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Lubeya MK, Chibwesha CJ, Mwanahamuntu M, Mukosha M, Vwalika B, Kawonga M. Determinants of the Implementation of Human Papillomavirus Vaccination in Zambia: Application of the Consolidated Framework for Implementation Research. Vaccines (Basel) 2023; 12:32. [PMID: 38250845 PMCID: PMC10821054 DOI: 10.3390/vaccines12010032] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/10/2023] [Accepted: 12/21/2023] [Indexed: 01/23/2024] Open
Abstract
Cervical cancer can be prevented, primarily by the administration of the human papillomavirus (HPV) vaccine. Healthcare workers (HCWs) and teachers play important roles when schools are used for vaccine delivery; however, challenges exist. This study aimed to understand the barriers and facilitators to HPV vaccination that are perceived by HCWs and teachers. Guided by the consolidated framework for implementation research (CFIR), key informant interviews were conducted in Lusaka district between June 2021 and November 2021 using a semi-structured questionnaire. Recorded interviews were transcribed verbatim and imported into NVIVO 12 for data management and analysis. We coded transcripts inductively and deductively based on the adapted CFIR codebook. We reached saturation with 23 participants. We identified barriers and facilitators across the five CFIR domains. Facilitators included offering the HPV vaccine free of charge, HPV vaccine effectiveness, stakeholder engagement, and timely planning of the HPV vaccination. Barriers included vaccine mistrust due to its perceived novelty, low levels of parental knowledge, myths and misinformation about the vaccine, lack of parental consent to vaccinate daughters, lack of transport for vaccination outreach, lack of staff incentives, and inadequate sensitisation. Using the CFIR as a guiding framework, we have identified implementation barriers and facilitators to HPV vaccination among HCWs and teachers. Most of the identified barriers are modifiable, hence it is prudent that these are addressed for a high HPV vaccine uptake.
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Affiliation(s)
- Mwansa Ketty Lubeya
- Department of Obstetrics and Gynaecology, School of Medicine, The University of Zambia, Lusaka 10101, Zambia; (M.M.); (B.V.)
- Women and Newborn Hospital, University Teaching Hospitals, Nationalist Road, Ridgeway, Lusaka 10101, Zambia
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 3193, South Africa; (M.M.); (M.K.)
| | - Carla J. Chibwesha
- Clinical HIV Research Unit, Helen Joseph Hospital, Johannesburg 2193, South Africa;
| | - Mulindi Mwanahamuntu
- Department of Obstetrics and Gynaecology, School of Medicine, The University of Zambia, Lusaka 10101, Zambia; (M.M.); (B.V.)
- Women and Newborn Hospital, University Teaching Hospitals, Nationalist Road, Ridgeway, Lusaka 10101, Zambia
| | - Moses Mukosha
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 3193, South Africa; (M.M.); (M.K.)
- Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka 10101, Zambia
| | - Bellington Vwalika
- Department of Obstetrics and Gynaecology, School of Medicine, The University of Zambia, Lusaka 10101, Zambia; (M.M.); (B.V.)
- Women and Newborn Hospital, University Teaching Hospitals, Nationalist Road, Ridgeway, Lusaka 10101, Zambia
| | - Mary Kawonga
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 3193, South Africa; (M.M.); (M.K.)
- Department of Public Health Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg 2193, South Africa
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Lubeya MK, Chibwesha CJ, Mwanahamuntu M, Mukosha M, Frank S, Kawonga M. "When you get the HPV vaccine, it will prevent cervical cancer; it will act as a shield": adolescent girls' knowledge and perceptions regarding the human papillomavirus vaccine in Zambia. Front Health Serv 2023; 3:1208458. [PMID: 37780403 PMCID: PMC10534003 DOI: 10.3389/frhs.2023.1208458] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 08/23/2023] [Indexed: 10/03/2023]
Abstract
Introduction The human papillomavirus (HPV) vaccination is an important preventive measure for HPV-related conditions such as cervical cancer. In 2019, Zambia introduced a free national HPV vaccination program for 14-year-old girls. However, the adolescents' knowledge and perceptions regarding the HPV vaccine are not well understood. Therefore, this study aimed to understand adolescent girls' knowledge and perceptions regarding the HPV vaccine and discuss its acceptability and uptake implications. Methods We conducted a qualitative study in the Lusaka district between June 2021 and November 2021 using semi-structured interviews with adolescent girls aged 15-18 years regardless of their HPV vaccination status. Interviews were transcribed verbatim, and NVIVO 12 was used for data management and analysis. We coded transcripts deductively and inductively based on emerging themes. Perceptions were coded using the health belief model constructs. Results We interviewed 30 adolescent girls to reach saturation. Seventeen girls reported having received at least one dose of the HPV vaccine. Participants expressed variable knowledge and awareness about HPV and the HPV vaccine. Participants exhibited positive attitudes towards the HPV vaccine and perceived it as beneficial. However, there were multiple perceived barriers to vaccination, such as the need for parental consent, not being in school, concerns about vaccine side effects, and belief in myths and misinformation. Conclusion The adolescent girls in this study showed variable knowledge and positive attitudes toward the HPV vaccine despite the many perceived barriers. To support increased HPV vaccine acceptability and uptake among adolescent girls in Zambia, it is critical to actively engage stakeholders involved in HPV vaccination, such as adolescents and their parents, and debunk myths and misconceptions about HPV vaccination. Health education in schools and communities should be implemented to increase knowledge about HPV and HPV vaccination among adolescents and their parents.
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Affiliation(s)
- Mwansa Ketty Lubeya
- Department of Obstetrics and Gynaecology, School of Medicine, The University of Zambia, Lusaka, Zambia
- Women and Newborn Hospital, University Teaching Hospitals, Lusaka, Zambia
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Carla J. Chibwesha
- Clinical HIV Research Unit, Helen Joseph Hospital, Johannesburg, South Africa
| | - Mulindi Mwanahamuntu
- Department of Obstetrics and Gynaecology, School of Medicine, The University of Zambia, Lusaka, Zambia
- Women and Newborn Hospital, University Teaching Hospitals, Lusaka, Zambia
| | - Moses Mukosha
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka, Zambia
| | - Simone Frank
- School of Medicine, North Carolina Translational and Clinical Sciences (NC TraCS) Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Mary Kawonga
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Public Health Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
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Lubeya MK, Mwanahamuntu M, Chibwesha CJ, Mukosha M, Monde MW, Kawonga M. Implementation Strategies Used to Increase Human Papillomavirus Vaccination Uptake by Adolescent Girls in Sub-Saharan Africa: A Scoping Review. Vaccines (Basel) 2023; 11:1246. [PMID: 37515061 PMCID: PMC10385137 DOI: 10.3390/vaccines11071246] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/25/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
Barriers to successful implementation of the human papillomavirus vaccination exist. However, there is limited evidence on implementation strategies in sub-Saharan Africa (SSA). Therefore, this scoping review aimed to identify implementation strategies used in SSA to increase HPV vaccination uptake for adolescent girls. This scoping review was guided by Joanna Briggs Institute guidelines for scoping reviews and an a priori protocol and reported based on the Preferred Reporting Items for Systematic Reviews and Metanalysis for Scoping Reviews (PRISMA-ScR). We searched PubMed, EMBASE, CINAHL, Scopus, Google Scholar, and gray literature. Two independent reviewers screened article titles and abstracts for possible inclusion, reviewed the full text, and extracted data from eligible articles using a structured data charting table. We identified strategies as specified in the Expert Recommendation for Implementing Change (ERIC) and reported their importance and feasibility. We retrieved 246 articles, included 28 of these, and identified 63 of the 73 ERIC implementation strategies with 667 individual uses, most of which were highly important and feasible. The most frequently used discrete strategies included the following: Build a coalition and change service sites 86% (24/28), distribute educational materials and conduct educational meetings 82% (23/28), develop educational materials, use mass media, involve patients/relatives and families, promote network weaving and stage implementation scale up 79% (22/28), as well as access new funding, promote adaptability, and tailor strategies 75% (21/28). This scoping review shows that implementation strategies of high feasibility and importance were frequently used, suggesting that some strategies may be cross-cutting, but should be contextualized when planned for use in any region.
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Affiliation(s)
- Mwansa Ketty Lubeya
- Department of Obstetrics and Gynaecology, School of Medicine, The University of Zambia, Lusaka 10101, Zambia
- Women and Newborn Hospital, University Teaching Hospitals, Lusaka 10101, Zambia
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa
| | - Mulindi Mwanahamuntu
- Department of Obstetrics and Gynaecology, School of Medicine, The University of Zambia, Lusaka 10101, Zambia
- Women and Newborn Hospital, University Teaching Hospitals, Lusaka 10101, Zambia
| | - Carla J Chibwesha
- Clinical HIV Research Unit, Helen Joseph Hospital, Johannesburg 2193, South Africa
| | - Moses Mukosha
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa
- Department of Pharmacy, School of Health Sciences, The University of Zambia, Lusaka 10101, Zambia
| | | | - Mary Kawonga
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa
- Department of Community Health, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg 2193, South Africa
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Lubeya MK, Chibwesha CJ, Mwanahamuntu M, Mukosha M, Maposa I, Kawonga M. Correlates of Parental Consent to Human Papillomavirus Vaccine Uptake by Their Adolescent Daughters in ZAMBIA: Application of the Health Belief Model. Vaccines (Basel) 2023; 11:vaccines11050912. [PMID: 37243016 DOI: 10.3390/vaccines11050912] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/20/2023] [Accepted: 04/24/2023] [Indexed: 05/28/2023] Open
Abstract
Parental consent for adolescent human papillomavirus (HPV) vaccine uptake is important; however, refusal is prevalent. Therefore, this study aimed to understand factors associated with parental consent for their adolescent daughter's HPV vaccination. A cross-sectional study was conducted in Lusaka, Zambia, between September and October 2021. We recruited parents from different social settings. The means and standard deviations or median and interquartile ranges were used as appropriate to summarise continuous variables. Simple and multiple logistic regression models were fitted with robust estimation of standard errors. The odds ratios are presented with 95% CI. Mediation analysis was conducted using a generalised structural equation model. The study enrolled 400 parents, mean age 45.7 years [95% CI, 44.3-47.1]. Two hundred and fifteen (53.8%) parents reported consenting to their daughters' HPV vaccination, and their daughters received it. None of the health belief model (HBM) construct scores showed an independent association with parental consent. Higher, compared to lower wealth index (AOR; 2.32, 95% CI: 1.29-4.16), knowing someone with genital warts (AOR = 2.23, 95 CI: 1.04-4.76), cervical cancer screening uptake (AOR = 1.93, 95% CI: 1.03-3.62) were associated with increased odds of parental consent. This study highlights factors influencing parental consent for their daughters' HPV vaccination. Ongoing sensitisation programs are important to improve their decision-making.
