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Luckett R, Ramogola-Masire D, Gompers A, Moraka N, Moyo S, Sedabadi L, Tawe L, Kashamba T, Gaborone K, Mathoma A, Noubary F, Kula M, Grover S, Dreyer G, Botha MH, Makhema J, Shapiro R, Hacker MR. Triage of HPV positivity in a high HIV prevalence setting: A prospective cohort study comparing visual triage methods and HPV genotype restriction in Botswana. Int J Gynaecol Obstet 2024; 165:507-518. [PMID: 37950533 PMCID: PMC11021160 DOI: 10.1002/ijgo.15225] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/08/2023] [Accepted: 10/12/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE Guidelines for effective triage following positive primary high-risk human papillomavirus (HPV) screening in low- and middle-income countries with high human immunodeficiency virus (HIV)-prevalence have not previously been established. In the present study, we evaluated the performance of three triage methods for positive HPV results in women living with HIV (WLHIV) and without HIV in Botswana. METHODS We conducted baseline enrollment of a prospective cohort study from February 2021 to August 2022 in South-East District, Botswana. Non-pregnant women aged 25 or older with an intact cervix and no prior diagnosis of cervical cancer were systematically consented for enrollment, with enrichment of the cohort for WLHIV. Those who consented completed a questionnaire and then collected vaginal self-samples for HPV testing. Primary HPV testing for 15 individual genotypes was conducted using Atila AmpFire® HPV assay. Those with positive HPV results returned for a triage visit where all underwent visual inspection with acetic acid (VIA), colposcopy, and biopsy. Triage strategies with VIA, colposcopy and 8-type HPV genotype restriction (16/18/31/33/35/45/52/58), separately and in combination, were compared using histopathology as the gold standard in diagnosing cervical intraepithelial neoplasia (CIN) 2 or worse (CIN2+). RESULTS Among 2969 women enrolled, 1480 (50%) tested HPV positive. The cohort included 1478 (50%) WLHIV; 99% were virologically suppressed after a mean of 8 years on antiretroviral therapy. In total, 1269 (86%) women had histopathology data for analysis. Among WLHIV who tested positive for HPV, 131 (19%) of 688 had CIN2+ compared with 71 (12%) of 581 in women without HIV. Screening by 8-type HPV genotype restriction was more sensitive as triage to detect CIN2+ in WLHIV 87.79% (95% CI: 80.92-92.85) and women without HIV 85.92% (95% CI: 75.62-93.03) when compared with VIA (WLHIV 62.31% [95% CI: 53.39-70.65], women without HIV 44.29% [95% CI: 32.41-56.66]) and colposcopy (WLHIV 70.77% [95% CI: 62.15-78.41], women without HIV 45.71% [95% CI: 33.74-58.06]). However, 8-type HPV genotype restriction had low specificity in WLHIV of 30.88% (95% CI: 27.06-34.90) and women without HIV 37.06% (95% CI: 32.85-41.41). These results were similar when CIN3+ was used as the outcome. When combining 8-type HPV genotype restriction with VIA as the triage strategy, there was improved specificity to detect CIN2+ in WLHIV of 81.65% (95% CI: 78.18-84.79) but dramatically reduced sensitivity of 56.15% (95% CI: 47.18-64.84). CONCLUSIONS Eight-type HPV genotype restriction is a promising component of effective triage for HPV positivity. However, novel triage strategies in LMICs with high HIV prevalence may be needed to avoid the trade-off between sensitivity and specificity with currently available options. CLINICAL TRIALS REGISTRATION This study is registered on Clinicaltrials.gov no. NCT04242823, https://clinicaltrials.gov/ct2/show/NCT04242823.
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Affiliation(s)
- Rebecca Luckett
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, USA
- Botswana Harvard Health Partnership, Gaborone, Botswana
- Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
- Harvard Medical School, Boston, USA
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
- Department of Obstetrics & Gynaecology, University of Pretoria, Pretoria, South Africa
| | - Annika Gompers
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, USA
| | | | - Sikhulile Moyo
- Botswana Harvard Health Partnership, Gaborone, Botswana
- Harvard T.H. Chan School of Public Health, Boston, USA
- School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
- Department of Pathology, University of Botswana, Gaborone, Botswana
| | - Leatile Sedabadi
- Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
| | - Leabaneng Tawe
- Department of Pathology, University of Botswana, Gaborone, Botswana
| | - Thanolo Kashamba
- Department of Pathology, University of Botswana, Gaborone, Botswana
| | | | - Anikie Mathoma
- Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
| | - Farzad Noubary
- Department of Health Sciences, Northeastern University, Boston, USA
| | - Maduke Kula
- National Cervical Cancer Prevention Program, Ministry of Health and Wellness Botswana, Gaborone, Botswana
| | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA
| | - Greta Dreyer
- Department of Obstetrics & Gynaecology, University of Pretoria, Pretoria, South Africa
| | - Matthys H Botha
- Department of Obstetrics & Gynaecology, Stellenbosch University, Cape Town, South Africa
| | - Joseph Makhema
- Botswana Harvard Health Partnership, Gaborone, Botswana
- Harvard T.H. Chan School of Public Health, Boston, USA
| | - Roger Shapiro
- Botswana Harvard Health Partnership, Gaborone, Botswana
- Harvard Medical School, Boston, USA
- Harvard T.H. Chan School of Public Health, Boston, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, USA
| | - Michele R Hacker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, USA
- Harvard Medical School, Boston, USA
- Harvard T.H. Chan School of Public Health, Boston, USA
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Abstract
We report a fatal case of SARS-CoV-2 and Mycobacterium tuberculosis coinfection in an infant, Botswana’s first paediatric COVID-19-associated fatality. The patient, a 3-month-old HIV-unexposed boy, presented with fever and respiratory distress in the setting of failure to thrive. Both the patient and his mother tested positive for rifampin-sensitive M. tuberculosis (Xpert MTB/Rif) and SARS-CoV-2 (real time-PCR). Initially stable on supplemental oxygen and antitubercular therapy, the patient experienced precipitous clinical decline 5 days after presentation and subsequently died. Autopsy identified evidence of disseminated tuberculosis (TB) as well as histopathological findings similar to those described in recent reports of SARS-CoV-2 infections, including diffuse microthrombosis. TB remains a serious public health threat in hyperendemic regions like sub-Saharan Africa, and is often diagnosed late in infants. In addition to raising the question of additive/synergistic pathophysiology and/or immune reconstitution, this case of coinfection also highlights the importance of leveraging the COVID-19 pandemic response to strengthen efforts for TB prevention, screening and detection.
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Affiliation(s)
| | - Thanolo Kashamba
- National Health Laboratory, Ministry of Health and Wellness Botswana, Gaborone, Botswana
| | - Jonathan Strysko
- Paediatrics and Adolescent Health, University of Botswana, Gaborone, Botswana.,Global Medicine, Botswana UPenn Partnership, Gaborone, Botswana.,Global Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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