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Dion H, Choi H, Huang M, Sathyan L, Herfel E, Makhulo B, Ambaka J, Ibrahim S, Huchko M. Evaluation of video-assisted HPV education in government-supported clinics in Western Kenya. PLOS Glob Public Health 2023; 3:e0002539. [PMID: 38109300 PMCID: PMC10727431 DOI: 10.1371/journal.pgph.0002539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 10/05/2023] [Indexed: 12/20/2023]
Abstract
Despite prevalent preventative methods of human papillomavirus (HPV), cervical cancer remains the foremost cause of cancer-related death among women of reproductive age in Western Kenya. HPV self-sampling is a preventative measure that can improve accessibility and availability to cervical cancer screening. Correct education about HPV is crucial to combating stigma and increasing HPV screening uptake. In this study, we evaluated the workflow impact of a video-assisted HPV education to promote self-sampling in clinical settings in Kisumu, Kenya. We conducted a descriptive workflow study nested in a two-part cluster-randomized control trial in six government-supported health clinics in Kisumu County. We observed the workflow of HPV screening video-assisted and standard health educations. and evaluated community and clinic health assistant facilitation (CCHA), duration, and feasibility of the intervention. Thirty HPV screening-eligible women who participated in the video intervention were recruited for three focus group discussions (FGDs). The FGDs aimed to better understand women's experience with the video screening, their impressions on the content, and feedback about intervention logistics. Across 33 observations, 16.5 women per day watched the educational video at intervention clinics, and 14 women per day heard standard Ministry of Health cervical cancer prevention education talks at control clinics. Sixty-three percent of women participated in HPV self-sampling in the intervention sites, compared to forty-six percent who screened after standard health talks at control sites. The workflow observations identified variable video projection and viewing space, access to power supply, and CCHA availability and ability to utilize the projector as major factors impacting education workflow. Women in FGDs appreciated the video modality, length of video, and education location. HPV video education is a suitable intervention, with further research recommended to determine the viability of sustainably implementing the intervention in a clinic environment. This research is fully funded by the Duke University Global Health Institute.
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Affiliation(s)
- Haley Dion
- Center for Global Reproductive Health, Duke Global Health Institute, Durham, North Carolina, United States of America
| | - Hanul Choi
- Center for Global Reproductive Health, Duke Global Health Institute, Durham, North Carolina, United States of America
| | - Michelle Huang
- Center for Global Reproductive Health, Duke Global Health Institute, Durham, North Carolina, United States of America
| | - Laya Sathyan
- Center for Global Reproductive Health, Duke Global Health Institute, Durham, North Carolina, United States of America
| | - Emily Herfel
- Center for Global Reproductive Health, Duke Global Health Institute, Durham, North Carolina, United States of America
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Breandan Makhulo
- Center for Global Reproductive Health, Duke Global Health Institute, Durham, North Carolina, United States of America
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Jeniffer Ambaka
- Center for Global Reproductive Health, Duke Global Health Institute, Durham, North Carolina, United States of America
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Saduma Ibrahim
- Center for Global Reproductive Health, Duke Global Health Institute, Durham, North Carolina, United States of America
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Megan Huchko
- Center for Global Reproductive Health, Duke Global Health Institute, Durham, North Carolina, United States of America
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, United States of America
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Mitchell L, Vellanki B, Tang L, Hunter K, Finnegan A, Swartz JJ, Huchko M. Contraceptive Provision to Women With Intellectual and Developmental Disabilities Enrolled in Medicaid. Obstet Gynecol 2023; 142:1477-1485. [PMID: 38051293 PMCID: PMC10642699 DOI: 10.1097/aog.0000000000005421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 08/06/2023] [Accepted: 08/17/2023] [Indexed: 10/28/2023]
Abstract
OBJECTIVE To compare contraceptive provision to women with and without intellectual and developmental disabilities enrolled in North Carolina Medicaid. METHODS Our retrospective cohort study used 2019 North Carolina Medicaid claims to identify women aged 15-44 years with and without intellectual and developmental disabilities at risk for pregnancy who were continuously enrolled during 2019 or had Family Planning Medicaid with at least one claim. We calculated the proportion in each cohort who received 1) most or moderately effective contraception, 2) long-acting reversible contraception, 3) short-acting contraception, and 4) individual methods. We classified contraceptive receipt by procedure type and disaggregated across sociodemographic characteristics. Adjusting for age, race, ethnicity, and urban or rural setting, we constructed logistic regression models to estimate most or moderately effective contraceptive provision odds by intellectual and developmental disability status and by level or type of intellectual and developmental disability. We performed subanalyses to estimate co-occurrence of provision and menstrual disorders. RESULTS Among 9,508 women with intellectual and developmental disabilities and 299,978 without, a significantly smaller proportion with intellectual and developmental disabilities received most or moderately effective contraception (30.1% vs 36.3%, P <.001). With the exception of injectable contraception, this trend was consistent across all measures and remained statistically significant after controlling for race, ethnicity, age, and urban or rural status (adjusted odds ratio 0.75, 95% CI 0.72-0.79; P <.001). Among those who received most or moderately effective contraception, a significantly greater proportion of women with intellectual and developmental disabilities had co-occurring menstrual disorders (31.3% vs 24.3%, P <.001). CONCLUSION These findings suggest disparities in contraceptive provision and potential differences in clinical indication by intellectual and developmental disability status. Future studies should investigate reasons for and barriers to contraceptive use among women with intellectual and developmental disabilities.
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Affiliation(s)
- Lauren Mitchell
- Duke Global Health Institute, the Sanford School of Public Policy, the Department of Political Science, Department of Obstetrics and Gynecology, and the Center for Global Reproductive Health, Duke University, Durham, and IntraHealth International, Chapel Hill, North Carolina
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Adewumi K, Nishimura H, Oketch SY, Adsul P, Huchko M. Barriers and Facilitators to Cervical Cancer Screening in Western Kenya: a Qualitative Study. J Cancer Educ 2022; 37:1122-1128. [PMID: 33411253 PMCID: PMC9257902 DOI: 10.1007/s13187-020-01928-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/22/2020] [Indexed: 06/12/2023]
Abstract
About nine out of 10 cervical cancer deaths occur in low-resource countries, with a particularly high burden in sub-Saharan Africa. The objectives of this study were to assess barriers and facilitators to cervical cancer screening in western Kenya from the perspectives of community members and healthcare providers. We conducted two focus groups with female community members (n = 24) and one with providers (n = 12) in Migori County, Kenya. Discussion guides queried about knowledge and awareness of cervical cancer prevention; structural, social, and personal barriers; and facilitators towards cervical cancer screening uptake. Group discussions were recorded, transcribed, and analyzed for emerging themes. Participants in both groups reported low awareness of HPV and cervical cancer screening in the community, and identified that as a main barrier to screening. Community members reported fear of pain and embarrassment as significant barriers to a screening pelvic exam. They also reported that providers' lack of knowledge and discomfort with a sensitive subject were significant barriers. A personal connection to cervical cancer and/or screening was associated with willingness to screen and awareness. Providers reported workload and lack of supplies and trained staff as significant barriers to offering services. Based on these findings, we identified three intervention components to address these facilitators and barriers to screening. They include utilizing existing social networks to expand awareness of cervical cancer risk and screening, training non-physician health workers to meet the demand for screening, and employing female-driven screening techniques such as self-collection of specimens for HPV testing. Cervical cancer prevention programs must take into account the local realities in which they occur. In low-resource areas in particular, identifying low-cost, effective, and culturally appropriate strategies for addressing poor screening uptake is important given limited funding. This study took a formative approach to identify facilitators and barriers to cervical cancer screening based on focus groups and interviews with community members and healthcare providers.