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Affiliation(s)
- Mwansa Ketty Lubeya
- Department of Obstetrics and Gynaecology, School of Medicine, The University of Zambia, Lusaka 10101, Zambia
- Women and Newborn Hospital, University Teaching Hospitals, Lusaka 10101, Zambia
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa
| | - Carla J Chibwesha
- Clinical HIV Research Unit, Helen Joseph Hospital, Johannesburg 2193, South Africa
| | - Mulindi Mwanahamuntu
- Department of Obstetrics and Gynaecology, School of Medicine, The University of Zambia, Lusaka 10101, Zambia
- Women and Newborn Hospital, University Teaching Hospitals, Lusaka 10101, Zambia
| | - Moses Mukosha
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa
- Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka 10101, Zambia
| | - Innocent Maposa
- Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, Witwatersrand University, Johannesburg 2193, South Africa
| | - Mary Kawonga
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa
- Department of Community Health, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg 2193, South Africa
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Abstract
Persistent human papillomavirus infection is the central cause of cervical cancer, the leading cause of cancer death among women worldwide. Clear evidence from both randomized trials and population based studies shows that vaccination against human papillomavirus reduces the incidence of cervical pre-cancer. These data suggest that the vaccine reduces the incidence of cervical cancer. However, human papillomavirus vaccine coverage is inadequate in all countries, especially in low and middle income countries where disease burden is highest. Supply side strategies to improve coverage include increasing the availability of low cost vaccines, school located delivery, single dose vaccine schedules, and development of vaccines that do not need refrigeration. Demand side strategies include enhancing provider recommendations, correcting misinformation, and public awareness campaigns. The near elimination of cervical cancer is achievable through increased uptake of human papillomavirus vaccination and efforts to increase screening for cervical cancer, especially when enacted to reduce disparities in across the world.
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Affiliation(s)
- Lisa Rahangdale
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Chemtai Mungo
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Siobhan O'Connor
- Department of Pathology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Carla J Chibwesha
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Clinical HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Noel T Brewer
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
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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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Chibwesha CJ, Mollan KR, Ford CE, Shibemba A, Saha PT, Lusaka M, Mbewe F, Allmon AG, Lungu R, Spiegel HML, Mweni E, Mwape H, Kankasa C, Chi BH, Stringer JSA. A Randomized Trial of Point-of-Care Early Infant HIV Diagnosis in Zambia. Clin Infect Dis 2021; 75:260-268. [PMID: 34718462 PMCID: PMC9410723 DOI: 10.1093/cid/ciab923] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 06/24/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Point-of-care (POC) early infant diagnosis (EID) provides same-day results and the potential for immediate initiation of antiretroviral therapy (ART). METHODS We conducted a pragmatic trial at six public clinics in Zambia. HIV-exposed infants were individually randomized to either: (a) POC EID - on-site testing with the Alere q HIV-1/2 Detect or (b) enhanced standard of care (SOC) EID - off-site testing at a public laboratory. HIV-infected infants were referred for ART and followed for 12 months. Our primary outcome was defined as alive, in care, and virally suppressed at 12 months. RESULTS Between March 2016 and November 2018, we randomized 4,000 HIV-exposed infants to POC (n=1,989) or SOC (n=2,011). All but two infants in the POC group received same-day results, while the median time to result in the SOC group was 27 (IQR: 22-30) days. Eighty-one (2%, 95% CI: 1.6-2.5%) infants were diagnosed with HIV. Although ART initiation was high, there were 15 (19%) deaths, 15 (19%) follow-up losses, and 31 (38%) virologic failures. By 12 months, only 20 of 81 (25%, 95% CI: 15-34%) HIV-infected infants were alive, in care, and virally suppressed: 13 (30%, 95% CI: 16-43%) infants in the POC group vs. 7 (19%, 95% CI: 6-32%) in the SOC group (RR: 1.56, 95% CI: 0.7-3.50). CONCLUSIONS POC EID eliminated diagnostic delays and accelerated ART initiation but did not translate into definitive improvement in 12-month outcomes. In settings where centralized EID is well functioning, POC EID is unlikely to improve pediatric HIV outcomes.
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Affiliation(s)
- Carla J Chibwesha
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,UNC Global Projects - Zambia, Lusaka, Zambia
| | - Katie R Mollan
- Biostatistics Core, Center for AIDS Research, University of North Carolina at Chapel Hill; Chapel Hill, NC, USA
| | - Catherine E Ford
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,UNC Global Projects - Zambia, Lusaka, Zambia
| | - Aaron Shibemba
- Department of Pathology and Microbiology, University Teaching Hospital, Lusaka, Zambia
| | - Pooja T Saha
- Biostatistics Core, Center for AIDS Research, University of North Carolina at Chapel Hill; Chapel Hill, NC, USA
| | | | | | - Andrew G Allmon
- Biostatistics Core, Center for AIDS Research, University of North Carolina at Chapel Hill; Chapel Hill, NC, USA
| | - Rose Lungu
- UNC Global Projects - Zambia, Lusaka, Zambia
| | | | | | | | - Chipepo Kankasa
- Department of Paediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Benjamin H Chi
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,UNC Global Projects - Zambia, Lusaka, Zambia
| | - Jeffrey S A Stringer
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,UNC Global Projects - Zambia, Lusaka, Zambia
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Lin LL, Lakomy DS, Chiao EY, Strother RM, Wirth M, Cesarman E, Borok M, Busakhala N, Chibwesha CJ, Chinula L, Ndlovu N, Orem J, Phipps W, Sewram V, Vogt SL, Sparano JA, Mitsuyasu RT, Krown SE, Gopal S. Clinical Trials for Treatment and Prevention of HIV-Associated Malignancies in Sub-Saharan Africa: Building Capacity and Overcoming Barriers. JCO Glob Oncol 2021; 6:1134-1146. [PMID: 32697667 PMCID: PMC7392698 DOI: 10.1200/go.20.00153] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 12/13/2022] Open
Abstract
PURPOSE The aim of this study was to review the current status of clinical trials for HIV-associated malignancies in people living with HIV in sub-Saharan Africa (SSA) and efforts made by the AIDS Malignancy Consortium (AMC) to build capacity in SSA for HIV malignancy research. METHODS All malignancy-related clinical trials in 49 SSA countries on ClinicalTrials.gov were reviewed and evaluated for inclusion and exclusion criteria pertaining to HIV status. Additional studies by AMC in SSA were compiled from Web-based resources, and narrative summaries were prepared to highlight AMC capacity building and training initiatives. RESULTS Of 96 cancer trials identified in SSA, only 11 focused specifically on people living with HIV, including studies in Kaposi sarcoma, cervical dysplasia and cancer, non-Hodgkin lymphoma, and ocular surface squamous neoplasia. Recognizing the increasing cancer burden in the region, AMC expanded its clinical trial activities to SSA in 2010, with 4 trials completed to date and 6 others in progress or development, and has made ongoing investments in developing research infrastructure in the region. CONCLUSION As the HIV-associated malignancy burden in SSA evolves, research into this domain has been limited. AMC, the only global HIV malignancy-focused research consortium, not only conducts vital HIV-associated malignancies research in SSA, but also develops pathology, personnel, and community-based infrastructure to meet these challenges in SSA. Nonetheless, there is an ongoing need to build on these efforts to improve HIV-associated malignancies outcomes in SSA.
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Affiliation(s)
- Lilie L Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David S Lakomy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.,Dartmouth Geisel School of Medicine, Hanover, NH
| | - Elizabeth Y Chiao
- Department of General Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.,Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Robert M Strother
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | | | - Ethel Cesarman
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY
| | - Margaret Borok
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Naftali Busakhala
- Department of Pharmacology and Toxicology, Moi University School of Medicine, Eldoret, Kenya
| | - Carla J Chibwesha
- Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC.,Clinical HIV Research Unit, Department of Medicine, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa.,Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Lameck Chinula
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC.,UNC Project-Malawi, Lilongwe, Malawi
| | - Ntokozo Ndlovu
- Department of Radiology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | | | - Warren Phipps
- Uganda Cancer Institute, Kampala, Uganda.,Department of Medicine, University of Washington, Seattle, WA.,Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Vikash Sewram
- African Cancer Institute, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Samantha L Vogt
- Department of Medical Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Joseph A Sparano
- Montefiore-Einstein Cancer Center, Montefiore Medical Center, Bronx, NY
| | - Ronald T Mitsuyasu
- Center for Clinical AIDS Research and Education, University of California, Los Angeles, Los Angeles, CA
| | | | - Satish Gopal
- Center for Global Health, National Cancer Institute, Rockville, MD
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Rohner E, Mulongo M, Pasipamire T, Oberlin AM, Goeieman B, Williams S, Lubeya MK, Rahangdale L, Chibwesha CJ. Mapping the cervical cancer screening cascade among women living with HIV in Johannesburg, South Africa a. Int J Gynaecol Obstet 2020; 152:53-59. [PMID: 33188707 DOI: 10.1002/ijgo.13485] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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: 09/07/2020] [Revised: 11/06/2020] [Accepted: 11/11/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To map the cervical cancer screening cascade among women living with HIV attending a public-sector cytology screening program in Johannesburg, South Africa. METHODS We conducted a retrospective cohort study of routinely collected clinical data captured in an electronic medical record system. Women (≥18 years) living with HIV with an abnormal Pap result between January 2013 and May 2018 were included. The proportion of women who received follow-up consistent with extant clinical guidelines, stratified by their initial Pap smear result, was examined. RESULTS The study included 2072 women: 1384 (66.8%) with a low-risk Pap result, 681 (32.9%) with a high-risk Pap result, and 7 (0.3%) with suspected cancer. Only 174 (25.6%) women with a high-risk Pap result underwent guideline-indicated management within 18 months. Among women with a low-risk Pap result, 375 (27.1%) received follow-up within 1 year; the cumulative incidence of follow-up increased to 63.1% at 3 years. All women with suspected cancer either received a colposcopic biopsy or were referred for further treatment. CONCLUSION Attrition among South African women living with HIV who attended cervical screening in an urban public-sector program was high. Developing tailored interventions to address bottlenecks in the care cascade and improve cervical screening outcomes will be central to eliminating cervical cancer.
