences were rare and included discomfort during speculum exam, long duration of screening and challenges with complying with postprocedural abstinence. Most participants felt that utilizing self-collected HPV testing could be acceptable for screening in their community. CONCLUSIONS Our exploratory qualitative sub-study demonstrated that the community-based screen-and-treat with VIA and thermocoagulation was widely accepted. Participants valued the accessible, timely, and painless thermocoagulation treatment and reported minimal side effects. Future considerations for reaching rural women can include community-based follow-up, cervical cancer education for male partners and self-sampling for HPV testing.
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Affiliation(s)
- Fan Lee
- University of North Carolina (UNC) Department of Obstetrics and Gynecology, Chapel Hill, USA.
| | | | | | | | | | | | | | - Jennifer Tang
- University of North Carolina (UNC) Department of Obstetrics and Gynecology, Chapel Hill, USA
- UNC-Project Malawi, Lilongwe, Malawi
| | - Lameck Chinula
- University of North Carolina (UNC) Department of Obstetrics and Gynecology, Chapel Hill, USA
- UNC-Project Malawi, Lilongwe, Malawi
- Kamuzu Central Hospital, Lilongwe, Malawi
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7
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Erem AS, Appiah-Kubi A, Konney TO, Amo-Antwi K, Bell SG, Johnson TRB, Johnston C, Tawiah Odoi A, Lawrence ER. Gynecologic Oncology Sub-Specialty Training in Ghana: A Model for Sustainable Impact on Gynecologic Cancer Care in Sub-Saharan Africa. Front Public Health 2020; 8:603391. [PMID: 33344404 PMCID: PMC7744480 DOI: 10.3389/fpubh.2020.603391] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 11/09/2020] [Indexed: 12/13/2022] Open
Abstract
African women have double the risk of dying from cancer than women in high-income countries. In Ghana, most women with gynecological malignancies present with advanced-stage disease when treatment is less effective. Barriers to improved cancer outcomes include the availability of cancer screening, affordability of treatment, and access to gynecologic oncology specialists. In response to a paucity of gynecologic oncology providers, an in-country fellowship training program was established at Komfo Anokye Teaching Hospital (KATH) in 2013. Historically, Ghanaian resident physicians were sent to other countries for fellowship training and were unlikely to repatriate. The establishment of an in-country training program not only addresses the challenge of "brain drain," but also builds local capacity in gynecologic oncology education and emphasizes culturally relevant and accessible healthcare. The four-years gynecologic oncology fellowship program at KATH was developed as part of a longitudinal multi-decade partnership between the University of Michigan and academic medical centers in Ghana. The fellowship trains obstetricians and gynecologists to provide subspecialist clinical and surgical care to patients with gynecologic malignancies. Fellows collaborate with the radiation, oncology and pathology departments, participate in monthly inter-institutional tumor board meetings, conduct research, advise on health policy issues, and train subsequent cohorts. This fellowship is representative of emerging twenty-first-century trends in which subspecialty training programs in low-income countries are strengthened by international collaborations. Providing specialized training in gynecologic oncology can help develop and maintain resources that will improve clinical outcomes for women in low-resources settings.
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Affiliation(s)
- Anna Sarah Erem
- Saba University School of Medicine, The Bottom, Saba, Netherlands
| | - Adu Appiah-Kubi
- Department of Obstetrics and Gynaecology, University of Health and Allied Sciences, Ho, Ghana.,Gynaecologic Oncology Unit, Department of Obstetrics and Gynaecology, Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana
| | - Thomas Okpoti Konney
- Gynaecologic Oncology Unit, Department of Obstetrics and Gynaecology, Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana.,Department of Obstetrics and Gynaecology, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Kwabena Amo-Antwi
- Gynaecologic Oncology Unit, Department of Obstetrics and Gynaecology, Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana
| | - Sarah G Bell
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States
| | - Timothy R B Johnson
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States
| | - Carolyn Johnston
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States
| | - Alexander Tawiah Odoi
- Gynaecologic Oncology Unit, Department of Obstetrics and Gynaecology, Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana.,Department of Obstetrics and Gynaecology, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Emma R Lawrence
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States
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Cherniak W, Tyler N, Arora K, Lapidos-Salaiz I, Sczudlo E, Lin A, Barnhart M, Flanigan J, Silkensen S. From potential to practice: how accelerating access to HPV tests and screen and treat programmes can help eliminate cervical cancer. Fam Med Community Health 2020; 7:e000182. [PMID: 32148728 PMCID: PMC6910768 DOI: 10.1136/fmch-2019-000182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 09/13/2019] [Accepted: 09/15/2019] [Indexed: 12/24/2022] Open
Abstract
Human papillomavirus (HPV) vaccination campaigns to prevent cervical cancer are being considered and implemented in countries around the world. While vaccination will protect future generations, it will not help the millions of women currently infected, leading to an estimated 311 000 deaths per year globally. This paper examines a selection of strategies that when applied to both existing and new technologies, could accelerate access to HPV testing. Authors from the US Agency for International Development, the National Institutes of Health, and the Bridge to Health Medical and Dental, a non-governmental organisation, joined forces to propose a scalable and country-directed solution for preventing cervical cancer using an end-to-end approach. Collectively, the authors offer seven evidence-based strategies, that when used alone or in combination have the ability to reduce HPV-caused cervical cancer deaths and disability. These strategies include (1) consistent HPV test intervals to decrease HPV DNA test costs; (2) exploring market shaping opportunities; (3) employing iterative user research methodologies like human-centred design; (4) target product profiles for new HPV tests; (5) encouraging innovation around cervical cancer screen and treat programmes; (6) developing national cancer control plans; and (7) integrating cervical cancer screen and treat services into existing infrastructure. By using the strategies outlined here, in combination with HPV vaccination campaigns, national governments will be able to scale and expand cervical cancer screening programmes and provide evidence-based treatment programmes for HPV-infected women.