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Affiliation(s)
- Konyin Adewumi
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, 27710, USA.
| | - Holly Nishimura
- School of Public Health, University of California at Berkeley, Berkeley, CA, USA
| | - Sandra Y Oketch
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Prajakta Adsul
- National Cancer Institute/National Institutes of Health, Bethesda, MD, USA
| | - Megan Huchko
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, 27710, USA
- Department of Obstetrics and Gynecology, Duke University, Durham, NC, USA
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Reid HW, Proeschold-Bell RJ, Makarushka C, Melgar Vega KD, Huchko M, Jeronimo J, Vasudevan L. Using the Consolidated Framework for Implementation Research to Inform the Design of the Mobile Inspección Visual con Ácido Acético System: Mixed Methods Case Study. JMIR Form Res 2022; 6:e32577. [PMID: 35737455 PMCID: PMC9264128 DOI: 10.2196/32577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 03/03/2022] [Accepted: 05/02/2022] [Indexed: 12/03/2022] Open
Abstract
Background There is growing evidence supporting the use of mobile health (mHealth) interventions in low- and middle-income countries to address resource limitations in the delivery of health information and services to vulnerable populations. In parallel, there is an increasing emphasis on the use of implementation science tools and frameworks for the early identification of implementation barriers and to improve the acceptability, appropriateness, and adoption of mHealth interventions in resource-limited settings. However, there are limited examples of the application of implementation science tools and frameworks to the formative phase of mHealth design for resource-limited settings despite the potential benefits of this work for enhancing subsequent implementation, scale-up, and sustainability. Objective We presented a case study on the use of an implementation science framework in mHealth design. In particular, we illustrated the usability of the Consolidated Framework for Implementation Research (CFIR) for organizing and interpreting formative research findings during the design of the mobile Inspección Visual con Ácido Acético (mIVAA) system in Lima, Peru. Methods We collected formative data from prospective users of the mIVAA intervention using multiple research methodologies, including structured observations, surveys, group and individual interviews, and discussions with local stakeholders at the partnering organization in Peru. These activities enabled the documentation of clinical workflows, perceived barriers to and facilitators of mIVAA, overarching barriers to cervical cancer screening in community-based settings, and related local policies and guidelines in health care. Using a convergent mixed methods analytic approach and the CFIR as an organizing framework, we mapped formative research findings to identify key implementation barriers and inform iterations of the mIVAA system design. Results In the setting of our case study, most implementation barriers were identified in the CFIR domains of intervention characteristics and inner setting. All but one barrier were addressed before mIVAA deployment by modifying the system design and adding supportive resources. Solutions involved improvements to infrastructure, including cellular data plans to avoid disruption from internet failure; improved process and flow, including an updated software interface; and better user role definition for image capture to be consistent with local health care laws. Conclusions The CFIR can serve as a comprehensive framework for organizing formative research data and identifying key implementation barriers during mHealth intervention design. In our case study of the mIVAA system in Peru, formative research contributing to the CFIR domains of intervention characteristics and inner setting elicited the most key barriers to implementation. The early identification of barriers enabled design iterations before system deployment. Future efforts to develop mHealth interventions for low- and middle-income countries may benefit from using the approach presented in this case study as well as prioritizing the CFIR domains of intervention characteristics and inner setting.
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Affiliation(s)
| | - Rae Jean Proeschold-Bell
- Duke Global Health Institute, Durham, NC, United States
- Center for Health Policy and Inequalities Research, Duke University, Durham, NC, United States
| | - Christina Makarushka
- Department of Family Medicine and Community Health, Duke University, Durham, NC, United States
| | | | - Megan Huchko
- Duke University School of Medicine, Durham, NC, United States
- Duke Global Health Institute, Durham, NC, United States
- Department of Obstetrics and Gynecology, Duke University, Durham, NC, United States
| | | | - Lavanya Vasudevan
- Duke University School of Medicine, Durham, NC, United States
- Duke Global Health Institute, Durham, NC, United States
- Center for Health Policy and Inequalities Research, Duke University, Durham, NC, United States
- Department of Family Medicine and Community Health, Duke University, Durham, NC, United States
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Stocks J, Ibrahim S, Park L, Huchko M. Mobile Phone Ownership and Use Among Women Screening for Cervical Cancer in a Community-Based Setting in Western Kenya: Observational Study. JMIR Public Health Surveill 2022; 8:e28885. [PMID: 35671089 PMCID: PMC9214615 DOI: 10.2196/28885] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 02/28/2022] [Accepted: 04/01/2022] [Indexed: 12/24/2022] Open
Abstract
Background Mobile phone ownership among women of reproductive age in western Kenya is not well described, and our understanding of its link with care-seeking behaviors is nascent. Understanding access to and use of mobile phones among this population as well as willingness to participate in mobile health interventions are important in improving and more effectively implementing mobile health strategies. Objective This study aims to describe patterns of mobile phone ownership and use among women attending cervical cancer screening and to identify key considerations for the use of SMS text message–guided linkage to treatment strategies and other programmatic implications for cervical cancer screening in Kenya. Methods This analysis was nested within a cluster randomized trial evaluating various strategies for human papillomavirus (HPV)–based cervical cancer screening and prevention in a rural area in western Kenya between February and November 2018. A total of 3299 women were surveyed at the time of screening and treatment. Questionnaires included items detailing demographics, health history, prior care-seeking behaviors, and patterns of mobile phone ownership and use. We used bivariate and multivariable log-binomial regression to analyze associations between independent variables and treatment uptake among women testing positive for high-risk HPV. Results Rates of mobile phone ownership (2351/3299, 71.26%) and reported daily use (2441/3299, 73.99%) were high among women. Most women (1953/3277, 59.59%) were comfortable receiving their screening results via SMS text messages, although the most commonly preferred method of notification was via phone calls. Higher levels of education (risk ratio 1.23, 95% CI 1.02-1.50), missing work to attend screening (risk ratio 1.29, 95% CI 1.10-1.52), and previous cervical cancer screening (risk ratio 1.27, 95% CI 1.05-1.55) were significantly associated with a higher risk of attending treatment after testing high-risk HPV–positive, although the rates of overall treatment uptake remained low (278/551, 50.5%) among this population. Those who shared a mobile phone with their partner or spouse were less likely to attend treatment than those who owned a phone (adjusted risk ratio 0.69, 95% CI 0.46-1.05). Treatment uptake did not vary significantly according to the type of notification method, which were SMS text message, phone call, or home visit. Conclusions Although the rates of mobile phone ownership and use among women in western Kenya are high, we found that individual preferences for communication of messages about HPV results and treatment varied and that treatment rates were low across the entire cohort, with no difference by modality (SMS text message, phone call, or home visit). Therefore, although text-based results performed as well as phone calls and home visits, our findings highlight the need for more work to tailor communication about HPV results and support women as they navigate the follow-up process.