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Affiliation(s)
- Eliane Rohner
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Clinical HIV Research Unit, Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Masangu Mulongo
- Clinical HIV Research Unit, Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa.,Right to Care, Helen Joseph Hospital, Johannesburg, South Africa
| | - Tafadzwa Pasipamire
- Clinical HIV Research Unit, Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Austin M Oberlin
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Clinical HIV Research Unit, Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa.,Right to Care, Helen Joseph Hospital, Johannesburg, South Africa
| | | | - Sophie Williams
- Clinical HIV Research Unit, Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa.,Right to Care, Helen Joseph Hospital, Johannesburg, South Africa
| | - Mwansa K Lubeya
- Department of Obstetrics and Gynecology, University of Zambia, Lusaka, Zambia
| | - Lisa Rahangdale
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Carla J Chibwesha
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Clinical HIV Research Unit, Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa.,Right to Care, Helen Joseph Hospital, Johannesburg, South Africa
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Desravines N, Chibwesha CJ, Rahangdale L. Low Dose 5-Fluorouracil Intravaginal Therapy for the Treatment of Cervical Intraepithelial Neoplasia 2/3: A Case Series. J Gynecol Surg 2020. [DOI: 10.1089/gyn.2019.0076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nerlyne Desravines
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC
| | - Carla J. Chibwesha
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC
- Clinical HIV Research Unit, Department of Medicine, University of the Witwatersrand; Helen Joseph Hospital, Johannesburg, South Africa
| | - Lisa Rahangdale
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC
- Lineberger Cancer Research Center, University of North Carolina, Chapel Hill, NC
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11
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Chi BH, Belizan JM, Blas MM, Chuang A, Wilson MD, Chibwesha CJ, Farquhar C, Cohen CR, Raj T. Evaluating Academic Mentorship Programs in Low- and Middle-Income Country Institutions: Proposed Framework and Metrics. Am J Trop Med Hyg 2019; 100:36-41. [PMID: 30430978 PMCID: PMC6329356 DOI: 10.4269/ajtmh.18-0561] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A growing number of low- and middle-income country (LMIC) institutions have developed and implemented formal programs to support mentorship. Although the individual-level benefits of mentorship are well established, such activities can also sustainably build institutional capacity, bridge inequities in health care, and catalyze scientific advancement. To date, however, evaluation of these programs remains limited, representing an important gap in our understanding about the impact of mentoring. Without rigorous and ongoing evaluation, there may be missed opportunities for identifying best practices, iteratively improving program activities, and demonstrating the returns on investment in mentorship. In this report, we propose a framework for evaluating mentorship programs in LMIC settings where resources may be constrained. We identify six domains: 1) mentor–mentee relationship, 2) career guidance, 3) academic productivity, 4) networking, 5) wellness, and 6) organizational capacity. Within each, we describe specific metrics and how they may be considered as part of evaluation plans. We emphasize the role of measurement and evaluation at the institutional level, so that programs may enhance their mentoring capacity and optimize the management of their resources. Although we advocate for a comprehensive approach to evaluation, we recognize that—depending on stage and relative maturity—some domains may be prioritized to address short- and medium-term program goals.
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Affiliation(s)
- Benjamin H Chi
- University of North Carolina, Chapel Hill, North Carolina
| | - Jose M Belizan
- Instituto de Efectividad Clinica y Sanitaria, Buenos Aires, Argentina
| | | | - Alice Chuang
- University of North Carolina, Chapel Hill, North Carolina
| | - Michael D Wilson
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana
| | | | | | - Craig R Cohen
- University of California Global Health Institute, San Francisco, California.,University of California, San Francisco, San Francisco, California
| | - Tony Raj
- St. John's Research Institute, Bengaluru, India
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12
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Affiliation(s)
- Carla J Chibwesha
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill
- Clinical HIV Research Unit, Department of Medicine, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| | - Jeffrey S A Stringer
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill
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13
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Geary M, Chibwesha CJ, Stringer E. Contemporary Issues in Women's Health. Int J Gynaecol Obstet 2019; 147:1-3. [DOI: 10.1002/ijgo.12937] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Michael Geary
- Department of Obstetrics and GynecologyRotunda Hospital Dublin Ireland
| | - Carla J. Chibwesha
- Department of Obstetrics and GynecologyUniversity of North Carolina at Chapel Hill Chapel Hill NC USA
| | - Elizabeth Stringer
- Department of Obstetrics and GynecologyUniversity of North Carolina at Chapel Hill Chapel Hill NC USA
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14
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Nyambe N, Hoover S, Pinder LF, Chibwesha CJ, Kapambwe S, Parham G, Subramanian S. Differences in Cervical Cancer Screening Knowledge and Practices by HIV Status and Geographic Location: Implication for Program Implementation in Zambia. Afr J Reprod Health 2019; 22:92-101. [PMID: 30632726 DOI: 10.29063/ajrh2018/v22i4.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The knowledge and perceptions of cervical cancer among HIV negative and positive women, aged 25-49 years, from rural and urban locations in Zambia was systematically accessed in this study to determine any differences. Data were coded and analyzed using NVivo software. Compared to HIV negative women, HIV positive women had more accurate information about cervical cancer. They were more likely to cite male circumcision as the best approach to cervical cancer prevention. HPV infection was more commonly mentioned as a risk factor among HIV positive women. However, HIV positive women displayed little knowledge about HPV being the major cause of cervical cancer. Among HIV positive women, lack of time was the major screening barrier cited while HIV negative women mentioned being symptomatic as a determinant for early detection. Compared to rural residents, urban residents cited a wider range of cervical cancer information sources, including media and workplace although all of the participants who stated that they had no knowledge of cervical cancer were urban residents. Overall, knowledge and perceptions of cervical cancer among study participants was high, although differences exist between subgroups. Sharing accurate and standardized information on cervical cancer would improve participation in cervical cancer screening services.
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Affiliation(s)
| | | | - Leeya F Pinder
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill
| | - Carla J Chibwesha
- UNC Global Projects- Zambia.,Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill
| | | | - Groesbeck Parham
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill
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15
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Oberlin AM, Pasipamire T, Chibwesha CJ. Exploring women's preferences for HPV-based cervical cancer screening in South Africa. Int J Gynaecol Obstet 2019; 146:192-199. [PMID: 31127861 DOI: 10.1002/ijgo.12869] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 07/24/2018] [Revised: 12/06/2018] [Accepted: 05/23/2019] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To determine preferences for HPV-based cervical cancer screening among South African women. METHODS A discrete choice experiment survey was conducted among 298 women who attended two public-sector clinics in South Africa from February 1 to May 31, 2018. Participants chose between hypothetical screening scenarios: method of swab collection (self or provider); timing of treatment (same day or return visit); type of clinic (static or mobile); cost of services (US $0 or US $4); and time spent at the clinic (30, 60, or 120 minutes). A logistic regression model was generated to evaluate the importance of each attribute. A market simulation analysis was performed to determine potential uptake of the various screening strategies. RESULTS The participants expressed strong preferences for free services (β=0.50; P<0.001) and same-day HPV testing and treatment (β=0.40; P<0.001). The market simulation indicated that 83.8% of women would be willing to undergo screening if services were free; the swab was collected by the provider; and treatment was offered at a return visit. Including same-day testing and treatment in the model increased uptake to 96.4%. CONCLUSION Offering same-day HPV testing and treatment could substantially improve uptake of cervical cancer screening in the South African public healthcare sector.
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Affiliation(s)
- Austin M Oberlin
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA.,Right to Care, Helen Joseph Hospital, Johannesburg, South Africa.,Clinical HIV Research Unit, Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Carla J Chibwesha
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA.,Right to Care, Helen Joseph Hospital, Johannesburg, South Africa.,Clinical HIV Research Unit, Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa
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16
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Frett Utter B, Parham GP, Mershon CH, Sikombe K, Musonda A, Matambo J, Kapambwe S, Msadabwe SC, Katundu K, Bateman A, Lishimpi K, Mwanahamuntu M, Chibwesha CJ. Availability of palliative care services in Zambia: A nationwide provincial and tertiary hospital survey. J Cancer Policy 2019. [DOI: 10.1016/j.jcpo.2019.100185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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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17
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Ford CE, Coetzee D, Winston J, Chibwesha CJ, Ekouevi DK, Welty TK, Tih PM, Maman S, Stringer EM, Stringer JSA, Chi BH. Maternal Decision-Making and Uptake of Health Services for the Prevention of Mother-to-Child HIV Transmission: A Secondary Analysis. Matern Child Health J 2019; 23:30-38. [PMID: 30022401 DOI: 10.1007/s10995-018-2588-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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] [Indexed: 11/26/2022]
Abstract
Objectives We investigated whether a woman's role in household decision-making was associated with receipt of services to prevent mother-to-child HIV transmission (PMTCT). Methods We conducted a secondary analysis of the PEARL study, an evaluation of PMTCT effectiveness in Cameroon, Cote d'Ivoire, South Africa, and Zambia. Our exposure of interest was the women's role (active vs. not active) in decision-making about her healthcare, large household purchases, children's schooling, and children's healthcare (i.e., four domains). Our primary outcomes were self-reported engagement at three steps in PMTCT: maternal antiretroviral use, infant antiretroviral prophylaxis, and infant HIV testing. Associations found to be significant in univariable logistic regression were included in separate multivariable models. Results From 2008 to 2009, 613 HIV-infected women were surveyed and provided information about their decision-making roles. Of these, 272 (44.4%) women reported antiretroviral use; 281 (45.9%) reported infant antiretroviral prophylaxis; and 194 (31.7%) reported infant HIV testing. Women who reported an active role were more likely to utilize infant HIV testing services, across all four measured domains of decision-making (adjusted odds ratios [AORs] 2.00-2.89 all p < .05). However, associations between decision-making and antiretroviral use-for both mother and infant-were generally not significant. An exception was active decision-making in a woman's own healthcare and reported maternal antiretroviral use (AOR 1.69, p < 0.05). Conclusions for Practice Associations between decision-making and PMTCT engagement were inconsistent and may be related to specific characteristics of individual health-seeking behaviors. Interventions seeking to improve PMTCT uptake should consider the type of health-seeking behavior to better optimize health services.