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Affiliation(s)
- William Cherniak
- Bridge to Health Medical and Dental, Toronto, Ontario, Canada.,Family and Community Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Nikki Tyler
- Bureau for Global Health, USAID, Washington, DC, USA
| | - Kriti Arora
- Bridge to Health Medical and Dental, Toronto, Ontario, Canada
| | | | - Emma Sczudlo
- Bridge to Health Medical and Dental, Toronto, Ontario, Canada
| | - Amy Lin
- Bureau for Global Health, USAID, Washington, DC, USA
| | | | - John Flanigan
- Center for Global Health, National Cancer Institute, Bethesda, Maryland, USA
| | - Shannon Silkensen
- Center for Global Health, National Cancer Institute, Bethesda, Maryland, USA
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9
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Subramanian S, Edwards P, Roberts ST, Musheke M, Mbizvo M. Integrated Care Delivery for HIV Prevention and Treatment in Adolescent Girls and Young Women in Zambia: Protocol for a Cluster-Randomized Controlled Trial. JMIR Res Protoc 2019; 8:e15314. [PMID: 31584004 PMCID: PMC6797972 DOI: 10.2196/15314] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/14/2019] [Accepted: 08/17/2019] [Indexed: 01/26/2023] Open
Abstract
Background Among countries in sub-Saharan Africa, Zambia has one of the highest incidences of HIV. Adolescent girls and young women (AGYW) are a particularly affected group because of their social and economic vulnerability. Objective The goal of this study is to test a multilevel package of interventions at the community and health system levels in Zambia in order to connect AGYW with a source of regular care, which will in turn allow for sustainable, successful implementation of regular HIV testing and adherence to antiretroviral treatment. Methods We will adapt prior tools to create the SHIELD (Support for HIV Integrated Education, Linkages to Care, and Destigmatization) intervention to educate and empower Zambian AGYW of 10-24 years of age and their families and to create community-based youth clubs to foster peer support. We will also develop integrated wellness care clinics to offer a youth-friendly environment that provides tailored clinical services. We will perform formative research, including focus groups and in-depth interviews, among AGYW, caregivers, and stakeholders to help inform the development and tailoring of the interventions. A cluster-randomized controlled trial will be implemented in Lusaka, with six clinic catchment areas randomized into three groups: zones with integrated wellness care clinics and SHIELD intervention, zones with only SHIELD intervention, and control zones with no intervention. We will assess HIV testing among the HIV-negative or unknown (HIV-/u) cohort, and retention in care along with viral load suppression will be evaluated in the HIV-positive (HIV+) cohort. We will use in-depth interviews and surveys to collect staff and stakeholder feedback after the trial. Cost-effectiveness of the interventions and return-on-investment impacts will be quantified using a microsimulation model. Results Interim results are expected in 2021, and the final results are expected in 2022. If this multilevel intervention is successful in establishing a comprehensive care continuum for HIV-affected AGYW, the Zambian Ministry of Health may advocate for expansion to additional settings to support national scale-up. Conclusions This integrated service delivery model can also be a platform to implement additional preventive services, so HIV-/u and HIV+ AGYW can receive comprehensive, integrated services. Trial Registration ClinicalTrials.gov NCT03995953; https://clinicaltrials.gov/ct2/show/NCT03995953 International Registered Report Identifier (IRRID) PRR1-10.2196/15314
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Affiliation(s)
| | - Patrick Edwards
- RTI International, Research Triangle Park, NC, United States
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10
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Pfaff C, Singano V, Akello H, Amberbir A, Berman J, Kwekwesa A, Matengeni A, Banda V, Msonko J, Speight C, Kabeya BM, van Oosterhout JJ. Early experiences in integrating cervical cancer screening and treatment into HIV services in Zomba Central Hospital, Malawi. Malawi Med J 2019; 30:211-214. [PMID: 30627358 PMCID: PMC6307048 DOI: 10.4314/mmj.v30i3.14] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background Malawi has the highest rate of cervical cancer globally and cervical cancer is six to eight times more common in women with HIV. HIV programmes provide an ideal setting to integrate cervical cancer screening. Methods Tisungane HIV clinic at Zomba Central Hospital has around 3,700 adult women receiving treatment. In October 2015, a model of integrated cervical cancer screening using visual inspection with acetic acid (VIA) was adopted. All women aged 20 and above in the HIV clinic were asked if they had cervical cancer screening in the past three years and, if not, were referred for screening. Screening was done daily by nurses in a room adjacent to the HIV clinic. Cold coagulation was used to treat pre-cancerous lesions. From October 2016, a modification to the HIV programme's electronic medical record was developed that assisted in matching numbers of women sent for screening with daily screening capacity and alerted providers to women with pre-cancerous lesions who missed referrals or treatment. Results Between May 2016 and March 2017, cervical cancer screening was performed in 957 women from the HIV clinic. Of the 686 (71%) women who underwent first ever screening, 23 (3.4%) were found to have VIA positive lesions suggestive of pre-cancer, of whom 8 (35%) had a same-day cold coagulation procedure, seven (30%) deferred cold coagulation to a later date (of whom 4 came for treatment), and 8 (35%) were referred to surgery due to size of lesion; 5/686 (0.7%) women had lesions suspicious of cancer. Conclusion Incorporating cervical cancer screening into services at HIV clinics is feasible. A structured approach to screening in the HIV clinic was important.
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Affiliation(s)
- Colin Pfaff
- Dignitas International, Zomba, Malawi.,Department of Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | | | | | | | | | | | | | | | | | - Biselele M Kabeya
- Department of Obstetrics and Gynaecology, Zomba Central Hospital, Zomba, Malawi
| | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi.,Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
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A tailored approach to building specialized surgical oncology capacity: Early experiences and outcomes in Malawi. Gynecol Oncol Rep 2018; 26:60-65. [PMID: 30364674 PMCID: PMC6197742 DOI: 10.1016/j.gore.2018.10.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 09/25/2018] [Accepted: 10/01/2018] [Indexed: 12/30/2022] Open
Abstract
Objectives Cervical cancer can often be cured by surgery alone, if diagnosed and treated early. However, of the cancer patients who live in the world's poorest countries less that 5% have access to safe, effective and timely cancer surgery. We designed a novel, competency-based curriculum to rapidly build surgical capacity for the treatment of cervical cancer. Here we report experiences and early outcomes of its implementation in Malawi. Methods Curriculum implementation consisted of preoperative evaluation of patients and surgical video review, discussion of surgical instruments and suture material, deconstruction of the surgical procedure into critical subcomponents including trainees walking through the steps of the procedure with the master trainers, high-volume surgical repetition over a short time interval, intra-operative mentoring, post-operative case review, and mental narration. This was preceded by self-directed learning and followed by clinical mentorship through electronic communication and quarterly on-site visits. Results Between June 2015–June 2017, 28 patients underwent radical abdominal hysterectomy with bilateral pelvic lymphadenectomy. The first 8 surgeries were performed over 5 days. After the 7th case the trainee could perform the procedure alone. During and between quarterly mentoring-visits the trainee independently performed the procedure on 20 additional patients. Major surgical complications were rare. Conclusions Life-saving surgical treatment for cervical cancer is now available for the first time, as a routine clinical service, in Central/Northern, Malawi. Rapidly building surgical capacity for the treatment of cervical cancer in Malawi. Initiation of a sustainable gynecologic oncology service platform in Malawi. A practical public health solution to cancer control in a region of severe poverty.