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Affiliation(s)
- Jacob Stocks
- Center for Global Reproductive Health, Duke Global Health Institute, Durham, NC, United States
| | | | - Lawrence Park
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, United States.,Research Design and Analysis Core, Duke Global Health Institute, Durham, NC, United States
| | - Megan Huchko
- Center for Global Reproductive Health, Duke Global Health Institute, Durham, NC, United States.,Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, United States
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Stocks J, Choi Y, Ibrahim S, Huchko M. Iterative Development of a Mobile Phone App to Support Community Health Volunteers During Cervical Cancer Screening in Western Kenya: Qualitative Study. JMIR Form Res 2022; 6:e27501. [PMID: 35200151 PMCID: PMC8914757 DOI: 10.2196/27501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 09/29/2021] [Accepted: 12/29/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND To achieve the World Health Organization targets for cervical cancer elimination, low- and middle-income countries will need to develop innovative strategies to provide human papillomavirus (HPV)-based screening at a population level. Although mobile health (mHealth) interventions may help realize these goals by filling gaps in electronic specimen tracking and patient education, effective implementation of mHealth interventions is dependent upon context-specific development that is acceptable and usable by the target population. Detailed feedback should be gathered at the design and development stages to yield final products that reflect the needs, desires, and capabilities of target users. OBJECTIVE The aim of this study is to develop an mHealth app (mSaada) to support HPV-based screening in partnership with community health volunteers (CHVs) and program planners in western Kenya. METHODS A team of student programmers developed a prototype to meet previously identified gaps in screening: patient education, protocol support, data capture, and specimen tracking. The prototype was iteratively developed through 2 waves of in-person working sessions with quantitative (survey) and qualitative (in-depth interview) feedback. Research staff engaged key stakeholders from both urban and rural locations and with varying levels of experience in delivering screening services. During the sessions, participants completed simulation exercises and role-play activities to become familiar with the platform. Once feedback was gathered and synthesized after each wave of in-person data collection, developers implemented changes to improve mSaada functionality. RESULTS A total of 18 CHVs and clinicians participated in the in-person sessions. Participants found mSaada useful, easy to use, and would meet the needs of CHVs to provide HPV-based cervical cancer screening (electronic data capture, client education resources, and specimen tracking). They provided key feedback to enhance user experience, workflow, and sustainability. Key changes included altering the appearance of the wireframes, adding translation in additional local languages, changing potentially insensitive figures, alphabetizing lengthy dropdown menus, adding clinically relevant logic checks when entering data, and incorporating the ability to make real time edits to client records. They also made recommendations for additional features that might enhance mSaada's impact at the facility and health system levels, specifically the inclusion of a report-generating tool consistent with the Ministry of Health standards. CONCLUSIONS Using a process of iterative feedback with key stakeholders and rapid response from developers, we have developed a mobile app ready for pilot testing in HPV-based screening programs led by CHVs.
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Affiliation(s)
- Jacob Stocks
- Center for Global Reproductive Health, Duke Global Health Institute, Durham, NC, United States
| | - Yujung Choi
- Center for Global Reproductive Health, Duke Global Health Institute, Durham, NC, United States
| | | | - Megan Huchko
- Center for Global Reproductive Health, Duke Global Health Institute, Durham, NC, United States.,Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, United States
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Ginjupalli R, Mundaden R, Choi Y, Herfel E, Oketch SY, Watt MH, Makhulo B, Bukusi EA, Huchko M. Developing a framework to describe stigma related to cervical cancer and HPV in western Kenya. BMC Womens Health 2022; 22:39. [PMID: 35148778 PMCID: PMC8832662 DOI: 10.1186/s12905-022-01619-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 02/01/2022] [Indexed: 11/21/2022] Open
Abstract
Background Despite a high prevalence of human papillomavirus (HPV) and cervical cancer in low and middle-income countries, stigma remains an issue. Addressing HPV and cervical cancer stigma could significantly improve health outcomes for these conditions. The objective of this study was to identify the manifestations of stigma and their potential impacts on health-seeking behavior. Methods Twenty-six in-depth interviews were conducted with women living with HIV, HIV-negative women, community health volunteers, and health care providers in Kisumu, Kenya in 2019. The interviews were designed to draw out existing attitudes or experiences related to stigma within the community. We conducted a thematic analysis of the interviews to identify internalized, anticipated, and discriminatory attitudes. Results Within internalized attitudes, a prominent observed theme was a fear of death associated with a positive HPV test. This stemmed from a lack of understanding of differences between HPV and cervical cancer and posed a significant barrier for women deciding to seek screening or to continue with treatment. Discriminatory attitudes of community members, including assumptions of promiscuity, infidelity, or HIV status, were perceived to prevent women from accessing screening and treatment opportunities. The interviews also exhibited a limited awareness of HPV in this region, which may have contributed to a lack of enacted stigma towards people living with HPV or cervical cancer. Conclusion Stigma has the potential to lead to decreased screening and treatment uptake through its drivers. This includes a decreased perception of personal risk due to a lack of knowledge, which results in increased HPV-risk behaviors. Future research must focus on creating and integrating stigma-reducing interventions, primarily to encourage women to seek out primary and secondary preventative measures. Supplementary Information The online version contains supplementary material available at 10.1186/s12905-022-01619-y.