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Affiliation(s)
- Catherine E Ford
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
- Department of Obstetrics and Gynecology, University of Illinois at Chicago, 820 South Wood St, M/C 808, Chicago, IL, 60612, USA.
| | - David Coetzee
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Jennifer Winston
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Carla J Chibwesha
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Didier K Ekouevi
- University of Bordeaux, ISPED, Centre INSERM U897, Bordeaux, France
| | - Thomas K Welty
- Cameroon Baptist Health Convention Health Board, Bamenda, Cameroon
| | - Pius M Tih
- Cameroon Baptist Health Convention Health Board, Bamenda, Cameroon
| | - Suzanne Maman
- Department of Health Behavior, University of North Carolina Gillings School of Public Health, Chapel Hill, NC, USA
| | - Elizabeth M Stringer
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Jeffrey S A Stringer
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Benjamin H Chi
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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18
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Oberlin AM, Rahangdale L, Chinula L, Fuseini NM, Chibwesha CJ. Making HPV vaccination available to girls everywhere. Int J Gynaecol Obstet 2018; 143:267-276. [PMID: 30144050 PMCID: PMC6221992 DOI: 10.1002/ijgo.12656] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [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: 04/06/2018] [Revised: 07/10/2018] [Accepted: 08/22/2018] [Indexed: 12/22/2022]
Abstract
Cervical cancer is currently the fourth leading cause of cancer death among women worldwide, with most cases occurring in low- and middle-income countries. Safe, highly effective vaccines against HPV have been on the market since 2006, yet only 6% of girls worldwide have received this life-saving cancer prevention intervention. International organizations, including PATH, Gavi, and the pharmaceutical companies Merck and GlaxoSmithKline, have provided support to eligible low- and middle-income countries to implement national HPV vaccination programs. Still, glaring disparities in the availability of national HPV vaccination programs and the coverage of the primary target population between the global north and south persist. We illustrate worldwide HPV vaccine implementation and coverage using an online data visualization, which is publicly available and can be used to gain unique insights. We also present three emerging solutions to transform future HPV vaccine delivery in low- and middle-income countries: low-cost generics, single-dose vaccination, and co-administration with other adolescent vaccines. By rapidly expanding access to HPV vaccination to girls everywhere, vaccine-type HPV infections can be virtually eliminated. At high vaccination-coverage levels, more than 80%-or approximately 230 000-of the cervical cancer deaths that occur each year can be averted.
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Affiliation(s)
- Austin M. Oberlin
- Division of Global Women’s Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, USA
- Right to Care, Helen Joseph Hospital, Johannesburg, South Africa
- Clinical HIV Research Unit, Department of Internal Medicine, University of the Witwatersrand, Helen Joseph Hospital, Johannesburg, South Africa
| | - Lisa Rahangdale
- Division of General Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Lameck Chinula
- Division of Global Women’s Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, USA
- UNC Project-Malawi, Tidziwe Centre, Kamuzu Central Hospital, Lilongwe, Malawi
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Nurain M. Fuseini
- Division of Global Women’s Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, USA
- Department of Obstetrics and Gynecology, Osborn Family Health Center, Our Lady of Lourdes Medical Center, Camden, USA
| | - Carla J. Chibwesha
- Division of Global Women’s Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, USA
- Right to Care, Helen Joseph Hospital, Johannesburg, South Africa
- Clinical HIV Research Unit, Department of Internal Medicine, University of the Witwatersrand, Helen Joseph Hospital, Johannesburg, South Africa
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19
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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20
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Chibwesha CJ. Using routinely collected clinical data to prevent stillbirths. BJOG 2018; 125:139. [PMID: 28318102 DOI: 10.1111/1471-0528.14559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- C J Chibwesha
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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21
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Ford C, Chibwesha CJ, Winston J, Jacobs C, Lubeya MK, Musonda P, Stringer JSA, Chi BH. Women's decision-making and uptake of services to prevent mother-to-child HIV transmission in Zambia. AIDS Care 2017; 30:426-434. [PMID: 28971710 DOI: 10.1080/09540121.2017.1381328] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Women's empowerment is associated with engagement in some areas of healthcare, but its role in prevention of mother-to-child HIV transmission (PMTCT) services has not been previously considered. In this secondary analysis, we investigated the association of women's decision-making and uptake of health services for PMTCT. Using data from population-based household surveys, we included women who reported delivery in the 2-year period prior to the survey and were HIV-infected. We measured a woman's self-reported role in decision-making in her own healthcare, making of large purchases, schooling of children, and healthcare for children. For each domain, respondents were categorized as having an "active" or "no active" role. We investigated associations between decision-making and specific steps along the PMTCT cascade: uptake of maternal antiretroviral drugs, uptake of infant HIV prophylaxis, and infant HIV testing. We calculated unadjusted and adjusted odds ratios via logistic regression. From March to December 2011, 344 HIV-infected mothers were surveyed and 276 completed the relevant survey questions. Of these, 190 (69%) took antiretroviral drugs during pregnancy; 175 (64%) of their HIV-exposed infants received antiretroviral prophylaxis; and 160 (58%) had their infant tested for HIV. There was no association between decision-making and maternal or infant antiretroviral drug use. We observed a significant association between decision-making and infant HIV testing in univariate analyses (OR 1.56-1.85; p < 0.05); however, odds ratios for the decision-making indicators were no longer statistically significant predictors of infant HIV testing in multivariate analyses. In conclusion, women who reported an active role in decision-making trended toward a higher likelihood of uptake of infant testing in the PMTCT cascade. Larger studies are needed to evaluate the impact of empowerment initiatives on the PMTCT service utilization overall and infant testing in particular.
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Affiliation(s)
- Catherine Ford
- a School of Medicine , University of North Carolina , Chapel Hill , NC , USA
| | - Carla J Chibwesha
- a School of Medicine , University of North Carolina , Chapel Hill , NC , USA
| | - Jennifer Winston
- a School of Medicine , University of North Carolina , Chapel Hill , NC , USA
| | - Choolwe Jacobs
- b School of Public Health , University of Zambia , Lusaka , Zambia
| | | | - Patrick Musonda
- b School of Public Health , University of Zambia , Lusaka , Zambia
| | | | - Benjamin H Chi
- a School of Medicine , University of North Carolina , Chapel Hill , NC , USA
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22
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Chibwesha CJ, Ford CE, Mollan KR, Stringer JSA. Point-of-Care Virologic Testing to Improve Outcomes of HIV-Infected Children in Zambia: A Clinical Trial Protocol. J Acquir Immune Defic Syndr 2017; 72 Suppl 2:S197-201. [PMID: 27355509 PMCID: PMC5113248 DOI: 10.1097/qai.0000000000001050] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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: 11/25/2022]
Abstract
INTRODUCTION In the absence of early infant diagnosis (EID) and immediate antiretroviral therapy (ART), some 50% of untreated HIV-infected infants die before age 2. Conventional EID requires sophisticated instruments that are typically placed in centralized or reference laboratories. In low-resource settings, centralized systems often lead to result turnaround times of several months, long delays in diagnosis, and adverse outcomes for HIV-infected children. Our clinical trial tests the effectiveness of a new point-of-care (POC) diagnostic technology to identify HIV-infected infants and start providing them life-saving ART as soon as possible. METHODS AND DESIGN The study uses a randomized, controlled design to test whether the Alere q platform for HIV DNA polymerase chain reaction (PCR) testing improves outcomes of HIV-infected children in Zambia. We aim to enroll 2867 HIV-exposed infants aged 4-12 weeks and to follow those who are HIV infected for 12 months as they receive HIV care at 6 public health facilities in Lusaka. The trial's primary endpoint is the proportion of HIV-infected infants in each study arm who start ART and remain alive, in care, and virally suppressed 12 months after their diagnostic blood draw. DISCUSSION Our trial will provide evidence for the incremental benefit of implementing a POC EID strategy in low-resource settings where only off-site PCR services are currently available. The results will be useful in guiding future decisions regarding investments in POC virologic testing as part of overall pediatric AIDS mitigation strategies in sub-Saharan Africa. TRIAL REGISTRATION clinicaltrials.gov NCT02682810.
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Affiliation(s)
- Carla J Chibwesha
- *Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC; †Department of Obstetrics and Gynaecology, University Teaching Hospital, Lusaka, Zambia; and ‡Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
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23
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Mohammed SI, Ren W, Flowers L, Rajwa B, Chibwesha CJ, Parham GP, Irudayaraj JMK. Point-of-care test for cervical cancer in LMICs. Oncotarget 2017; 7:18787-97. [PMID: 26934314 PMCID: PMC4951329 DOI: 10.18632/oncotarget.7709] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [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: 11/13/2015] [Accepted: 02/09/2016] [Indexed: 12/21/2022] Open
Abstract
Cervical cancer screening using Papanicolaou's smear test has been highly effective in reducing death from this disease. However, this test is unaffordable in low- and middle-income countries, and its complexity has limited wide-scale uptake. Alternative tests, such as visual inspection with acetic acid or Lugol's iodine and human papillomavirus DNA, are sub-optimal in terms of specificity and sensitivity, thus sensitive and affordable tests with high specificity for on-site reporting are needed. Using proteomics and bioinformatics, we have identified valosin-containing protein (VCP) as differentially expressed between normal specimens and those with cervical intra-epithelial neoplasia grade 2/3 (CIN2/CIN3+) or worse. VCP-specific immunohistochemical staining (validated by a point-of-care technology) provided sensitive (93%) and specific (88%) identification of CIN2/CIN3+ and may serve as a critical biomarker for cervical-cancer screening. Future efforts will focus on further refinements to enhance analytic sensitivity and specificity of our proposed test, as well as on prototype development.