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Campos NG, Lince-Deroche N, Chibwesha CJ, Firnhaber C, Smith JS, Michelow P, Meyer-Rath G, Jamieson L, Jordaan S, Sharma M, Regan C, Sy S, Liu G, Tsu V, Jeronimo J, Kim JJ. Cost-Effectiveness of Cervical Cancer Screening in Women Living With HIV in South Africa: A Mathematical Modeling Study. J Acquir Immune Defic Syndr 2018; 79:195-205. [PMID: 29916959 PMCID: PMC6143200 DOI: 10.1097/qai.0000000000001778] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 06/13/2018] [Indexed: 01/25/2023]
Abstract
BACKGROUND Women with HIV face an increased risk of human papillomavirus (HPV) acquisition and persistence, cervical intraepithelial neoplasia, and invasive cervical cancer. Our objective was to determine the cost-effectiveness of different cervical cancer screening strategies among women with HIV in South Africa. METHODS We modified a mathematical model of HPV infection and cervical disease to reflect coinfection with HIV. The model was calibrated to epidemiologic data from HIV-infected women in South Africa. Clinical and economic data were drawn from in-country data sources. The model was used to project reductions in the lifetime risk of cervical cancer and incremental cost-effectiveness ratios (ICERs) of Pap and HPV DNA screening and management algorithms beginning at HIV diagnosis, at 1-, 2-, or 3-year intervals. Strategies with an ICER below South Africa's 2016 per capita gross domestic product (US$5270) were considered "cost-effective." RESULTS HPV testing followed by treatment (test-and-treat) at 2-year intervals was the most effective strategy that was also cost-effective, reducing lifetime cancer risk by 56.6% with an ICER of US$3010 per year of life saved. Other cost-effective strategies included Pap (referral threshold: HSIL+) at 1-, 2-, and 3-year intervals, and HPV test-and-treat at 3-year intervals. Pap (ASCUS+), HPV testing with 16/18 genotyping, and HPV testing with Pap or visual triage of HPV-positive women were less effective and more costly than alternatives. CONCLUSIONS Considering per capita gross domestic product as the benchmark for cost-effectiveness, HPV test-and-treat is optimal in South Africa. At lower cost-effectiveness benchmarks, Pap (HSIL+) would be optimal.
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Affiliation(s)
- Nicole G. Campos
- Harvard T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, MA
| | - Naomi Lince-Deroche
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Carla J. Chibwesha
- Division of Global Women's Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Clinical HIV Research Unit, Helen Joseph Hospital, Johannesburg, South Africa
| | - Cynthia Firnhaber
- Clinical HIV Research Unit, Helen Joseph Hospital, Johannesburg, South Africa
- Right to Care, Helen Joseph Hospital, Johannesburg, South Africa
| | - Jennifer S. Smith
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Pam Michelow
- National Health Laboratory Service, Johannesburg, South Africa
- Anatomical Pathology Department, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health and Development, School of Public Health, Boston University, Boston, MA
| | - Lise Jamieson
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Suzette Jordaan
- National Health Laboratory Service, Johannesburg, South Africa
| | - Monisha Sharma
- Harvard T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, MA
- Department of Epidemiology, University of Washington, Seattle, WA
| | - Catherine Regan
- Harvard T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, MA
| | - Stephen Sy
- Harvard T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, MA
| | - Gui Liu
- Department of Epidemiology, University of Washington, Seattle, WA
| | | | - Jose Jeronimo
- Global Coalition Against Cervical Cancer, Arlington, VA
| | - Jane J. Kim
- Harvard T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, MA
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Impact of HIV on human papilloma virus-mediated cervical disease progression. AIDS 2018; 32:1715-1717. [PMID: 30001245 DOI: 10.1097/qad.0000000000001841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Allen LN, Pullar J, Wickramasinghe KK, Williams J, Roberts N, Mikkelsen B, Varghese C, Townsend N. Evaluation of research on interventions aligned to WHO 'Best Buys' for NCDs in low-income and lower-middle-income countries: a systematic review from 1990 to 2015. BMJ Glob Health 2018. [PMID: 29527342 PMCID: PMC5841523 DOI: 10.1136/bmjgh-2017-000535] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background Non-communicable diseases (NCDs) are the leading cause of death and disability worldwide, with low-income and middle-income countries experiencing a disproportionately high burden. Since 2010 WHO has promoted 24 highly cost-effective interventions for NCDs, dubbed ‘best buys’. It is unclear whether these interventions have been evaluated in low-income and lower-middle-income countries (LLMICs). Aim To systematically review research on interventions aligned to WHO ‘best buys’ for NCDs in LLMICs. Methods We searched 13 major databases and included papers conducted in the 83 World Bank-defined LLMICs, published between 1 January 1990 and 5 February 2015. Two reviewers independently screened papers and assessed risk of bias. We adopted a narrative approach to data synthesis. The primary outcomes were NCD-related mortality and morbidity, and risk factor prevalence. Results We identified 2672 records, of which 36 were included (608 940 participants). No studies on ‘best buys’ were found in 89% of LLMICs. Nineteen of the 36 studies reported on the effectiveness of tobacco-related ‘best buys’, presenting good evidence for group interventions in reducing tobacco use but weaker evidence for interventions targeting individuals. There were fewer studies on smoking bans, warning labels and mass media campaigns, and no studies on taxes or marketing restrictions. There was supportive evidence that cervical screening and hepatitis B immunisation prevent cancer in LLMICs. A single randomised controlled trial supported polypharmacy for cardiovascular disease. Fourteen of the ‘best buy’ interventions did not have any good evidence for effectiveness in LLMICs. Conclusions We found studies on only 11 of the 24 interventions aligned with the WHO ‘best buys’ from LLMIC settings. Most LLMICs have not conducted research on these interventions in their populations. LLMICs should take action to implement and evaluate ‘best buys’ in their national context, based on national priorities, and starting with interventions with the strongest evidence base.