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Affiliation(s)
- Ramya Ginjupalli
- Center for Global Reproductive Health, Duke Global Health Institute, 310 Trent Dr, Durham, NC, 27710, USA.
| | - Rachel Mundaden
- Center for Global Reproductive Health, Duke Global Health Institute, 310 Trent Dr, Durham, NC, 27710, USA
| | - Yujung Choi
- Center for Global Reproductive Health, Duke Global Health Institute, 310 Trent Dr, Durham, NC, 27710, USA
| | - Emily Herfel
- Center for Global Reproductive Health, Duke Global Health Institute, 310 Trent Dr, Durham, NC, 27710, USA.,Department of Obstetrics and Gynecology, Duke University, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Sandra Yvonne Oketch
- Center for Microbiology Research, Kenya Medical Research Institute, Off Mbagathi Road, P.O. Box 54840 00200, Nairobi, Kenya
| | - Melissa H Watt
- Department of Population Health Sciences, University of Utah, Williams Building, Room 1N490, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Breandan Makhulo
- Center for Microbiology Research, Kenya Medical Research Institute, Off Mbagathi Road, P.O. Box 54840 00200, Nairobi, Kenya
| | - Elizabeth Anne Bukusi
- Center for Microbiology Research, Kenya Medical Research Institute, Off Mbagathi Road, P.O. Box 54840 00200, Nairobi, Kenya
| | - Megan Huchko
- Center for Global Reproductive Health, Duke Global Health Institute, 310 Trent Dr, Durham, NC, 27710, USA.,Department of Obstetrics and Gynecology, Duke University, 2301 Erwin Road, Durham, NC, 27710, USA
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Mungo C, Osongo CO, Ambaka J, Randa MA, Omoto J, Cohen CR, Huchko M. Safety and Acceptability of Thermal Ablation for Treatment of Human Papillomavirus Among Women Living With HIV in Western Kenya. JCO Glob Oncol 2021; 6:1024-1033. [PMID: 32634066 PMCID: PMC7392781 DOI: 10.1200/go.20.00035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE The WHO now recommends thermal ablation as an alternative to cryotherapy within “screen-and-treat” cervical cancer programs in low- and middle-income countries (LMICs). We conducted a safety and acceptability clinical trial of thermal ablation in a Kenyan Ministry of Health hospital among women living with HIV (WLWH; ClinicalTrials.gov identifier: NCT04191967). METHODS Between August 2019 and February 2020, WLWH age 25-65 years underwent human papillomavirus (HPV) self-collection in western Kenya. HPV-positive women underwent visual inspection with acetic acid, biopsy, and treatment with thermal ablation performed by a nonphysician clinician, if eligible by standard guidelines. A questionnaire was administered after treatment to assess for pain and treatment acceptability. Adverse events (AEs) were evaluated 4-6 weeks after treatment with a standardized grading tool. RESULTS A total of 293 HPV-positive WLWH underwent thermal ablation in the study period. The mean age was 40.4 years (standard deviation, 8.7 years). After treatment, 15 (5.1%), 231 (78.8%), 42 (14.3%), and 5 (1.8%) reported none, mild, moderate, and severe pain with treatment, respectively. At follow-up, spotting, vaginal discharge, and pelvic pain were reported by 99 (37.8%), 258 (98.5%), and 46 (17.6%), respectively, for a median of 3.3 (interquartile range [IQR], 2-3), 14 (IQR, 7-21), and 7 (IQR, 3-7) days, respectively. Most participants graded their AEs as mild (grade 1): 94 (95.0%) for bleeding, 125 (48.5%) for vaginal discharge, and 37 (80.4%) for pelvic pain. No grade 3 or 4 AEs were reported. The vast majority (99.2%) were satisfied with the treatment and would recommend it to a friend. CONCLUSION Thermal ablation performed by nonphysicians in the public health sector in Kenya proved safe and highly acceptable in treating HPV-positive WLWH.
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Affiliation(s)
- Chemtai Mungo
- Division of Prevention Science, Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, CA
| | | | | | | | - Jackton Omoto
- Department of Obstetrics and Gynecology, Maseno University School of Medicine, Kisumu, Kenya
| | - Craig R Cohen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA
| | - Megan Huchko
- Department of Obstetrics and Gynecology, Duke University, Durham, NC
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Gravitt PE, Silver MI, Hussey HM, Arrossi S, Huchko M, Jeronimo J, Kapambwe S, Kumar S, Meza G, Nervi L, Paz-Soldan VA, Woo YL. Achieving equity in cervical cancer screening in low- and middle-income countries (LMICs): Strengthening health systems using a systems thinking approach. Prev Med 2021; 144:106322. [PMID: 33678230 DOI: 10.1016/j.ypmed.2020.106322] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 11/04/2020] [Accepted: 11/05/2020] [Indexed: 01/01/2023]
Abstract
The World Health Organization (WHO) is leading a call to action to eliminate cervical cancer by the end of the century through global implementation of two effective evidence-based preventive interventions: HPV vaccination and cervical screening and management (CSM). Models estimate that without intervention, over the next 50 years 12.2 million new cases of cervical cancer will occur, nearly 60% of which are preventable only through CSM. Given that more than 80% of the cervical cancer occurs in low- and middle-income countries (LMICs), scaling up sustainable CSM programs in these countries is a top priority for achieving the global elimination goals. Multiple technologies have been developed and validated to meet this need. Now it is critical to identify strategies to implement these technologies into complex, adaptive health care delivery systems. As part of the coordinated cervical cancer elimination effort, we applied a systems thinking lens to reflect on our experiences with implementation of HPV-based CSM programs using the WHO health systems framework. While many common health system barriers were identified, the effectiveness of implementation strategies to address them was context dependent; often reflecting differences in stakeholder's belief in the quality of the evidence supporting a CSM algorithm, the appropriateness of the evidence and algorithm to context, and the 'implementability' of the algorithm under realistic assessments of resource availability and constraints. A structured planning process, with early and broad stakeholder engagement, will ensure that shared-decisions in CSM implementation are appropriately aligned with the culture, values, and resource realities of the setting.
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Affiliation(s)
- Patti E Gravitt
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA.
| | | | - Heather M Hussey
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Megan Huchko
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | | | | | | | - Graciela Meza
- Universidad Nacional de la Amazonia Peruana, Iquitos, Peru
| | - Laura Nervi
- College of Population Health, University of New Mexico, Albuquerque, NM, USA
| | - Valerie A Paz-Soldan
- Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
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Olwanda EE, Kahn JG, Choi Y, Islam JY, Huchko M. Comparison of the costs of HPV testing through community health campaigns versus home-based testing in rural Western Kenya: a microcosting study. BMJ Open 2020; 10:e033979. [PMID: 33109637 PMCID: PMC7592277 DOI: 10.1136/bmjopen-2019-033979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 07/29/2020] [Accepted: 09/21/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To estimate the cost of human papillomavirus (HPV)-based screening through community health campaigns (CHCs) and home-based testing. SETTING CHCs and home-based testing in six communities in rural Western Kenya. PARTICIPANTS CHCs and home-based screening reached 2297 and 1002 women aged 25-65 years, respectively. OUTCOME MEASURES Outcome measures were overall cost per woman screened achieved through the CHCs and home-based testing and the cost per woman for each activity comprising the screening intervention. RESULTS The mean cost per woman screened through CHCs and home-based testing were similar, at $37.7 (range $26.4-$52.0) and $37.1 (range $27.6-$54.0), respectively. For CHCs, personnel represented 49% of overall cost, supplies 25%, services 5% and capital goods 23%. For home-based testing, these were: personnel 73%, supplies 25%, services 1% and capital goods 2%. A greater number of participants was associated with a lower cost per participant. CONCLUSIONS The mean cost per woman screened is comparable for CHC and home-based testing, with differences in type of input. The CHCs generally reached more eligible women in the six communities, whereas home-based strategies more efficiently reached populations with low screening rates. TRIAL REGISTRATION NUMBER NCT02124252.