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Affiliation(s)
- Sulma I Mohammed
- Department of Comparative Pathobiology, Purdue University Center for Cancer Research, Purdue University, West Lafayette, Indiana 47907, USA.,Bindley Bioscience Center, Purdue University Center for Cancer Research, Purdue University, West Lafayette, Indiana 47907, USA
| | - Wen Ren
- Department of Agricultural and Biological Engineering, Purdue University, West Lafayette, Indiana 47907, USA.,Bindley Bioscience Center, Purdue University Center for Cancer Research, Purdue University, West Lafayette, Indiana 47907, USA
| | - Lisa Flowers
- Department of Gynecology and Obstetrics, Emory University, Atlanta, Georgia 30322, USA
| | - Bartek Rajwa
- Bindley Bioscience Center, Purdue University Center for Cancer Research, Purdue University, West Lafayette, Indiana 47907, USA
| | - Carla J Chibwesha
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA
| | - Groesbeck P Parham
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA
| | - Joseph M K Irudayaraj
- Department of Agricultural and Biological Engineering, Purdue University, West Lafayette, Indiana 47907, USA.,Bindley Bioscience Center, Purdue University Center for Cancer Research, Purdue University, West Lafayette, Indiana 47907, USA
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Makura CBT, Schnippel K, Michelow P, Chibwesha CJ, Goeieman B, Jordaan S, Firnhaber C. Choropleth Mapping of Cervical Cancer Screening in South Africa Using Healthcare Facility-level Data from the National Laboratory Network. AIMS Public Health 2016; 3:849-862. [PMID: 29546199 PMCID: PMC5690409 DOI: 10.3934/publichealth.2016.4.849] [Citation(s) in RCA: 10] [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: 08/06/2016] [Accepted: 10/14/2016] [Indexed: 11/18/2022] Open
Abstract
Background In South Africa, cervical cancer remains among the most common cancers and a leading cause of cancer death. Co-infection with HIV increases the risk of developing cervical pre-cancer and cancer. We analysed National Health Laboratory Service cervical cytology data to investigate geographic variations of Pap smear coverage, quality, and high grade lesions. Methods Facility-level data were extracted from the NHLS for April 2013–March 2014. We present results and choropleth maps detailing coverage, adequacy and high-grade Pap smear cytology abnormalities defined as Pap smears suspicious for invasive carcinoma, high-grade squamous intraepithelial lesions (HSIL) or atypical squamous cells: cannot exclude HSIL (ASC-H). Results 4,562 facilities submitted 791,067 cytology slides. The interquartile range (IQR) for Pap smear coverage among HIV-infected women was 26–41%; similar to coverage in women aged 30 and older (IQR: 26–42%). 6/52 districts had adequacy rates above the national standard (70%) and 2/52 districts had adequacy rates below 35%. We observed marked variation in Pap smear abnormalities across the country, with the proportion of high-grade cytology abnormalities ≥0.3% in 17/52 districts. Conclusion Using district-level choropleth maps, we are able to display variations in Pap smear coverage, quality, and results across South Africa. This approach may be used to improve resource allocation, achieving better equity in cervical cancer prevention.
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Affiliation(s)
| | - Kathryn Schnippel
- Right to Care, Johannesburg, South Africa.,Clinical HIV Research Unit, Department of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Pamela Michelow
- Cytology Unit, Department of Anatomical Pathology, Faculty of Health Sciences, University of the Witwatersrand.,National Health Laboratory Service, Johannesburg, South Africa
| | - Carla J Chibwesha
- Right to Care, Johannesburg, South Africa.,Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Suzette Jordaan
- National Health Laboratory Service, Johannesburg, South Africa
| | - Cynthia Firnhaber
- Right to Care, Johannesburg, South Africa.,Clinical HIV Research Unit, Department of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Hancock NL, Stuart GS, Tang JH, Chibwesha CJ, Stringer JSA, Chi BH. Renewing focus on family planning service quality globally. Contracept Reprod Med 2016; 1:10. [PMID: 29201399 PMCID: PMC5693493 DOI: 10.1186/s40834-016-0021-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 04/25/2016] [Indexed: 11/10/2022] Open
Abstract
Reducing the global unmet need for contraception is currently a priority for many governments, multi-lateral initiatives, non-governmental organizations, and donors. Evidence strongly suggests that the provision of quality family planning services can increase uptake, prevalence, and continuation of contraception. While an accepted framework to define the components of family planning service quality exists, translating this framework into assessment tools that are accessible, easily utilized, and valid for service providers has remained a challenge. We propose new approaches to improve the standardization and accessibility of family planning service quality assessment tools to simplify family planning service quality evaluation. With easier approaches to program evaluation, quality improvements can be performed more swiftly to help increase uptake and continuation of contraception to improve the health of women and their families.
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Affiliation(s)
- Nancy L. Hancock
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Campus Box 7577, Chapel Hill, NC 27599-7577 USA
- Centre for Infectious Disease Research in Zambia, PO Box 34681, 5032 Great North Road, Lusaka, Zambia
| | - Gretchen S. Stuart
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Campus Box 7577, Chapel Hill, NC 27599-7577 USA
| | - Jennifer H. Tang
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Campus Box 7577, Chapel Hill, NC 27599-7577 USA
- UNC Project-Malawi, Tidziwe Centre, Private Bag A-104, Lilongwe, Malawi
| | - Carla J. Chibwesha
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Campus Box 7577, Chapel Hill, NC 27599-7577 USA
| | - Jeffrey S. A. Stringer
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Campus Box 7577, Chapel Hill, NC 27599-7577 USA
| | - Benjamin H. Chi
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Campus Box 7577, Chapel Hill, NC 27599-7577 USA
- Centre for Infectious Disease Research in Zambia, PO Box 34681, 5032 Great North Road, Lusaka, Zambia
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26
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Hancock NL, Chibwesha CJ, Bosomprah S, Newman J, Mubiana-Mbewe M, Sitali ES, Bolton-Moore C, Mbwili-Muleya C, Chi BH. Contraceptive use among HIV-infected women and men receiving antiretroviral therapy in Lusaka, Zambia: a cross-sectional survey. BMC Public Health 2016; 16:392. [PMID: 27175483 PMCID: PMC4865985 DOI: 10.1186/s12889-016-3070-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Accepted: 05/04/2016] [Indexed: 12/02/2022] Open
Abstract
Background Family planning (FP) is an essential health service and an important part of comprehensive HIV care. However, there is limited information about the contraceptive needs of people living with HIV in sub-Saharan Africa, which in turn has hampered efforts to expand and integrate FP services into existing HIV programs. Methods We performed a cross-sectional survey to determine FP prevalence and predictors among HIV-positive women and men attending 18 public antiretroviral therapy (ART) clinics in Lusaka, Zambia. Trained peer counselors administered the 10-question survey to those seeking care for five days at each of the target sites. Results From February to April 2014, we surveyed 7,046 HIV-infected patients receiving routine HIV services. Use of modern contraception was reported by 69 % of female ART patients and 79 % of male ART patients. However, highly effective contraceptive use and dual method use were low among women (38 and 25 %, respectively) and men (19 and 14 %, respectively). HIV disclosure status (adjusted odds ratio (AOR) = 4.91, 95 % confidence interval (CI) = 3.32–7.24 for women, AOR = 3.58, 95 % CI = 2.39–5.38 for men) and sexual activity in the last 6 months (AOR = 5.80, 95 % CI = 4.51–7.47 for women, AOR = 6.24, 95 % CI = 3.51–11.08 for men) were associated with modern contraceptive use in multivariable regression. Most respondents said they would access FP services if made available within ART clinic. Conclusions While FP-ART integration may be a promising strategy for increasing FP service uptake, such services must focus on assessing sexual activity and advocating for dual method use to increase effective contraceptive use and prevent unintended pregnancies.
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Affiliation(s)
- Nancy L Hancock
- Department of Obstetrics and Gynecology, UNC Global Women's Health, University of North Carolina School of Medicine, 3009 Old Clinic Building, Campus, Box 7577, Chapel Hill, NC, 27599-7577, USA. .,Centre for Infectious Disease Research in Zambia, PO Box 34681, 5032 Great North Road, Lusaka, Zambia.