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Affiliation(s)
- Luke N Allen
- Centre on Population Approaches for NCD Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jessica Pullar
- Centre on Population Approaches for NCD Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Kremlin Khamarj Wickramasinghe
- Centre on Population Approaches for NCD Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Julianne Williams
- Centre on Population Approaches for NCD Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nia Roberts
- Health Library, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Bente Mikkelsen
- Global Coordination Mechanism for Noncommunicable Diseases, WHO, Geneva, Switzerland
| | - Cherian Varghese
- Department for Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention, WHO, Geneva, Switzerland
| | - Nick Townsend
- Centre on Population Approaches for NCD Prevention, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Kabalika C, Mulenga D, Mazaba ML, Siziya S. Acceptance of Cervical Cancer Screening and its Correlates Among Women of a Peri-Urban High-Density Residential Area in Ndola, Zambia. Int J MCH AIDS 2018; 7:17-27. [PMID: 30305986 PMCID: PMC6168797 DOI: 10.21106/ijma.223] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Zambia has one of the highest cervical cancer incidence and mortality rates in the world. Cervical cancer screening leads to reduction in the incidence of invasive disease. The objectives of the study were to determine the level of acceptance of cervical cancer screening and its correlates among women of a peri-urban high-density residential area in Ndola, Zambia. METHODS A cross sectional study was conducted. With a population size of 12,000 women in reproductive age and using an expected frequency of 50 + 5% and at 95% confidence interval, the required sample size was 372. A stratified sampling method was used to select participants. Independent factors that were associated with the outcome were established using multi-variate logistic regression. Adjusted odds ratios and their 95% confidence intervals are reported. RESULTS In total, 355 out of 372 questionnaires were administered, achieving a response rate of 95.4%. Out of 355 participants, 9 (2.5%) had ever been screened for cervical cancer. In bivariate analyses, factors associated with screened were knowledge of body part affected, screening as a prevention tool, whether cervical cancer was curable in its early stages or not, awareness of cervical cancer screening, knowledge on frequency of screening and cervical cancer screening causing harm. However, in multivariate analysis, participants who knew that cervical cancer screening prevented cervical cancer were 3.58 (95% CI [1.49, 8.64]) times more likely to have been screened than those who did not have the knowledge. Participants who knew that cervical cancer is curable were 2.76 (95% CI [1.92, 8.31]) times more likely to have been screened than those who did not have the knowledge. CONCLUSION AND GLOBAL HEALTH IMPLICATIONS The uptake of screening was low. Interventions should be designed to increase uptake of screening for cervical cancer by considering factors that have been identified in the current study that are independently associated with cervical cancer screening among this population.
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Affiliation(s)
- Chiluba Kabalika
- Clinical Sciences Department, Michael Chilufya Sata School of Medicine, Copperbelt University, Ndola, Zambia
| | - David Mulenga
- Clinical Sciences Department, Michael Chilufya Sata School of Medicine, Copperbelt University, Ndola, Zambia
| | - Mazyanga Lucy Mazaba
- The Health Press, Zambia. Institute of Public Health, Ministry of Health, Lusaka, Zambia
| | - Seter Siziya
- Clinical Sciences Department, Michael Chilufya Sata School of Medicine, Copperbelt University, Ndola, Zambia
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Julião I, Savva-Bordalo J, Lunet N. Cervical cancer screening opportunities for Guinea-Bissau. Porto Biomed J 2017; 2:306-310. [PMID: 32258787 PMCID: PMC6806762 DOI: 10.1016/j.pbj.2017.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 03/13/2017] [Indexed: 12/21/2022] Open
Abstract
Guinea-Bissau is a severely resource constrained country, in search of political stability and development in every sector of public life. International aid is permanent and healthcare is one of the most targeted fields, focusing mostly on infectious diseases, maternity, infant malnutrition, access to healthcare and gender inequality in health. As in the rest of Sub-Saharan Africa, cervical cancer is gathering increasing attention from the community and ruling officers. The potential of screening for control of cervical cancer raised the interest of adapting screening methods to low-resource settings. This started the search for the best resource-adapted strategies, which promoted several trials that currently shape the development of screening programs in these countries. Prevention and control strategies are also being adapted taking into account the availability of human Papillomavirus vaccination. Nonetheless, several barriers are still in place for widespread vaccination programs, and cervical cancer screening and treatment remain central in the control of cervical cancer in low-resource settings. We intend to discuss current cervical cancer screening approaches in low-resource countries and opportunities for their implementation in Guinea-Bissau.
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Affiliation(s)
- Ivo Julião
- Instituto Português de Oncologia do Porto, Porto, Portugal
| | | | - Nuno Lunet
- Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
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Chibwesha C, Pinder LF, Musonda A, Sikombe K, Matambo J, Bateman AC, Mershon CH, Mwanahamuntu M, Kapambwe S, Lishimpi K, Parham GP. A comprehensive assessment of breast and cervical cancer control infrastructure in Zambia. J Cancer Policy 2017. [DOI: 10.1016/j.jcpo.2017.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
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18
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Sigfrid L, Murphy G, Haldane V, Chuah FLH, Ong SE, Cervero-Liceras F, Watt N, Alvaro A, Otero-Garcia L, Balabanova D, Hogarth S, Maimaris W, Buse K, Mckee M, Piot P, Perel P, Legido-Quigley H. Integrating cervical cancer with HIV healthcare services: A systematic review. PLoS One 2017; 12:e0181156. [PMID: 28732037 PMCID: PMC5521786 DOI: 10.1371/journal.pone.0181156] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 06/27/2017] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Cervical cancer is a major public health problem. Even though readily preventable, it is the fourth leading cause of death in women globally. Women living with HIV are at increased risk of invasive cervical cancer, highlighting the need for access to screening and treatment for this population. Integration of services has been proposed as an effective way of improving access to cervical cancer screening especially in areas of high HIV prevalence as well as lower resourced settings. This paper presents the results of a systematic review of programs integrating cervical cancer and HIV services globally, including feasibility, acceptability, clinical outcomes and facilitators for service delivery. METHODS This is part of a larger systematic review on integration of services for HIV and non-communicable diseases. To be considered for inclusion studies had to report on programs to integrate cervical cancer and HIV services at the level of service delivery. We searched multiple databases including Global Health, Medline and Embase from inception until December 2015. Articles were screened independently by two reviewers for inclusion and data were extracted and assessed for risk of bias. MAIN RESULTS 11,057 records were identified initially. 7,616 articles were screened by title and abstract for inclusion. A total of 21 papers reporting interventions integrating cervical cancer care and HIV services met the criteria for inclusion. All but one study described integration of cervical cancer screening services into existing HIV services. Most programs also offered treatment of minor lesions, a 'screen-and-treat' approach, with some also offering treatment of larger lesions within the same visit. Three distinct models of integration were identified. One model described integration within the same clinic through training of existing staff. Another model described integration through co-location of services, with the third model describing programs of integration through complex coordination across the care pathway. The studies suggested that integration of cervical cancer services with HIV services using all models was feasible and acceptable to patients. However, several barriers were reported, including high loss to follow up for further treatment, limited human-resources, and logistical and chain management support. Using visual screening methods can facilitate screening and treatment of minor to larger lesions in a single 'screen-and-treat' visit. Complex integration in a single-visit was shown to reduce loss to follow up. The use of existing health infrastructure and funding together with comprehensive staff training and supervision, community engagement and digital technology were some of the many other facilitators for integration reported across models. CONCLUSIONS This review shows that integration of cervical cancer screening and treatment with HIV services using different models of service delivery is feasible as well as acceptable to women living with HIV. However, the descriptive nature of most papers and lack of data on the effect on long-term outcomes for HIV or cervical cancer limits the inference on the effectiveness of the integrated programs. There is a need for strengthening of health systems across the care continuum and for high quality studies evaluating the effect of integration on HIV as well as on cervical cancer outcomes.