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Affiliation(s)
| | - James G Kahn
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA
| | - Yujung Choi
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Duke University, Department of Obstetrics and Gynecology, Durham, NC, USA
| | - Jessica Yasmine Islam
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Megan Huchko
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Duke University, Department of Obstetrics and Gynecology, Durham, NC, USA
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Asiedu MN, Agudogo JS, Dotson ME, Skerrett E, Krieger MS, Lam CT, Agyei D, Amewu J, Asah-Opoku K, Huchko M, Schmitt JW, Samba A, Srofenyoh E, Ramanujam N. A novel speculum-free imaging strategy for visualization of the internal female lower reproductive system. Sci Rep 2020; 10:16570. [PMID: 33024146 PMCID: PMC7538883 DOI: 10.1038/s41598-020-72219-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 08/25/2020] [Indexed: 12/16/2022] Open
Abstract
Fear of the speculum and feelings of vulnerability during the gynecologic exams are two of the biggest barriers to cervical cancer screening for women. To address these barriers, we have developed a novel, low-cost tool called the Callascope to reimagine the gynecological exam, enabling clinician and self-imaging of the cervix without the need for a speculum. The Callascope contains a 2 megapixel camera and contrast agent spray mechanism housed within a form factor designed to eliminate the need for a speculum during contrast agent administration and image capture. Preliminary bench testing for comparison of the Callascope camera to a $20,000 high-end colposcope demonstrated that the Callascope camera meets visual requirements for cervical imaging. Bench testing of the spray mechanism demonstrates that the contrast agent delivery enables satisfactory administration and cervix coverage. Clinical studies performed at Duke University Medical Center, Durham, USA and in Greater Accra Regional Hospital, Accra, Ghana assessed (1) the Callascope's ability to visualize the cervix compared to the standard-of-care speculum exam, (2) the feasibility and willingness of women to use the Callascope for self-exams, and (3) the feasibility and willingness of clinicians and their patients to use the Callascope for clinician-based examinations. Cervix visualization was comparable between the Callascope and speculum (83% or 44/53 women vs. 100%) when performed by a clinician. Visualization was achieved in 95% (21/22) of women who used the Callascope for self-imaging. Post-exam surveys indicated that participants preferred the Callascope to a speculum-based exam. Our results indicate the Callascope is a viable option for clinician-based and self-exam speculum-free cervical imaging.Clinical study registration ClinicalTrials.gov https://clinicaltrials.gov/ct2/show/record/ NCT00900575, Pan African Clinical Trial Registry (PACTR) https://www.pactr.org/ PACTR201905806116817.
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Affiliation(s)
- Mercy N. Asiedu
- grid.26009.3d0000 0004 1936 7961Department of Biomedical Engineering, Duke University, Gross Hall Rm 370, Durham, NC 27713 USA ,grid.26009.3d0000 0004 1936 7961Center for Global Women’s Health Technologies, Duke University, Durham, NC USA ,grid.26009.3d0000 0004 1936 7961Duke Global Health Institute, Duke University, Durham, NC USA
| | - Júlia S. Agudogo
- grid.26009.3d0000 0004 1936 7961Department of Biomedical Engineering, Duke University, Gross Hall Rm 370, Durham, NC 27713 USA ,grid.26009.3d0000 0004 1936 7961Center for Global Women’s Health Technologies, Duke University, Durham, NC USA
| | - Mary E. Dotson
- grid.26009.3d0000 0004 1936 7961Center for Global Women’s Health Technologies, Duke University, Durham, NC USA
| | - Erica Skerrett
- grid.26009.3d0000 0004 1936 7961Department of Biomedical Engineering, Duke University, Gross Hall Rm 370, Durham, NC 27713 USA ,grid.26009.3d0000 0004 1936 7961Center for Global Women’s Health Technologies, Duke University, Durham, NC USA ,grid.26009.3d0000 0004 1936 7961Duke Global Health Institute, Duke University, Durham, NC USA
| | - Marlee S. Krieger
- grid.26009.3d0000 0004 1936 7961Department of Biomedical Engineering, Duke University, Gross Hall Rm 370, Durham, NC 27713 USA ,grid.26009.3d0000 0004 1936 7961Center for Global Women’s Health Technologies, Duke University, Durham, NC USA
| | - Christopher T. Lam
- grid.26009.3d0000 0004 1936 7961Department of Biomedical Engineering, Duke University, Gross Hall Rm 370, Durham, NC 27713 USA ,grid.26009.3d0000 0004 1936 7961Center for Global Women’s Health Technologies, Duke University, Durham, NC USA ,grid.26009.3d0000 0004 1936 7961Duke Global Health Institute, Duke University, Durham, NC USA
| | - Doris Agyei
- Family Planning and Reproductive Health Unit, Greater Accra Regional Hospital, Accra, Ghana
| | - Juliet Amewu
- Family Planning and Reproductive Health Unit, Greater Accra Regional Hospital, Accra, Ghana
| | - Kwaku Asah-Opoku
- grid.415489.50000 0004 0546 3805Department of Obstetrics and Gynecology, Korle Bu Teaching Hospital, Accra, Ghana ,grid.8652.90000 0004 1937 1485The University of Ghana Medical School, Accra, Ghana
| | - Megan Huchko
- grid.26009.3d0000 0004 1936 7961Duke Global Health Institute, Duke University, Durham, NC USA ,grid.414179.e0000 0001 2232 0951Department of Obstetrics and Gynecology, Duke Medical Center, Durham, NC USA
| | - John W. Schmitt
- grid.26009.3d0000 0004 1936 7961Duke Global Health Institute, Duke University, Durham, NC USA ,grid.414179.e0000 0001 2232 0951Department of Obstetrics and Gynecology, Duke Medical Center, Durham, NC USA
| | - Ali Samba
- grid.415489.50000 0004 0546 3805Department of Obstetrics and Gynecology, Korle Bu Teaching Hospital, Accra, Ghana ,grid.8652.90000 0004 1937 1485The University of Ghana Medical School, Accra, Ghana
| | - Emmanuel Srofenyoh
- Family Planning and Reproductive Health Unit, Greater Accra Regional Hospital, Accra, Ghana
| | - Nirmala Ramanujam
- grid.26009.3d0000 0004 1936 7961Department of Biomedical Engineering, Duke University, Gross Hall Rm 370, Durham, NC 27713 USA ,grid.26009.3d0000 0004 1936 7961Center for Global Women’s Health Technologies, Duke University, Durham, NC USA ,grid.26009.3d0000 0004 1936 7961Duke Global Health Institute, Duke University, Durham, NC USA
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Mungo C, Ibrahim S, Bukusi EA, Truong HHM, Cohen CR, Huchko M. Scaling up cervical cancer prevention in Western Kenya: Treatment access following a community-based HPV testing approach. Int J Gynaecol Obstet 2020; 152:60-67. [PMID: 32347550 DOI: 10.1002/ijgo.13171] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 01/28/2020] [Accepted: 04/14/2020] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To evaluate access to treatment after community-based HPV testing as testing within screen-and-treat programs has the potential to lower mortality from cervical cancer in low-resource settings. METHODS A prospective cohort study was conducted in western Kenya in 2018. Women aged 25-65 years underwent HPV self-testing. HPV-positive women were referred for cryotherapy. Participant data were obtained from questionnaires during screening and treatment. The proportion successfully accessing treatment and variables associated with successful treatment was determined. RESULTS Of the 750 women included, 140 (18.6%) tested positive for HPV. Of them, 135 were notified of their results, of whom 77 (59.2%) sought treatment and 73 (52.1%) received cryotherapy. Women who received treatment had a shorter time from screening to result notification (median 92 days, interquartile range [IQR] 84-104) compared to those who did not (97 days, IQR 89-106; P=0.061). In adjusted analyses, women with a history of cervical cancer screening (odds ratio [OR] 11, 95% confidence interval [CI] 1.42-85.20) and those electing result notification through a home visit (OR 4, 95% CI 1.23-14.17) were significantly more likely to acquire treatment at follow-up. CONCLUSION Linkage to treatment after community-based HPV screening in this population was low, highlighting the need for strategies aimed at strengthening treatment linkage in similar settings.