| | - Carla J Chibwesha
- Department of Obstetrics and Gynecology, UNC Global Women's Health, University of North Carolina School of Medicine, 3009 Old Clinic Building, Campus, Box 7577, Chapel Hill, NC, 27599-7577, USA
| | - Samuel Bosomprah
- Centre for Infectious Disease Research in Zambia, PO Box 34681, 5032 Great North Road, Lusaka, Zambia
| | - Jonathan Newman
- Centre for Infectious Disease Research in Zambia, PO Box 34681, 5032 Great North Road, Lusaka, Zambia
| | - Mwangelwa Mubiana-Mbewe
- Centre for Infectious Disease Research in Zambia, PO Box 34681, 5032 Great North Road, Lusaka, Zambia
| | - Elizabeth Siyama Sitali
- Centre for Infectious Disease Research in Zambia, PO Box 34681, 5032 Great North Road, Lusaka, Zambia
| | - Carolyn Bolton-Moore
- Department of Obstetrics and Gynecology, UNC Global Women's Health, University of North Carolina School of Medicine, 3009 Old Clinic Building, Campus, Box 7577, Chapel Hill, NC, 27599-7577, USA.,Centre for Infectious Disease Research in Zambia, PO Box 34681, 5032 Great North Road, Lusaka, Zambia
| | - Clara Mbwili-Muleya
- Lusaka District Community Health Office, Ministry of Community Development, Mother and Child Health, PO Box 50827, Lusaka, Zambia
| | - Benjamin H Chi
- Department of Obstetrics and Gynecology, UNC Global Women's Health, University of North Carolina School of Medicine, 3009 Old Clinic Building, Campus, Box 7577, Chapel Hill, NC, 27599-7577, USA.,Centre for Infectious Disease Research in Zambia, PO Box 34681, 5032 Great North Road, Lusaka, Zambia
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27
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Bengtson AM, Chibwesha CJ, Westreich D, Mubiana-Mbewe M, Vwalika B, Miller WC, Mapani M, Musonda P, Pettifor A, Chi BH. Duration of cART Before Delivery and Low Infant Birthweight Among HIV-Infected Women in Lusaka, Zambia. J Acquir Immune Defic Syndr 2016; 71:563-9. [PMID: 26627103 PMCID: PMC4788590 DOI: 10.1097/qai.0000000000000909] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [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] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To estimate the association between duration of combination antiretroviral therapy (cART) during pregnancy and low infant birthweight (LBW), among women ≥37 weeks of gestation. DESIGN We conducted a retrospective cohort study of HIV-infected women who met eligibility criteria based on CD4 count ≤350 but had not started cART at entry into antenatal care. Our cohort was restricted to births that occurred ≥37 weeks of gestation. METHODS We used Poisson models with robust variance estimators to estimate risk ratios (RRs) and 95% confidence intervals (CIs). RESULTS Of 50,765 HIV-infected women with antenatal visits between January 2009 and September 2013, 4474 women met the inclusion criteria. LBW occurred in 302 pregnancies (7%). Nearly two-thirds of women (62%) eligible to initiate cART never started treatment. Overall, 14% were on cART for ≤8 weeks, 22% for 9-20 weeks, and 2% for 21-36 weeks. There was no evidence of an increased risk of LBW for women receiving cART for ≤8 weeks (RR = 1.22; 95% CI: 0.77 to 1.91), 9-20 weeks (RR = 1.23; 95% CI: 0.82 to 1.83), or 21-36 weeks (RR = 0.87; 95% CI: 0.22 to 3.46), compared with women who never initiated treatment. These findings were consistent across several sensitivity analyses. CONCLUSIONS Longer duration of cART was not associated with poor fetal growth among term pregnancies in our cohort. However, the relationship between cART and adverse pregnancy outcomes remains complicated. Continued work is required to investigate causality. An understanding cART's impact on adverse pregnancy outcomes is essential as cART becomes the cornerstone of preventing mother-to-child transmission programs globally.
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Affiliation(s)
- Angela M. Bengtson
- Department of Epidemiology, University of North Carolina-Chapel Hill
- Centre for Infectious Disease Research in Zambia
| | - Carla J. Chibwesha
- Department of Obstetrics and Gynecology, University of North Carolina-Chapel Hill
| | - Daniel Westreich
- Department of Epidemiology, University of North Carolina-Chapel Hill
| | | | | | - William C. Miller
- Department of Epidemiology, University of North Carolina-Chapel Hill
- Department of Medicine, University of North Carolina-Chapel Hill
| | | | | | - Audrey Pettifor
- Department of Epidemiology, University of North Carolina-Chapel Hill
| | - Benjamin H. Chi
- Centre for Infectious Disease Research in Zambia
- Department of Obstetrics and Gynecology, University of North Carolina-Chapel Hill
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28
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Mbulawa ZZA, Wilkin TJ, Goeieman B, Swarts A, Williams S, Levin S, Faesen M, Smith JS, Chibwesha CJ, Williamson AL, Firnhaber C. Xpert human papillomavirus test is a promising cervical cancer screening test for HIV-seropositive women. ACTA ACUST UNITED AC 2016; 2:56-60. [PMID: 29074186 PMCID: PMC5886871 DOI: 10.1016/j.pvr.2016.02.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 02/09/2016] [Accepted: 02/29/2016] [Indexed: 11/30/2022]
Abstract
This study investigated the performance of Cepheid Xpert human papillomavirus (HPV) assay in South African human immunodeficiency virus (HIV)-infected women and compared its performance with that of hybrid capture-2 (hc2). Methods: Stored cervical specimens from HIV-infected women that had previously been tested using hc2 were tested using Xpert. Results: The overall HR-HPV prevalence was found to be 62.0% (720/1161) by Xpert and 61.2% (711/1161) by hc2. 13.6% (158/1161) were HPV16 positive, 18.8% (218/1161) were HPV18/45, 37.3% (434/1161) were HPV31/33/35/52/58, 12.7% (147/1161) were HPV51/59 and 23.3% (270/1161) were HPV39/68/56/66. Overall agreement with hc2 was 90%; Cohen’s kappa was 0.78 (95% CI 0.74–0.82) indicating substantial agreement. Detection of HPV16, HPV18/45, and HPV31/33/35/52/58 were independently associated with cervical intraepithelial neoplasia (CIN)−2+ (P<0.0001 for each); while HPV51/59 and HPV39/68/56/66 were not. Women infected with HPV16, HPV18/45 or HPV31/33/35/52/58 were found to have significantly higher amounts of HPV DNA detected for those with CIN2+ compared to those without CIN2+, P<0.0001 for each. Xpert and hc2 were similarly sensitive (88.3% and 91.5%, respectively) and specific (48.4% and 51.0%) for CIN2+ and CIN3 (sensitivity: 95.8% and 97.9%; specificity: 41.4% and 42.8%). Conclusions: Xpert is a promising screening test in HIV-infected women that performs similarly to hc2.
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Affiliation(s)
- Zizipho Z A Mbulawa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa; Centre for HIV and STIs, National Institute for Communicable Disease, National Health Laboratory Service, South Africa.
| | - Timothy J Wilkin
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
| | | | - Avril Swarts
- Clinical HIV Research Unit, Department of Medicine, University of the Witswatersand, Johannesburg, South Africa.
| | | | | | | | - Jennifer S Smith
- Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Carla J Chibwesha
- Right to Care, Johannesburg, South Africa; Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA.
| | - Anna-Lise Williamson
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa; UCT-SAMRC Clinical Gynaecological Cancer Research Centre, University of Cape Town, South Africa; National Health Laboratory Service, Groote Schuur Hospital, Observatory, Cape Town 7925, South Africa.
| | - Cynthia Firnhaber
- Right to Care, Johannesburg, South Africa; Clinical HIV Research Unit, Department of Medicine, University of the Witswatersand, Johannesburg, South Africa.
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Bengtson AM, Chibwesha CJ, Westreich D, Mubiana-Mbewe M, Chi BH, Miller WC, Mapani M, Pence BW, Musonda P, Stringer JS, Pettifor A. A risk score to identify HIV-infected women most likely to become lost to follow-up in the postpartum period. AIDS Care 2016; 28:1035-45. [PMID: 26887526 DOI: 10.1080/09540121.2016.1144869] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Access to lifelong combination antiretroviral therapy (cART) is expanding among HIV-infected pregnant and breastfeeding women throughout sub-Saharan Africa (SSA). For this strategy to meaningfully improve maternal HIV outcomes, retention in HIV care is essential. We developed a risk score to identify women with high likelihood of loss to follow-up (LTFU) at 6 months postpartum from HIV care, using data from public health facilities in Lusaka, Zambia. LTFU was defined as not presenting for HIV care within 60 days of the last scheduled appointment. We used logistic regression to assess demographic, obstetric and HIV predictors of LTFU and to develop a simple risk score. Sensitivity and specificity were assessed at each risk score cut-point. Among 2029 pregnant women initiating cART between 2009 and 2011, 507 (25%) were LTFU by 6 months postpartum. Parity, education, employment status, WHO clinical stage, duration of cART during pregnancy and number of antenatal care visits were associated with LTFU (p-value < .10). A risk score cut-point of 11 (42nd percentile) had 85% sensitivity (95% CI 82%, 88%) and 22% specificity (95% CI 20%, 24%) to detect women LTFU and would exclude 20% of women from a retention intervention. A risk score cut-point of 18 (69th percentile) identified the 23% of women with the highest probability of LTFU and had sensitivity 32% (95% CI 28%, 36%) and specificity 80% (95% CI 78%, 82%). A risk score approach may be useful to triage a subset of women most likely to be LTFU for targeted retention interventions.
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Affiliation(s)
- Angela M Bengtson
- a Department of Epidemiology , University of North Carolina , Chapel Hill , NC , USA
| | - Carla J Chibwesha
- b Department of Obstetrics and Gynecology , University of North Carolina , Chapel Hill , NC , USA
| | - Daniel Westreich
- a Department of Epidemiology , University of North Carolina , Chapel Hill , NC , USA
| | | | - Benjamin H Chi
- b Department of Obstetrics and Gynecology , University of North Carolina , Chapel Hill , NC , USA.,c Centre for Infectious Disease Research , Zambia , Africa
| | - William C Miller
- a Department of Epidemiology , University of North Carolina , Chapel Hill , NC , USA.,d Department of Medicine , University of North Carolina , Chapel Hill , NC , USA
| | - Muntanga Mapani
- b Department of Obstetrics and Gynecology , University of North Carolina , Chapel Hill , NC , USA
| | - Brian W Pence
- a Department of Epidemiology , University of North Carolina , Chapel Hill , NC , USA
| | - Patrick Musonda
- e Department of Public Health , University of Zambia School of Medicine , Lusaka , Zambia , Africa
| | - Jeffrey Sa Stringer
- b Department of Obstetrics and Gynecology , University of North Carolina , Chapel Hill , NC , USA
| | - Audrey Pettifor
- a Department of Epidemiology , University of North Carolina , Chapel Hill , NC , USA
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30
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Schnippel K, Michelow P, Chibwesha CJ, Makura C, Lince-Deroche N, Goeieman B, Mulongo M, Jordaan S, Firnhaber C. Cost-effectiveness of using the Cervex-Brush (broom) compared to the elongated spatula for collection of conventional cervical cytology samples within a high-burden HIV setting: a model-based analysis. BMC Health Serv Res 2015; 15:499. [PMID: 26545585 PMCID: PMC4636771 DOI: 10.1186/s12913-015-1163-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 11/03/2015] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND From 2010 to 2014, approximately 2 million Pap smears from HIV-infected women were submitted to the South African National Health Laboratory Services (NHLS) through the national cervical cancer screening programme. The objective of this analysis was to determine whether using the plastic Cervex brush ("broom") would be a cost-effective approach to improve cytology specimen quality as compared to the wooden spatula used currently. METHODS A decision analysis model was built using the expected adequacy rates for samples collected with the spatula (<$0.02) and broom ($0.23) and the probability of detecting cervical dysplasia. NHLS data was used for testing volumes and rates of HIV-positivity, suitability of specimens, and presence of endocervical cells. Expected positivity of Pap smears in HIV-infected women (73 %), odds ratios of the effectiveness of the broom (OR: 1.57), and improved sensitivity when endocervical cells present (OR: 1.89) are from literature. NHLS costs were used for the collection devices and conventional cytology ($4.89). Cost of clinic visit is from WHO CHOICE ($8.36). RESULTS In 2010, 80 % of specimens submitted to NHLS were adequate for evaluation; in 2014, only 54 % met the same criteria. For HIV-infected women, according to the guidelines model, using the wooden spatula costs $6.25 million per year, $16.79 per woman tested. Under intended practice, for each additional HSIL case detected among HIV-infected women, the South African cervical cancer screening programme could save $13.64 (95 % CI: $13.52 to $13.76) by using the broom as its standard of care collection device through increased collection of endocervical cells and consequent reduction in repeat Pap smears. CONCLUSION Under a wide range of parameters tested using a simulation model, the more expensive plastic broom could save the South African cervical cancer screening programme money and increase detection of high-grade cervical dysplasia in HIV-infected women compared to the current wooden spatula.