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Affiliation(s)
- Louise Sigfrid
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Georgina Murphy
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Victoria Haldane
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Fiona Leh Hoon Chuah
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Suan Ee Ong
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | | | - Nicola Watt
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Laura Otero-Garcia
- Nursing Section, Faculty of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
- Ciber of Epidemiology and Public Health (CIBERESP-ISCIII) Madrid, Spain
| | - Dina Balabanova
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Sue Hogarth
- London Borough of Waltham Forest, London, United Kingdom
| | - Will Maimaris
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- Haringey Council. Civic Centre, London, United Kingdom
| | - Kent Buse
- Strategic Policy Directions, UNAIDS, Geneva, Switzerland
| | - Martin Mckee
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Peter Piot
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Pablo Perel
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Helena Legido-Quigley
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
- London School of Hygiene & Tropical Medicine, London, United Kingdom
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Clinical Performance Validation of 4 Point-of-Care Cervical Cancer Screening Tests in HIV-Infected Women in Zambia. J Low Genit Tract Dis 2017; 20:218-23. [PMID: 27030883 DOI: 10.1097/lgt.0000000000000206] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We sought to determine the clinical performance of visual inspection with acetic acid (VIA), digital cervicography (DC), Xpert human papillomavirus (HPV), and OncoE6 for cervical cancer screening in an HIV-infected population. MATERIALS AND METHODS HIV-infected women 18 years or older were included in this cross-sectional validation study conducted in Lusaka, Zambia. The screening tests were compared against a histological gold standard. We calculated sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios, and odds ratios using cervical intraepithelial neoplasia grade 2 or worse (CIN 2+) and grade 3 or worse (CIN 3+) thresholds. RESULTS Between January and June 2015, a total of 200 women were enrolled. Fifteen percent were screen positive by VIA, 20% by DC, 47% by Xpert HPV, and 6% by OncoE6. Using a CIN 2+ threshold, the sensitivity and specificity of VIA were 48% (95% CI = 30%-67%) and 92% (95% CI = 86%-95%), respectively. Similarly, the sensitivity and specificity of DC were 59% (95% CI = 41%-76%) and 88% (95% CI = 82%-93%), respectively. The sensitivity and specificity of Xpert HPV were 88% (95% CI = 71%-97%) and 60% (95% CI = 52%-68%), respectively. Finally, the sensitivity and specificity of OncoE6 were 31% (95% CI = 16%-50%) and 99% (95% CI = 97%-100%), respectively. CONCLUSIONS VIA and DC displayed moderate sensitivity and high specificity. Xpert HPV performed equivalently to currently approved HPV DNA tests, with high sensitivity and moderate specificity. OncoE6 displayed excellent specificity but low sensitivity. These results confirm an important role for VIA, DC, and Xpert HPV in screen-and-treat cervical cancer prevention in low- and middle-income countries, such as Zambia.
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Implementation and Operational Research: Age Distribution and Determinants of Invasive Cervical Cancer in a "Screen-and-Treat" Program Integrated With HIV/AIDS Care in Zambia. J Acquir Immune Defic Syndr 2015; 70:e20-6. [PMID: 26322673 DOI: 10.1097/qai.0000000000000685] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Cervical cancer screening efforts linked to HIV/AIDS care programs are being expanded across sub-Saharan Africa. Evidence on the age distribution and determinants of invasive cervical cancer (ICC) cases detected in such programs is limited. METHODS We analyzed program operations data from the Cervical Cancer Prevention Program in Zambia, the largest public sector programs of its kind in sub-Saharan Africa. We examined age distribution patterns by HIV serostatus of histologically confirmed ICC cases and used multivariable logistic regression to evaluate independent risk factors for ICC among younger (≤35 years) and older (>35 years) women. RESULTS Between January 2006 and April 2010, of 48,626 women undergoing screening, 571 (1.2%) were diagnosed with ICC, including 262 (46%) HIV seropositive (median age: 35 years), 131 (23%) HIV seronegative (median age: 40 years), and 178 (31%) of unknown HIV serostatus (median age: 38 years). Among younger (≤35 years) women, being HIV seropositive was associated with a 4-fold higher risk of ICC [adjusted odds ratio = 4.1 (95% confidence interval: 2.8, 5.9)] than being HIV seronegative. The risk of ICC increased with increasing age among HIV-seronegative women and women with unknown HIV serostatus, but among HIV-seropositive women, the risk peaked around age 35 and nonsignificantly declined with increasing ages. Other factors related to ICC included being married (vs. being unmarried/widowed) in both younger and older women, and with having 2+ (vs. ≤1) lifetime sexual partners among younger women. CONCLUSIONS HIV infection seems to have increased the risk of cervical cancer among younger women in Zambia, pointing to the urgent need for expanding targeted screening interventions.
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McCree R, Giattas MR, Sahasrabuddhe VV, Jolly PE, Martin MY, Usdan SL, Kohler C, Lisovicz N. Expanding Cervical Cancer Screening and Treatment in Tanzania: Stakeholders' Perceptions of Structural Influences on Scale-Up. Oncologist 2015; 20:621-6. [PMID: 25926351 DOI: 10.1634/theoncologist.2013-0305] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 01/23/2015] [Indexed: 12/29/2022] Open
Abstract
UNLABELLED Tanzania has the highest burden of cervical cancer in East Africa. This study aims to identify perceived barriers and facilitators that influence scale-up of regional and population-level cervical cancer screening and treatment programs in Tanzania. Convenience sampling was used to select participants for this qualitative study among 35 key informants. Twenty-eight stakeholders from public-sector health facilities, academia, government, and nongovernmental organizations completed in-depth interviews, and a seven-member municipal health management team participated in a focus group discussion. The investigation identified themes related to the infrastructure of health services for cervical cancer prevention, service delivery, political will, and sociocultural influences on screening and treatment. Decentralizing service delivery, improving access to screening and treatment, increasing the number of trained health workers, and garnering political will were perceived as key facilitators for enhancing and initiating screening and treatment services. In conclusion, participants perceived that system-level structural factors should be addressed to expand regional and population-level service delivery of screening and treatment. IMPLICATIONS FOR PRACTICE Tanzanian women have a high burden of cervical cancer. Understanding the perceived structural factors that may influence screening coverage for cervical cancer and availability of treatment may be beneficial for program scale-up. This study showed that multiple factors contribute to the challenge of cervical cancer screening and treatment in Tanzania. In addition, it highlighted systematic developments aimed at expanding services. This study is important because the themes that emerged from the results may help inform programs that plan to improve screening and treatment in Tanzania and potentially in other areas with high burdens of cervical cancer.