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Zhang D, Advani S, Huchko M, Braithwaite D. Impact of healthcare access and HIV testing on utilisation of cervical cancer screening among US women at high risk of HIV infection: cross-sectional analysis of 2016 BRFSS data. BMJ Open 2020; 10:e031823. [PMID: 31911515 PMCID: PMC6955489 DOI: 10.1136/bmjopen-2019-031823] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 12/12/2019] [Accepted: 12/13/2019] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Previous studies identified several factors associated with cervical cancer screening. However, many of them used samples from the general population and limited studies focused on women with high-risk health behaviours. We aimed to disentangle the association of cervical cancer screening with healthcare access and HIV testing among women at a high risk of HIV infection. DESIGN Nationwide cross-sectional survey in the USA. SETTING 2016 Behavioral Risk Factor Surveillance System. PARTICIPANTS 3448 women with a history of high-risk behaviours associated with HIV infection EXPOSURE AND OUTCOME: Clinical check-up, having personal healthcare provider, health coverage and HIV testing history were treated as exposures. Appropriate cervical cancer screening, which was defined according to 2016 US Preventive Services Task Force guideline, was treated as the outcome of interest. DATA ANALYSIS Multivariable logistic regression model was performed to evaluate associations of healthcare access and HIV testing with the uptake of cervical cancer screening; adjusted odds ratio (aOR) and 95% CI were reported. We further investigated if educational attainment modified associations identified in the primary multivariable model. RESULTS A total of 2911 (84.4%) high-risk women in our sample underwent cervical cancer screening. In the multivariable model, delayed clinical check-up (≥5 years ago vs within the past year: aOR: 0.19, 95% CI: 0.14 to 0.26), having no health insurance (aOR: 0.60, 95% CI: 0.46 to 0.79) and no history of HIV testing (no testing vs testing within the past year: aOR: 0.46, 95% CI: 0.35 to 0.61) were inversely associated with cervical cancer screening utilisation. CONCLUSION Factors reflecting healthcare access, specifically clinical check-up and health coverage, as well as history of HIV testing were associated with cervical cancer screening in this population-based study of high-risk women. Targeted interventions are warranted to further increase cervical cancer screening among women at high risk of HIV infection.
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Affiliation(s)
- Dongyu Zhang
- Department of Oncology, Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Shailesh Advani
- Department of Oncology, Georgetown University School of Medicine, Washington, District of Columbia, USA
- Social Behavioral Research Branch, National Institutes of Health, Bethesda, Maryland, USA
| | - Megan Huchko
- Department of Obstetrics and Gynecology, Duke Global Health Institute, Durham, North Carolina, USA
| | - Dejana Braithwaite
- Department of Oncology, Georgetown University School of Medicine, Washington, District of Columbia, USA
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Huchko M, Adewumi K, Oketch S, Saduma I, Bukusi E. 'I'm here to save my life': a qualitative study of experiences navigating a cryotherapy referral system for human papillomavirus-positive women in western Kenya. BMJ Open 2019; 9:e028669. [PMID: 31345973 PMCID: PMC6661588 DOI: 10.1136/bmjopen-2018-028669] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
BACKGROUND We sought to understand the beliefs, social norms and logistical factors that affect human papillomavirus (HPV)-positive women's uptake of cryotherapy treatment as part of a two-part cervical cancer screening strategy in rural Kenya. METHODS In-depth interviews within a parent cluster-randomised trial. SETTING Government-run county hospital in western Kenya. PARTICIPANTS 273 of 372 (73.4%) HPV-positive women who underwent cryotherapy RESULTS: Many women feared that an HPV infection meant they would develop cancer. Almost all women reported initial fear of the treatment procedure, followed by a more positive experience than anticipated. Lacking funds for transportation to the treatment site was the most common barrier. Women felt that decentralised treatment would be the most important facilitator of greater access. Spousal encouragement and financial support were key facilitators of treatment access, however many women felt that other husbands in the community would not be supportive. Women described successfully acquiring treatment as empowering, and almost all would recommend seeking cryotherapy to other women who test HPV-positive. Most felt eager to share their own experiences with others to encourage treatment. CONCLUSIONS The main facilitators of treatment access were understanding of the health risks and sense of empowerment. A decentralised treatment model or transportation support may facilitate access, along with improved health messaging about HPV infection, cancer and the treatment process. Focusing on women's personal feelings of empowerment may further improve uptake and satisfaction. These data will be used to design a strategy to improve linkage to treatment. TRIAL REGISTRATION NCT02124252.