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Affiliation(s)
- Kathryn Schnippel
- Right to Care, Johannesburg, South Africa.
- Clinical HIV Research Unit, Department of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Pamela Michelow
- Cytology Unit, Department of Anatomical Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
- National Health Laboratory Service, Johannesburg, South Africa.
| | - Carla J Chibwesha
- Right to Care, Johannesburg, South Africa.
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
| | | | - Naomi Lince-Deroche
- Health Economics and Epidemiology Research Office, Department of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | | | | | - Suzette Jordaan
- Cytology Unit, Department of Anatomical Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
- National Health Laboratory Service, Johannesburg, South Africa.
| | - Cynthia Firnhaber
- Right to Care, Johannesburg, South Africa.
- Clinical HIV Research Unit, Department of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
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31
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Bateman AC, Katundu K, Mwanahamuntu MH, Kapambwe S, Sahasrabuddhe VV, Hicks ML, Chi BH, Stringer JSA, Parham GP, Chibwesha CJ. The burden of cervical pre-cancer and cancer in HIV positive women in Zambia: a modeling study. BMC Cancer 2015. [PMID: 26205980 PMCID: PMC4512016 DOI: 10.1186/s12885-015-1558-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [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: 12/03/2022] Open
Abstract
Background HIV infection is associated with a higher incidence of precancerous cervical lesions and their progression to invasive cervical cancer (ICC). Zambia is a global epicenter of HIV and ICC, yet the overall burden of cervical pre-cancer [cervical intraepithelial neoplasia 3 (CIN3)] and ICC among its HIV positive adult female population is unknown. The objective of this study was to determine the burden of cervical disease among HIV positive women in Zambia by estimating the number with CIN3 and ICC. Methods We conducted a cross-sectional study among 309 HIV positive women attending screening in Lusaka (Zambia’s most populated province) to measure the cervical disease burden by visual inspection with acetic acid enhanced by digital cervicography (DC), cytology, and histology. We then used estimates of the prevalence of CIN3 and ICC from the cross-sectional study and Spectrum model-based estimates for HIV infection among Zambian women to estimate the burden of CIN3 and ICC among HIV positive women nationally. Results Over half (52 %) of the study participants screened positive by DC, while 45 % had cytologic evidence of high grade squamous intraepithelial lesions (SIL) or worse. Histopathologic evaluation revealed that 20 % of women had evidence of CIN2 or worse, 11 % had CIN3 or worse, and 2 % had ICC. Using the Spectrum model, we therefore estimate that 34,051 HIV positive women in Zambia have CIN3 and 7,297 have ICC. Conclusions The DC, cytology, and histology results revealed a large cervical disease burden in this previously unscreened HIV positive population. This very large burden indicates that continued scale-up of cervical cancer screening and treatment is urgently needed.
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Affiliation(s)
- Allen C Bateman
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. .,University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Katundu Katundu
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
| | - Mulindi H Mwanahamuntu
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. .,University of Zambia, Lusaka, Zambia.
| | - Sharon Kapambwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
| | | | | | - Benjamin H Chi
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. .,University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | | | - Groesbeck P Parham
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. .,University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. .,University of Zambia, Lusaka, Zambia.
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32
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Parham GP, Mwanahamuntu MH, Kapambwe S, Muwonge R, Bateman AC, Blevins M, Chibwesha CJ, Pfaendler KS, Mudenda V, Shibemba AL, Chisele S, Mkumba G, Vwalika B, Hicks ML, Vermund SH, Chi BH, Stringer JSA, Sankaranarayanan R, Sahasrabuddhe VV. Population-level scale-up of cervical cancer prevention services in a low-resource setting: development, implementation, and evaluation of the cervical cancer prevention program in Zambia. PLoS One 2015; 10:e0122169. [PMID: 25885821 PMCID: PMC4401717 DOI: 10.1371/journal.pone.0122169] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 02/07/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Very few efforts have been undertaken to scale-up low-cost approaches to cervical cancer prevention in low-resource countries. METHODS In a public sector cervical cancer prevention program in Zambia, nurses provided visual-inspection with acetic acid (VIA) and cryotherapy in clinics co-housed with HIV/AIDS programs, and referred women with complex lesions for histopathologic evaluation. Low-cost technological adaptations were deployed for improving VIA detection, facilitating expert physician opinion, and ensuring quality assurance. Key process and outcome indicators were derived by analyzing electronic medical records to evaluate program expansion efforts. FINDINGS Between 2006-2013, screening services were expanded from 2 to 12 clinics in Lusaka, the most-populous province in Zambia, through which 102,942 women were screened. The majority (71.7%) were in the target age-range of 25-49 years; 28% were HIV-positive. Out of 101,867 with evaluable data, 20,419 (20%) were VIA positive, of whom 11,508 (56.4%) were treated with cryotherapy, and 8,911 (43.6%) were referred for histopathologic evaluation. Most women (87%, 86,301 of 98,961 evaluable) received same-day services (including 5% undergoing same-visit cryotherapy and 82% screening VIA-negative). The proportion of women with cervical intraepithelial neoplasia grade 2 and worse (CIN2+) among those referred for histopathologic evaluation was 44.1% (1,735/3,938 with histopathology results). Detection rates for CIN2+ and invasive cervical cancer were 17 and 7 per 1,000 women screened, respectively. Women with HIV were more likely to screen positive, to be referred for histopathologic evaluation, and to have cervical precancer and cancer than HIV-negative women. INTERPRETATION We creatively disrupted the 'no screening' status quo prevailing in Zambia and addressed the heavy burden of cervical disease among previously unscreened women by establishing and scaling-up public-sector screening and treatment services at a population level. Key determinants for successful expansion included leveraging HIV/AIDS program investments, and context-specific information technology applications for quality assurance and filling human resource gaps.
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Affiliation(s)
- Groesbeck P. Parham
- Center for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of Zambia, Lusaka, Zambia
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- International Agency for Research on Cancer, Lyon, France
| | - Mulindi H. Mwanahamuntu
- Center for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of Zambia, Lusaka, Zambia
| | - Sharon Kapambwe
- Center for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of Zambia, Lusaka, Zambia
| | | | - Allen C. Bateman
- Center for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Meridith Blevins
- Vanderbilt University, Nashville, Tennessee, United States of America
| | - Carla J. Chibwesha
- Center for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Krista S. Pfaendler
- Center for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of California, Irvine, Irvine, California, United States of America
| | | | | | | | | | | | - Michael L. Hicks
- Michigan Cancer Institute, Pontiac, Michigan, United States of America
| | - Sten H. Vermund
- Vanderbilt University, Nashville, Tennessee, United States of America
| | - Benjamin H. Chi
- Center for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Jeffrey S. A. Stringer
- Center for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | | | - Vikrant V. Sahasrabuddhe
- Vanderbilt University, Nashville, Tennessee, United States of America
- National Cancer Institute, Bethesda, Maryland, United States of America
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Bateman AC, Katundu K, Polepole P, Shibemba A, Mwanahamuntu M, Dittmer DP, Parham GP, Chibwesha CJ. Identification of human papillomaviruses from formalin-fixed, paraffin-embedded pre-cancer and invasive cervical cancer specimens in Zambia: a cross-sectional study. Virol J 2015; 12:2. [PMID: 25591541 PMCID: PMC4304620 DOI: 10.1186/s12985-014-0234-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 12/22/2014] [Indexed: 12/18/2022] Open
Abstract
Background The most common human papillomavirus (HPV) genotypes isolated from cervical cancer in select African countries are HPV-16, HPV-18, HPV-35, and HPV-45, but the most common genotypes in Zambia are unknown. The overall objective of this study was to assess the potential impact of current HPV vaccines in preventing cervical cancer in Zambia, by determining the combined prevalence of HPV-16 and/or HPV-18 in invasive cervical cancer (ICC) and high-grade pre-cancer [cervical intraepithelial neoplasia 2 or 3 (CIN2/3)] cases. Findings We compared DNA extraction techniques to determine which assay performs well in the Zambian context, where unbuffered formalin is used to fix specimens. We then tested specimens with the Abbott RealTime High-Risk HPV test to estimate the prevalence of HPV-16/18 in formalin-fixed, paraffin-embedded ICC and CIN2/3 specimens. DNA extraction using heat (without xylene) was more successful than xylene-based extraction. Over 80% of specimens tested using heat extraction and the Abbott RealTime HPV test were positive for HPV. HPV-16 and/or HPV-18 were identified in 65/93 (69.9%) ICC specimens positive for HPV and in 38/65 (58.5%) CIN2/3 specimens positive for HPV. Conclusions To our knowledge this is the first report to identify HPV genotypes in cervical cancers in Zambia. A combined HPV-16/18 prevalence of 69.9% in ICC specimens suggests that current vaccines will be highly protective against cervical cancer in Zambia.