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Affiliation(s)
- Renicha McCree
- Center for Global Health, National Cancer Institute, Rockville, Maryland, USA;
| | | | - Vikrant V Sahasrabuddhe
- National Cancer Institute, Rockville, Maryland, USA; Department of Global Health, Vanderbilt University, Nashville, Tennessee, USA
| | | | | | | | - Connie Kohler
- Health Behavior, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Kapambwe S, Parham G, Mwanahamuntu M, Chirwa S, Mwanza J, Amuyunzu-Nyamongo M. Innovative approaches to promoting cervical health and raising cervical cancer awareness by use of existing cultural structures in resource-limited countries: experiences with traditional marriage counseling in Zambia. Glob Health Promot 2014; 20:57-64. [PMID: 24722743 DOI: 10.1177/1757975913502689] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The Cervical Cancer Prevention Program in Zambia (CCPPZ) has increasingly used community-level structures to increase the uptake and ensure the sustainability of the program. Traditional marriage counselors, the alangizi, who have existed in the Zambian society for many years, are one of the structures used by the program to impart cervical cancer knowledge and increase access to screening and care using an existing community structure. Several steps were followed in developing this intervention: (a) ensuring the alangizi understood the process of screening by encouraging them to go through the screening process; (b) workshops were arranged for the alangizi to meet and share experiences during which lessons were given on cervical cancer by health workers as well; and (c) eight alangizi were chosen to help document the lessons as part of ensuring that cervical cancer information is accurate and passed in a consistent manner. Over 70 alangizi, who had undergone cervical cancer screening, were trained by CCPPZ. A 'Cervical Cancer Training Manual for Marriage Counsellors' was developed to help the alangizi integrate cervical cancer lessons in their routine teachings. An evaluation was conducted during the training of the alangizi that forms the basis for this paper. The results show that although the alangizi face key challenges in their work (e.g. changing social contexts), they are still considered relevant by most communities in Zambia and are potentially an important avenue for cervical cancer and other health information. This paper shows that it is possible to integrate sexual and reproductive health messages into existing structures in the community. However, it is important to design culturally specific and sensitive healthcare strategies that embrace locally accepted good practices.
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Affiliation(s)
- Sharon Kapambwe
- 1.Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
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Adebamowo CA, Casper C, Bhatia K, Mbulaiteye SM, Sasco AJ, Phipps W, Vermund SH, Krown SE. Challenges in the detection, prevention, and treatment of HIV-associated malignancies in low- and middle-income countries in Africa. J Acquir Immune Defic Syndr 2014; 67 Suppl 1:S17-26. [PMID: 25117957 PMCID: PMC4392880 DOI: 10.1097/qai.0000000000000255] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Cancers associated with immunosuppression and infections have long been recognized as a major complication of HIV/AIDS. More recently, persons living with HIV are increasingly diagnosed with a wider spectrum of HIV-associated malignancies (HIVAM) as they live longer on combination antiretroviral therapy. This has spurred research to characterize the epidemiology and determine the optimal management of HIVAM with a focus on low-and middle-income countries (LMICs). Given background coinfections, environmental exposures, host genetic profiles, antiretroviral therapy usage, and varying capacities for early diagnosis and treatment, one can expect the biology of cancers in HIV-infected persons in LMICs to have a significant impact on chronic HIV care, as is now the case in high-income countries. Thus, new strategies must be developed to effectively prevent, diagnose, and treat HIVAM in LMICs; provide physical/clinical infrastructures; train the cancer and HIV workforce; and expand research capacity-particularly given the challenges posed by the limitations on available transportation and financial resources and the population's general rural concentration. Opportunities exist to extend resources supported by the President's Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis, and Malaria to improve the health-care infrastructure and train the personnel required to prevent and manage cancers in persons living with HIV. These HIV chronic care infrastructures could also serve cancer patients regardless of their HIV status, facilitating long-term care and treatment for persons who do not live near cancer centers, so that they receive the same degree of care as those receiving chronic HIV care today.
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Affiliation(s)
- Clement A. Adebamowo
- Office of Research and Training, Institute of Human Virology Nigeria, Abuja, Nigeria, and Department of Epidemiology and Public Health, Institute of Human Virology and Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD
| | - Corey Casper
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Kishor Bhatia
- AIDS Malignancy Program, Office of HIV and AIDS Malignancy, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Sam M. Mbulaiteye
- Infections and Immunoepidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Department of Health and Human Services, Rockville, MD
| | - Annie J. Sasco
- Centre INSERM U 897-Epidémiologie-Biostatistique, Université de Bordeaux, Inserm U 897-Epidémiologie et Biostatistiques, L’Institut de Santé Publique, d’Épidémiologie et de Développement de l’Université de Bordeaux, Bordeaux, France
| | - Warren Phipps
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Sten H. Vermund
- Institute of Global Health and Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Susan E. Krown
- AIDS Malignancy Consortium and Memorial Sloan-Kettering Cancer Center (emerita), New York, NY
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Mwanahamuntu MH, Sahasrabuddhe VV, Blevins M, Kapambwe S, Shepherd BE, Chibwesha C, Pfaendler KS, Mkumba G, Vwalika B, Hicks ML, Vermund SH, Stringer JS, Parham GP. Utilization of cervical cancer screening services and trends in screening positivity rates in a 'screen-and-treat' program integrated with HIV/AIDS care in Zambia. PLoS One 2013; 8:e74607. [PMID: 24058599 PMCID: PMC3776830 DOI: 10.1371/journal.pone.0074607] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 08/03/2013] [Indexed: 11/23/2022] Open
Abstract
Background In the absence of stand-alone infrastructures for delivering cervical cancer screening services, efforts are underway in sub-Saharan Africa to dovetail screening with ongoing vertical health initiatives like HIV/AIDS care programs. Yet, evidence demonstrating the utilization of cervical cancer prevention services in such integrated programs by women of the general population is lacking. Methods We analyzed program operations data from the Cervical Cancer Prevention Program in Zambia (CCPPZ), the largest public sector programs of its kind in sub-Saharan Africa. We evaluated patterns of utilization of screening services by HIV serostatus, examined contemporaneous trends in screening outcomes, and used multivariable modeling to identify factors associated with screening test positivity. Results Between January 2006 and April 2011, CCPPZ services were utilized by 56,247 women who underwent cervical cancer screening with visual inspection with acetic acid (VIA), aided by digital cervicography. The proportion of women accessing these services who were HIV-seropositive declined from 54% to 23% between 2006–2010, which coincided with increasing proportions of HIV-seronegative women (from 22% to 38%) and women whose HIV serostatus was unknown (from 24% to 39%) (all p-for trend<0.001). The rates of VIA screening positivity declined from 47% to 17% during the same period (p-for trend <0.001), and this decline was consistent across all HIV serostatus categories. After adjusting for demographic and sexual/reproductive factors, HIV-seropositive women were more than twice as likely (Odds ratio 2.62, 95% CI 2.49, 2.76) to screen VIA-positive than HIV-seronegative women. Conclusions This is the first ‘real world’ demonstration in a public sector implementation program in a sub-Saharan African setting that with successful program scale-up efforts, nurse-led cervical cancer screening programs targeting women with HIV can expand and serve all women, regardless of HIV serostatus. Screening program performance can improve with adequate emphasis on training, quality control, and telemedicine-support for nurse-providers in clinical decision making.