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Affiliation(s)
- Megan Huchko
- Center for Global Reproductive Health, Duke Global Health Institute, Durham, North Carolina, USA
- Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Konyin Adewumi
- Center for Global Reproductive Health, Duke Global Health Institute, Durham, North Carolina, USA
- Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sandra Oketch
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Ibrahim Saduma
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth Bukusi
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Obstetrics and Gynecology, Aga Khan University - Kenya, Nairobi, Kenya
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Nakalembe M, Makanga P, Mubiru F, Swanson M, Martin J, Huchko M. Prevalence, correlates, and predictive value of high-risk human papillomavirus mRNA detection in a community-based cervical cancer screening program in western Uganda. Infect Agent Cancer 2019; 14:14. [PMID: 31114629 PMCID: PMC6515623 DOI: 10.1186/s13027-019-0230-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 05/07/2019] [Indexed: 12/26/2022] Open
Abstract
Background New strategies are needed to combat the high incidence of cervical cancer in resource-limited settings such as sub-Saharan Africa. Screening for high-risk human papillomavirus (hrHPV) DNA is sensitive for pre-cancer, but its lack of specificity results in substantial overtreatment in low resource settings where additional testing (e.g., colposcopy) is rarely available. Testing for hrHPV E6/E7 mRNA may enhance specificity, but little is known about its performance characteristics in resource-limited settings. Methods In a series of community health fairs in rural Uganda, women aged 25 to 49 years provided self-collected vaginal samples, which were tested for hrHPV (types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68) E6/E7 mRNA with the Aptima® assay. Positive specimens underwent testing for HPV-16 and 18/45. After excluding pregnant women, all women testing positive for any hrHPV subsequently were offered cervical biopsy to determine pathology. Results A total of 1892 women provided a vaginal sample for hrHPV testing during 24 health fairs. The median age was 34 years, HIV prevalence was 10, and 95% had not been previously screened. Prevalence of any hrHPV E6/E7 mRNA was 21% (95% confidence interval (CI): 19 to 23%); the prevalence of HPV-16 was 2.6%, HPV-18/45 1.9%, and HPV 16 and 18/45 were jointly found in 0.1% of the study population. Younger age, pregnancy and HIV-positivity were independently associated with any hrHPV infection. Of the 255 evaluable cervical biopsies, the positive predictive value of detecting any hrHPV E6/E7 mRNA for presence of cervical intraepithelial neoplasia grade 2 or higher ("CIN 2+") was 8.2% (95% CI: 5.1 to 12%). The positive predictive value associated with detection of HPV-16 mRNA (15%) or HPV-18/45 mRNA (15%) was only slightly higher. Conclusion Among community-based women in Uganda, the prevalence of any hrHPV E6/E7 mRNA in vaginal samples was high, but the prevalence of the most oncogenic HPV types (16, 18, or 45) was substantially lower. Positive predictive value of hrHPV mRNA-positivity for CIN 2+ was also low, including when restricting to HPV 16/18/45-positivity. The findings emphasize the need to identify more specific screening approaches for cervical cancer.
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Affiliation(s)
- Miriam Nakalembe
- 1Department of Obstetrics and Gynecology, Infectious Diseases Institute, Makerere University Kampala, Kampala, Uganda
| | - Philippa Makanga
- 1Department of Obstetrics and Gynecology, Infectious Diseases Institute, Makerere University Kampala, Kampala, Uganda
| | - Frank Mubiru
- 1Department of Obstetrics and Gynecology, Infectious Diseases Institute, Makerere University Kampala, Kampala, Uganda
| | - Megan Swanson
- Department of Obstetrics and Gynecology, University of California, San Francisco, Uganda
| | - Jeffrey Martin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, Uganda
| | - Megan Huchko
- 4Department of Obstetrics and Gynecology, Global Health Institute, Duke University, Durham, North Carolina USA
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Swanson M, Gimei P, Huchko M. Rethinking the ASCO Resource-Stratified Cervical Cancer Screening Guidelines in the Context of Existing Health Infrastructure in Basic Settings. J Glob Oncol 2018; 4:1-3. [PMID: 30241171 PMCID: PMC6180754 DOI: 10.1200/jgo.17.00025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Megan Swanson
- Megan Swanson, University of California at San Francisco, San Francisco, CA; Peter Gimei, Uganda Cancer Institute, Kampala, Uganda; and Megan Huchko, Duke University and Duke Global Health Institute, Durham, NC
| | - Peter Gimei
- Megan Swanson, University of California at San Francisco, San Francisco, CA; Peter Gimei, Uganda Cancer Institute, Kampala, Uganda; and Megan Huchko, Duke University and Duke Global Health Institute, Durham, NC
| | - Megan Huchko
- Megan Swanson, University of California at San Francisco, San Francisco, CA; Peter Gimei, Uganda Cancer Institute, Kampala, Uganda; and Megan Huchko, Duke University and Duke Global Health Institute, Durham, NC
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Swanson M, Nakalembe M, Huchko M. HPV positivity among women in Central Uganda participating in a Community Health Campaign offering self-collected HPV-based cervical cancer screening. Gynecol Oncol 2017. [DOI: 10.1016/j.ygyno.2017.07.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mungo C, Conell C, Maloba M, Bukusi E, Cohen C, Huchko M. Reproducibility of p16INK4a Biomarker Levels, as Measured by ELISA, Among HIV-Positive Women in Western Kenya With Normal Cervical Exams During a 12-Month Follow-Up. J Glob Oncol 2016. [DOI: 10.1200/jgo.2016.004242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract 42 Background: Cervical cancer disproportionately affects women in low- and middle-income countries (LMICs), and cytology-based programs are not feasible for use in these settings. This has prompted a search for alternative cervical-cancer screening or surveillance methods that can be adopted in LMICs to address the high disease burden. In this study, we seek to evaluate the performance and reliability of cervical p16INK4a biomarker as measured by an ELISA assay among a group of HIV-positive women in a low-resource setting who had normal screening results by gold standard at baseline and at 12-month follow-up. Methods: This prospective study took place at the Family AIDS Care and Education Services (FACES) clinic in Kisumu, Kenya. Participants underwent cervical cancer screening using VIA, colposcopy and collection of cervical HPV p16INK4a samples. Women with negative colposcopies were rescreened at 12-months, and cervical p16INK4a samples were collected. Among women with negative colposcopies at both baseline and follow-up, we investigated the reproducibility of p16INK4a biomarker levels within the same woman between the two visits. Biomarker levels were determined using an ELISA-based biochemical assay. We compared median p16INK4a levels between baseline and follow-up using the paired t-test. We also examined correlation using correlation coefficients and a Bland-Atman plot of differences versus average. A multivariate regression model was fit to identify demographic and clinical variables associated with absolute change in p16INK4a levels. Results: Among the ninety-three women who had normal cervical exams, mean p16INK4a levels increased significantly between baseline and follow-up period, at 20.2 U/ml vs 30.1 U/ml (p<0.01). The correlation coefficient between the values at the two time points was 0.61 (p<0.01), indicating a moderate but not perfect agreement between baseline and follow-up biomarker levels. A Bland-Altman plot of difference versus average of the two measures showed a mean difference of 10 units/ml, indicating poor agreement between the two measurements. In a multivariate regression model including age at screening, HPV status, hormonal contraception use, use of ART, VIA results, and CD4 count at baseline and follow-up, only age at screening and HPV status were significantly associated with greater absolute change in p16INK4a measurements (p< 0.01). Conclusion: Our results suggest that there is variability in levels of p16INK4a biomarker as measured by ELISA in HIV-positive women in low-resource settings with normal screening as determined by colposcopy over a 12-month follow-up period. Biomarker levels varied significantly more among older women and those who were HPV positive at baseline, despite normal cervical exams. These data suggest that elevations in p16INK4a biomarker levels may not be a reliable marker of dysplasia in this group of women. Further research in this population as well as replication of these results will be important. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST: Chemtai Mungo No relationship to disclose Carol Conell No relationship to disclose May Maloba No relationship to disclose Elizabeth Bukusi No relationship to disclose Craig Cohen Consulting or Advisory Role: Symbiomix Inc. Megan Huchko No relationship to disclose
