Utilisation of cervical cancer screening among women living with HIV at Kenya's national referral hospital

Cervical cancer screening delay and associated factors among women with HIV in Lesotho: a mixed-methods study

BACKGROUND

Cervical cancer is the fourth most common cancer in women worldwide, and women with human immunodeficiency virus (HIV) are particularly at risk of developing it. Regular screening effectively prevents morbidity and mortality. This mixed-methods study quantitatively assessed cervical cancer screening uptake and qualitatively explored the process of undergoing cervical cancer screening to understand possible reasons for delayed screening among women with HIV in Lesotho.

METHODS

Between October 2020 and March 2022, the Viral load Triggered ART care in Lesotho (VITAL) trial enrolled women aged 18 years and older with HIV who were taking antiretroviral therapy (ART). Cervical cancer screening delay was defined as reporting a screening that occurred more than two years ago or never having been screened. Cervical cancer screening uptake and the association between screening delay and sociodemographic variables were assessed using a multivariable mixed-effects logistic regression model accounting for clustering at clinic level. In-depth interviews were conducted with 16 women to obtain information on awareness, perceptions, and barriers to cervical cancer screening and were analyzed using thematic analysis.

RESULTS

Quantitative data were available for 3790 women. Among them, cervical cancer screening was delayed in 1814 (47.9%), including 1533 (40.5%) who were never screened. Compared to women aged 25 to 39 years, women aged 18 to 24 years (adjusted odds ratio (aOR) 2.8; 95% confidence interval (CI) 2.1-3.7), women aged 40 to 59 years (aOR 1.3; CI 1.1-1.6), and women older than 60 years (aOR 3.9; CI 3.0-5.1) were at higher risk of screening delay. Furthermore, time on ART below 6 months (aOR 1.6; CI 1.1-2.3) compared to above 6 months was associated with screening delay. Qualitative data identified limited awareness of cervical cancer risks and screening guidelines, misconceptions and fears created by the influence of other women's narratives, and low internal motivation as the main barriers to screening uptake.

CONCLUSIONS

Cervical cancer screening delay was common. Limited personal awareness and motivation as well as the negative influence of other women were the primary internal barriers to cervical cancer screening. Awareness and screening campaigns in Lesotho should consider these factors.

TRIAL REGISTRATION

clinicaltrials.gov, NCT04527874, August 27, 2020.

Providers and women's perspectives on opportunities, challenges and recommendations to improve cervical cancer screening in women living with HIV at Mbarara Regional Referral Hospital: a qualitative study

BACKGROUND

Cervical cancer screening uptake remains low despite being a critical prevention method for adult women living with HIV(WLHIV). These women experience greater incidence and persistence of high-risk human papillomavirus (HPV) and severe outcomes, including cervical cancer comorbidity and death.

OBJECTIVE

We explored the opportunities, challenges, and recommendations of clinical care providers and WLHIV to improve cervical cancer screening uptake among WLHIV in Southwestern Uganda.

METHODS

In a cross-sectional qualitative study from January to June 2021 at Mbarara Regional Referral Hospital, we interviewed six key informant clinical care providers and held four focus group discussions with women living with HIV. Data was coded using Atlas ti software and analysed using thematic inductive analysis.

RESULTS

The participants identified several prevailing opportunities for cervical cancer screening, including skilled clinical care workers, public awareness for demand creation, optimized clinic flow, provider-led referrals, and peer-led information sharing that ease clinic navigation and shorten participant throughput. However, challenges occurred due to standalone services resulting in double queuing, longer clinic visit hours, missed chances for screening alongside unsupported lower health facilities leading to crowding at the referral hospital, and inadequate patient privacy measures leading to shame and stigma and the misconception that cervical cancer is incurable. Integrating HPV-DNA testing in HIV services was perceived with ambivalence; some participants worried about the quality of sample collection, while others valued the privacy it offered. Optimising self-collected DNA testing and sufficient counselling were recommended to improve cervical cancer screening uptake.

CONCLUSION

Opportunities for cervical cancer screening included trained clinical care professionals, increased public awareness, improved clinic flow, provider referrals, and peer education. Challenges, such as unsupported lower-level health facilities, misconceptions, inadequate patient privacy, and uncertainty about integrating HPV-DNA screening into HIV services, were cited. Adequate counselling and self-sample collection were recommended to foster screening. Our findings may guide healthcare programs integrating cervical cancer screening into HIV clinics to reach the 70% World Health Organisation targets by 2030.

Factors associated with late diagnosis of cervical cancer at two national referral hospitals, Kenya 2017: A case control study

Background

Cervical cancer is the leading cause of cancer mortality among women in Kenya. Two thirds of cervical cancer cases in Kenya are diagnosed in advanced stages. We aimed to identify factors associated with late diagnosis of cervical cancer, to guide policy interventions.

Methods

An unmatched case control study (ratio 1:2) was conducted among women aged ≥ 18 years with cervical cancer at Kenyatta National and Moi Teaching and Referral Hospitals. We defined a case as patients with International Federation of Gynecology and Obstetrics (FIGO) stage ≥ 2A and controls as those with stage ≤ 1B. A structured questionnaire was used to document exposure variables. We calculated adjusted odds ratio (aOR) to identify any associations.

Results

We enrolled 192 participants (64 cases, 128 controls). Mean age 39.2 (±9.3) years, 145 (76 %) were married, 77 (40 %) had primary level education, 168 (88 %) had their first pregnancy ≤ 24 years of age, 85 (44 %) were > para 3 and 150 (78 %) used contraceptives. Late diagnosis of cervical cancer was associated with cost of travel to cancer centres > USD 6.1 (aOR 6.43 95% CI [1.30, 31.72]), age > 50 years (aOR 4.71; 95% CI [1.18, 18.80]), anxiety over cost of cancer care (aOR 5.6; 95% CI [1.05, 32.72]) and ultrasound examination during evaluation of symptoms (aOR 4.89; 95% CI [1.07-22.42]). Previous treatment for gynecological infections (aOR 0.10; 95% CI [0.02, 0.47]) was protective against late diagnosis.

Conclusion

Cost of seeking care and the quality of the diagnostic process were important factors in this study. Decentralization of care, innovative health financing solutions and clear diagnostic and referral algorithms for women presenting with gynecological symptoms could reduce late-stage diagnosis in Kenya.