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Affiliation(s)
- Mulindi H Mwanahamuntu
- Center for Infectious Disease Research in Zambia, Lusaka, Zambia ; University Teaching Hospital, Lusaka, Zambia
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25
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Ezechi OC, Gab-Okafor CV, Ostergren PO, Odberg Pettersson K. Willingness and acceptability of cervical cancer screening among HIV positive Nigerian women. BMC Public Health 2013; 13:46. [PMID: 23327453 PMCID: PMC3567931 DOI: 10.1186/1471-2458-13-46] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Accepted: 01/08/2013] [Indexed: 12/02/2022] Open
Abstract
Background The proven benefit of integrating cervical cancer screening programme into HIV care has led to its adoption as a standard of care. However this is not operational in most HIV clinics in Nigeria. Of the various reasons given for non-implementation, none is backed by scientific evidence. This study was conducted to assess the willingness and acceptability of cervical cancer screening among HIV positive Nigerian women. Methods A cross sectional study of HIV positive women attending a large HIV treatment centre in Lagos, Nigeria. Respondents were identified using stratified sampling method. A pretested questionnaire was used to obtain information by trained research assistants. Obtained information were coded and managed using SPSS for windows version 19. Multivariate logistic regression model was used to determine independent predictor for acceptance of cervical cancer screening. Results Of the 1517 respondents that returned completed questionnaires, 853 (56.2%) were aware of cervical cancer. Though previous cervical cancer screening was low at 9.4%, 79.8% (1210) accepted to take the test. Cost of the test (35.2%) and religious denial (14.0%) were the most common reasons given for refusal to take the test. After controlling for confounding variables in a multivariate logistic regression model, having a tertiary education (OR = 1.4; 95% CI: 1.03-1.84), no living child (OR: 1.5; 95% CI: 1.1-2.0), recent HIV diagnosis (OR: 1.5; 95% CI: 1.1-2.0) and being aware of cervical cancer (OR: 1.5; 95% CI: 1.2-2.0) retained independent association with acceptance to screen for cervical cancer. Conclusions The study shows that HIV positive women in our environment are willing to screen for cervical cancer and that the integration of reproductive health service into existing HIV programmes will strengthen rather than disrupt the services.
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Affiliation(s)
- Oliver C Ezechi
- Clinical Sciences Division, Nigerian Institute of Medical Research, Lagos, Nigeria.
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26
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Awareness, Acceptability and Uptake of Human Papilloma Virus Vaccine Among Cameroonian School-Attending Female Adolescents. J Community Health 2012; 37:1127-35. [DOI: 10.1007/s10900-012-9554-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Sahasrabuddhe VV, Parham GP, Mwanahamuntu MH, Vermund SH. Cervical cancer prevention in low- and middle-income countries: feasible, affordable, essential. Cancer Prev Res (Phila) 2012; 5:11-7. [PMID: 22158053 PMCID: PMC3586242 DOI: 10.1158/1940-6207.capr-11-0540] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The annual worldwide burden of the preventable disease cervical cancer is more than 530,000 new cases and 275,000 deaths, with the majority occurring in low- and middle-income countries (LMIC), where cervical cancer screening and early treatment are uncommon. Widely used in high-income countries, Pap smear (cytology based) screening is expensive and challenging for implementation in LMICs, where lower-cost, effective alternatives such as visual inspection with acetic acid (VIA) and rapid human papillomavirus (HPV)-based screening tests offer promise for scaling up prevention services. Integrating HPV screening with VIA in "screen-and-treat-or-refer" programs offers the dual benefits of HPV screening to maximize detection and using VIA to triage for advanced lesions/cancer, as well as a pelvic exam to address other gynecologic issues. A major issue in LMICs is coinfection with human immunodeficiency virus (HIV) and HPV, which further increases the risk for cervical cancer and marks a population with perhaps the greatest need of cervical cancer prevention. Public-private partnerships to enhance the availability of cervical cancer prevention services within HIV/AIDS care delivery platforms through initiatives such as Pink Ribbon Red Ribbon present an historic opportunity to expand cervical cancer screening in LMICs.
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Affiliation(s)
- Vikrant V. Sahasrabuddhe
- Vanderbilt Institute for Global Health and Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Groesbeck P. Parham
- Center for Infectious Disease Research in Zambia and Department of Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
- University Teaching Hospital and University of Zambia School of Medicine, Lusaka, Zambia
| | | | - Sten H. Vermund
- Vanderbilt Institute for Global Health and Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
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Sahasrabuddhe VV, Parham GP, Mwanahamuntu MH, Vermund SH. Cervical cancer prevention in low- and middle-income countries: feasible, affordable, essential. CANCER PREVENTION RESEARCH (PHILADELPHIA, PA.) 2011. [PMID: 22158053 DOI: 10.1016/s0140-6736(11)61522-567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The annual worldwide burden of the preventable disease cervical cancer is more than 530,000 new cases and 275,000 deaths, with the majority occurring in low- and middle-income countries (LMIC), where cervical cancer screening and early treatment are uncommon. Widely used in high-income countries, Pap smear (cytology based) screening is expensive and challenging for implementation in LMICs, where lower-cost, effective alternatives such as visual inspection with acetic acid (VIA) and rapid human papillomavirus (HPV)-based screening tests offer promise for scaling up prevention services. Integrating HPV screening with VIA in "screen-and-treat-or-refer" programs offers the dual benefits of HPV screening to maximize detection and using VIA to triage for advanced lesions/cancer, as well as a pelvic exam to address other gynecologic issues. A major issue in LMICs is coinfection with human immunodeficiency virus (HIV) and HPV, which further increases the risk for cervical cancer and marks a population with perhaps the greatest need of cervical cancer prevention. Public-private partnerships to enhance the availability of cervical cancer prevention services within HIV/AIDS care delivery platforms through initiatives such as Pink Ribbon Red Ribbon present an historic opportunity to expand cervical cancer screening in LMICs.