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Affiliation(s)
- Chemtai Mungo
- Chemtai Mungo, Kaiser Permanente Hospital, San Francisco, CA; Carol Conell, Division of Research, Kaiser Permanente, Oakland, CA; May Maloba and Elizabeth Bukusi, Kenya Medical Research Institute, Kisumu, Kenya; and Craig Cohen and Megan Huchko, University of California, San Francisco. San Francisco, CA
| | - Carol Conell
- Chemtai Mungo, Kaiser Permanente Hospital, San Francisco, CA; Carol Conell, Division of Research, Kaiser Permanente, Oakland, CA; May Maloba and Elizabeth Bukusi, Kenya Medical Research Institute, Kisumu, Kenya; and Craig Cohen and Megan Huchko, University of California, San Francisco. San Francisco, CA
| | - May Maloba
- Chemtai Mungo, Kaiser Permanente Hospital, San Francisco, CA; Carol Conell, Division of Research, Kaiser Permanente, Oakland, CA; May Maloba and Elizabeth Bukusi, Kenya Medical Research Institute, Kisumu, Kenya; and Craig Cohen and Megan Huchko, University of California, San Francisco. San Francisco, CA
| | - Elizabeth Bukusi
- Chemtai Mungo, Kaiser Permanente Hospital, San Francisco, CA; Carol Conell, Division of Research, Kaiser Permanente, Oakland, CA; May Maloba and Elizabeth Bukusi, Kenya Medical Research Institute, Kisumu, Kenya; and Craig Cohen and Megan Huchko, University of California, San Francisco. San Francisco, CA
| | - Craig Cohen
- Chemtai Mungo, Kaiser Permanente Hospital, San Francisco, CA; Carol Conell, Division of Research, Kaiser Permanente, Oakland, CA; May Maloba and Elizabeth Bukusi, Kenya Medical Research Institute, Kisumu, Kenya; and Craig Cohen and Megan Huchko, University of California, San Francisco. San Francisco, CA
| | - Megan Huchko
- Chemtai Mungo, Kaiser Permanente Hospital, San Francisco, CA; Carol Conell, Division of Research, Kaiser Permanente, Oakland, CA; May Maloba and Elizabeth Bukusi, Kenya Medical Research Institute, Kisumu, Kenya; and Craig Cohen and Megan Huchko, University of California, San Francisco. San Francisco, CA
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Nishimura H, Yatich N, Huchko M. Facilitators and Barriers to Cervical Cancer Screening in Migori County, Kenya. J Glob Oncol 2016. [DOI: 10.1200/jgo.2016.003970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract 77 Background: Cervical cancer, a disease that is largely preventable through organized screening programs, still impacts over 500,000 women every year. Sub-Saharan Africa has the highest global incidence and mortality, largely due to lack of screening coverage. Low-cost and simple-to-implement screening technologies can potentially impact the rates of cervical cancer, if they are acceptable and scalable. As part of a trial to evaluate implementation strategies for cervical cancer prevention in western Kenya, we sought to identify the barriers and facilitators of screening, as well as opinions on a strategy employing self-collection of specimens for human papillomavirus (HPV) testing. Methods: Providers and female community members were recruited for focus groups using purposive sampling. Two focus group discussions (FGDs) with community members (n=24) and one FGD with providers (n=12) and key stakeholders were held in Migori County, Kenya, using structured guides to assess and current cervical cancer knowledge, screening practices, barriers to screening and potential strategies to facilitate screening access and uptake, including self-collected HPV testing. Results: Participants in both groups assessed the education around HPV, cervical cancer, and screening as very low in the community, and identified this lack of education as the main barrier to screening. Community members reported fear of pain and embarrassment as significant barriers to a screening pelvic exam. They also reported that lack of knowledge and discomfort among providers were significant barriers. Having undergone screening themselves or talking to someone with experience increased willingness to screen. Providers reported workload and lack of supplies and trained staff as significant barriers. Most participants in both FGDs felt that self-collection would help address barriers. Women expressed willingness to self-collect if given adequate instructions and if knowledgeable counselors were present to discuss results. Conclusion: Cervical cancer prevention strategies employing effective educational components and self-collected HPV testing could address many of the identified barriers to screening. Key findings from analysis of the focus group transcripts will be used to inform the implementation of community health campaigns. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST: No COIs from the authors.
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Affiliation(s)
- Holly Nishimura
- Holly Nishimura, Nelly Yatich, and Megan Huchko, University of California, San Francisco
| | - Nelly Yatich
- Holly Nishimura, Nelly Yatich, and Megan Huchko, University of California, San Francisco
| | - Megan Huchko
- Holly Nishimura, Nelly Yatich, and Megan Huchko, University of California, San Francisco
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Adamson P, Medina-Marino A, Kinkel F, Huchko M. Acceptability of cervical cancer screening using a self-collected tampon
for HPV testing among HIV-infected women in Pretoria, South Africa. Ann Glob Health 2015. [DOI: 10.1016/j.aogh.2015.02.698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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21
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Owiti PO, Penner J, Oyanga A, Huchko M, Onchiri FM, Cohen C, Bukusi EA. World Health Organization's stage 4 conditions among adults accessing outpatient HIV care: a retrospective cohort study in Kisumu, Kenya. J Acquir Immune Defic Syndr 2014; 65:e152-5. [PMID: 24577188 PMCID: PMC3939608 DOI: 10.1097/qai.0000000000000020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Patrick O Owiti
- Centre for Microbiology Research, Research Care and Training Program, Kenya Medical Research Institute-FACES, Kisumu, Nyanza Kenya
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22
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Abstract
Ruby Singhrao and colleagues propose four arguments for why cervical cancer screening and treatment should be prioritized. Please see later in the article for the Editors' Summary
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Affiliation(s)
- Ruby Singhrao
- Global Health Sciences, University of California San Francisco, San Francisco, California, USA.
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23
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Mungo C, Cohen C, Bukusi E, Huchko M. O482 PREVALENCE, CHARACTERISTICS, AND OUTCOMES OF HIV+ WOMEN DIAGNOSED WITH INVASIVE CANCER OF THE CERVIX AT FACES, KISUMU, KENYA. Int J Gynaecol Obstet 2012. [DOI: 10.1016/s0020-7292(12)60912-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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