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Affiliation(s)
- Vikrant V Sahasrabuddhe
- Vanderbilt Institute for Global Health and Department of Pediatrics, Vanderbilt University School of Medicine, 2525 West End Avenue, Nashville, TN 37203, USA
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29
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Banura C, Mirembe FM, Katahoire AR, Namujju PB, Mbonye AK, Wabwire FM. Epidemiology of HPV genotypes in Uganda and the role of the current preventive vaccines: A systematic review. Infect Agent Cancer 2011; 6:11. [PMID: 21749691 PMCID: PMC3163594 DOI: 10.1186/1750-9378-6-11] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Accepted: 07/12/2011] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Limited data are available on the distribution of human papillomavirus (HPV) genotypes in the general population and in invasive cervical cancer (ICC) in Uganda. Yet, with the advent of preventive HPV vaccines that target HPV 16 and 18 responsible for causing about 70% of ICC cases in the world, such information is crucial to predict how vaccination and HPV-based screening will influence prevention of ICC. METHODS To review the distribution of HPV infection and prevalent genotypes, electronic databases (e.g. PubMed/MEDLINE and HINARI) were searched for peer reviewed English articles on HPV infection up to November 30, 2010. Eligible studies were selected according to the following criteria: DNA-confirmed cervical or male genital HPV prevalence and genotypes, HPV incidence estimates and HPV seroprevalence among participants. RESULTS Twenty studies were included in the review. Among HIV negative adult women, the prevalence of HR-HPV infections ranged from 10.2% -40.0% compared to 37.0% -100.0% among HIV positive women. Among HIV positive young women aged below 25 years, the prevalence of HR-HPV genotypes ranged from 41.6% -75.0% compared to 23.7% -67.1% among HIV negative women. Multiple infections with non vaccine HR-HPV genotypes were frequent in both HIV positive and HIV negative women. The main risk factors for prevalent HPV infections were age, lifetime number of sexual partners and HIV infection. Incident infections with HR-HPV genotypes were more frequent among adult HIV positive than HIV negative women estimated at 17.3 and 7.0 per 100 person-years, respectively. Similarly, incident HR-HPV among young women aged below 25 years were more frequent among HIV positive (40.0 per 100 person-years) than HIV negative women (20.3 per 100 person-years) women. The main risk factor for incident infection was HIV infection. HPV 16 and 18 were the most common genotypes in ICC with HPV 16/18 contributing up to 73.5% of cases with single infections.Among uncircumcised adult HIV positive males, HR-HPV prevalence ranged from 55.3% -76.6% compared to 38.6% -47.6% in HIV negative males. Incident and multiple HR-HPV infections were frequent in HIV positive males. Being uncircumcised was the main risk factor for both prevalent and incident HPV infection. CONCLUSION Infections with HR-HPV genotypes were very common particularly among HIV positive individuals and young women irrespective of HIV status. Given the high prevalence of HIV infection, HPV-associated conditions represent a major public health burden in Uganda. However, although the most common HPV genotypes in ICC cases in Uganda were those targeted by current preventive vaccines, there were a large number of individuals infected with other HR-HPV genotypes. Technology allowing, these other HR-HPV types should be considered in the development of the next generation of vaccines.
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Affiliation(s)
- Cecily Banura
- Child Health and Development Centre, Makerere University College of Health Sciences, P. O. Box 6717, Kampala, Uganda
| | - Florence M Mirembe
- Department of Obstetrics and Gynecology, Makerere University College of Health Sciences, P.O. Box 7072, Kampala Uganda
| | - Anne R Katahoire
- Child Health and Development Centre, Makerere University College of Health Sciences, P. O. Box 6717, Kampala, Uganda
| | - Proscovia B Namujju
- Uganda Virus Research Institute, P.O. Box 49, Entebbe, Uganda
- National Institute for Health and Welfare, Oulu, Finland
| | - Anthony K Mbonye
- Department of Community Health Ministry of Health, P.O. Box 7272, Kampala, Uganda
| | - Fred M Wabwire
- School of Public Health, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
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Mwanahamuntu MH, Sahasrabuddhe VV, Kapambwe S, Pfaendler KS, Chibwesha C, Mkumba G, Mudenda V, Hicks ML, Vermund SH, Stringer JSA, Parham GP. Advancing cervical cancer prevention initiatives in resource-constrained settings: insights from the Cervical Cancer Prevention Program in Zambia. PLoS Med 2011; 8:e1001032. [PMID: 21610859 PMCID: PMC3096609 DOI: 10.1371/journal.pmed.1001032] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Groesbeck Parham and colleagues describe their Cervical Cancer Prevention Program in Zambia, which has provided services to over 58,000 women over the past five years, and share lessons learned from the program's implementation and integration with existing HIV/AIDS programs.
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Affiliation(s)
- Mulindi H. Mwanahamuntu
- Centre for Infectious Disease Research in
Zambia, Lusaka, Zambia
- University Teaching Hospital, Lusaka,
Zambia
| | | | - Sharon Kapambwe
- Centre for Infectious Disease Research in
Zambia, Lusaka, Zambia
- University Teaching Hospital, Lusaka,
Zambia
| | | | - Carla Chibwesha
- Centre for Infectious Disease Research in
Zambia, Lusaka, Zambia
- University of Alabama at Birmingham,
Birmingham, Alabama, United States of America
| | - Gracilia Mkumba
- Centre for Infectious Disease Research in
Zambia, Lusaka, Zambia
- University Teaching Hospital, Lusaka,
Zambia
| | | | - Michael L. Hicks
- Michigan Cancer Institute, Pontiac, Michigan,
United States of America
| | - Sten H. Vermund
- Vanderbilt University, Nashville, Tennessee,
United States of America
| | - Jeffrey S. A. Stringer
- Centre for Infectious Disease Research in
Zambia, Lusaka, Zambia
- University of Alabama at Birmingham,
Birmingham, Alabama, United States of America
| | - Groesbeck P. Parham
- Centre for Infectious Disease Research in
Zambia, Lusaka, Zambia
- University Teaching Hospital, Lusaka,
Zambia
- University of Alabama at Birmingham,
Birmingham, Alabama, United States of America
- * E-mail: or
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