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Affiliation(s)
- Allen C Bateman
- Centre for Infectious Disease Research in Zambia, Plot 5032 Great North Road, Lusaka, Zambia. .,Department of Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
| | - Katundu Katundu
- Centre for Infectious Disease Research in Zambia, Plot 5032 Great North Road, Lusaka, Zambia.
| | | | | | - Mulindi Mwanahamuntu
- Centre for Infectious Disease Research in Zambia, Plot 5032 Great North Road, Lusaka, Zambia. .,University of Zambia Teaching Hospital, Lusaka, Zambia.
| | - Dirk P Dittmer
- Program in Global Oncology, UNC Lineberger Comprehensive Cancer Center and School of Medicine, UNC, Chapel Hill, North Carolina, USA.
| | - Groesbeck P Parham
- Centre for Infectious Disease Research in Zambia, Plot 5032 Great North Road, Lusaka, Zambia. .,University of Zambia Teaching Hospital, Lusaka, Zambia. .,Department of Obstetrics and Gynecology, UNC School of Medicine, UNC, Chapel Hill, North Carolina, USA.
| | - Carla J Chibwesha
- Centre for Infectious Disease Research in Zambia, Plot 5032 Great North Road, Lusaka, Zambia. .,Department of Obstetrics and Gynecology, UNC School of Medicine, UNC, Chapel Hill, North Carolina, USA.
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Bateman AC, Chibwesha CJ, Parham GP. Minimizing verification bias in cervical cancer screening of HIV-infected women. Int J Gynaecol Obstet 2014; 128:269-70. [PMID: 25467910 DOI: 10.1016/j.ijgo.2014.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 08/29/2014] [Accepted: 10/18/2014] [Indexed: 11/17/2022]
Affiliation(s)
- Allen C Bateman
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Department of Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Carla J Chibwesha
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Department of Obstetrics and Gynecology, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Groesbeck P Parham
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Department of Obstetrics and Gynecology, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; University Teaching Hospital, Lusaka, Zambia
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De Vuyst H, Alemany L, Lacey C, Chibwesha CJ, Sahasrabuddhe V, Banura C, Denny L, Parham GP. The burden of human papillomavirus infections and related diseases in sub-saharan Africa. Vaccine 2014; 31 Suppl 5:F32-46. [PMID: 24331746 DOI: 10.1016/j.vaccine.2012.07.092] [Citation(s) in RCA: 153] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Revised: 07/06/2012] [Accepted: 07/10/2012] [Indexed: 11/17/2022]
Abstract
Despite the scarcity of high quality cancer registries and lack of reliable mortality data, it is clear that human papillomavirus (HPV)-associated diseases, particularly cervical cancer, are major causes of morbidity and mortality in sub-Saharan Africa (SSA). Cervical cancer incidence rates in SSA are the highest in the world and the disease is the most common cause of cancer death among women in the region. The high incidence of cervical cancer is a consequence of the inability of most countries to either initiate or sustain cervical cancer prevention services. In addition, it appears that the prevalence of HPV in women with normal cytology is higher than in more developed areas of the world, at an average of 24%. There is, however, significant regional variation in SSA, with the highest incidence of HPV infection and cervical cancer found in Eastern and Western Africa. It is expected that, due to aging and growth of the population, but also to lack of access to appropriate prevention services and the concomitant human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) epidemic, cervical cancer incidence and mortality rates in SSA will rise over the next 20 years. HPV16 and 18 are the most common genotypes in cervical cancer in SSA, although other carcinogenic HPV types, such as HPV45 and 35, are also relatively more frequent compared with other world regions. Data on other HPV-related anogenital cancers including those of the vulva, vagina, anus, and penis, are limited. Genital warts are common and associated with HPV types 6 and 11. HIV infection increases incidence and prevalence of all HPV-associated diseases. Sociocultural determinants of HPV-related disease, as well as the impact of forces that result in social destabilization, demand further study. Strategies to reduce the excessive burden of HPV-related diseases in SSA include age-appropriate prophylactic HPV vaccination, cervical cancer prevention services for women of the reproductive ages, and control of HIV/AIDS. This article forms part of a regional report entitled "Comprehensive Control of HPV Infections and Related Diseases in the Sub-Saharan Africa Region" Vaccine Volume 31, Supplement 5, 2013. Updates of the progress in the field are presented in a separate monograph entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.
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Affiliation(s)
- Hugo De Vuyst
- Infection and Cancer Epidemiology Group, International Agency for Research on Cancer (WHO-IARC), Lyon, France
| | - Laia Alemany
- Unit of Infections and Cancer (UNIC), Cancer Epidemiology Research Program (CERP), Institut Català d'Oncologia - Catalan Institute of Oncology (ICO), L'Hospitalet de Llobregat (Barcelona), Spain; CIBER en Epidemiología y Salud Pública (CIBERESP), Spain
| | - Charles Lacey
- Centre for Immunology and Infection, Hull York Medical School, University of York, York, UK
| | - Carla J Chibwesha
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, U.S.A and Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Vikrant Sahasrabuddhe
- Hormonal and Reproductive Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Cecily Banura
- Department of Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda
| | - Lynette Denny
- Department of Obstetrics and Gynaecology and Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Groote Schuur Hospital, Observatory, Cape Town, South Africa
| | - Groesbeck P Parham
- Department of Obstetrics and Gynecology, UNC Global Women's Health, University of North Carolina - Chapel Hill, North Carolina, USA.
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Liu KC, Chibwesha CJ. Intrapartum management for prevention of mother-to-child transmission of HIV in resource-limited settings: a review of the literature. Afr J Reprod Health 2013; 17:107-117. [PMID: 24689322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Prevention of mother-to-child transmission (PMTCT) of HIV guidelines in resource-limited settings focus on antenatal and postnatal management. In this review of the literature, we present findings from select studies, highlight best practices, and present evidence-based guidelines for intrapartum PMTCT management that are applicable to resource-limited settings. We discuss the roles of intrapartum HIV testing, intrapartum antiretroviral medications, mode of delivery in settings with and without HIV RNA testing, other delivery practices, and infant care in the immediate postnatal period. With the advent of Option B+, which recommends all HIV-infected pregnant women commence lifelong combination antiretroviral therapy (ART), the potential impact for intrapartum interventions will be greatest for those women who recently have seroconverted and those with unknown HIV status. Research on intrapartum PMTCT interventions should focus on these populations.
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Stringer JSA, Chisembele-Taylor A, Chibwesha CJ, Chi HF, Ayles H, Manda H, Mazimba W, Schuttner L, Sindano N, Williams FB, Chintu N, Chilengi R. Protocol-driven primary care and community linkages to improve population health in rural Zambia: the Better Health Outcomes through Mentoring and Assessment (BHOMA) project. BMC Health Serv Res 2013; 13 Suppl 2:S7. [PMID: 23819614 PMCID: PMC3668289 DOI: 10.1186/1472-6963-13-s2-s7] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Zambia's under-resourced public health system will not be able to deliver on its health-related Millennium Development Goals without a substantial acceleration in mortality reduction. Reducing mortality will depend not only upon increasing access to health care but also upon improving the quality of care that is delivered. Our project proposes to improve the quality of clinical care and to improve utilization of that care, through a targeted quality improvement (QI) intervention delivered at the facility and community level. DESCRIPTION OF IMPLEMENTATION The project is being carried out 42 primary health care facilities that serve a largely rural population of more than 450,000 in Zambia's Lusaka Province. We have deployed six QI teams to implement consensus clinical protocols, forms, and systems at each site. The QI teams define new clinical quality expectations and provide tools needed to deliver on those expectations. They also monitor the care that is provided and mentor facility staff to improve care quality. We also engage community health workers to actively refer and follow up patients. EVALUATION DESIGN Project implementation occurs over a period of four years in a stepped expansion to six randomly selected new facilities every three months. Three annual household surveys will determine population estimates of age-standardized mortality and under-5 mortality in each community before, during, and after implementation. Surveys will also provide measures of childhood vaccine coverage, pregnancy care utilization, and general adult health. Health facility surveys will assess coverage of primary health interventions and measures of health system effectiveness. DISCUSSION The patient-provider interaction is an important interface where the community and the health system meet. Our project aims to reduce population mortality by substantially improving this interaction. Our success will hinge upon the ability of mentoring and continuous QI to improve clinical service delivery. It will also be critical that once the quality of services improves, increasing proportions of the population will recognize their value and begin to utilize them.
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Affiliation(s)
- Jeffrey SA Stringer
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Angela Chisembele-Taylor
- Primary Care and Health Systems Department, Centre for Infectious Disease Research, Lusaka, Zambia
| | - Carla J Chibwesha
- Primary Care and Health Systems Department, Centre for Infectious Disease Research, Lusaka, Zambia
| | - Harmony F Chi
- Development Department, Centre for Infectious Disease Research, Lusaka, Zambia
| | - Helen Ayles
- ZAMBART PROJECT, Zambia AIDS Related Tuberculosis Project, Lusaka, Zambia
| | - Handson Manda
- Primary Care and Health Systems Department, Centre for Infectious Disease Research, Lusaka, Zambia
| | - Wendy Mazimba
- Primary Care and Health Systems Department, Centre for Infectious Disease Research, Lusaka, Zambia
| | - Linnaea Schuttner
- Primary Care and Health Systems Department, Centre for Infectious Disease Research, Lusaka, Zambia
| | - Ntazana Sindano
- Primary Care and Health Systems Department, Centre for Infectious Disease Research, Lusaka, Zambia
| | - Frank B Williams
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Namwinga Chintu
- Primary Care and Health Systems Department, Centre for Infectious Disease Research, Lusaka, Zambia
| | - Roma Chilengi
- Primary Care and Health Systems Department, Centre for Infectious Disease Research, Lusaka, Zambia
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Abstract
Cervical cancer remains the second commonest cancer among women worldwide, and more than 85% of the global burden of this disease occurs in the developing world. HIV-infected women have a higher likelihood of developing persistent high-risk human papillomavirus (HPV) infection, precancer, and invasive cervical cancer than seronegative women. Although highly effective primary and secondary prevention strategies are currently available, they remain inaccessible to the vast majority of women. Because of their simplicity and affordability, see-and-treat cervical cancer screening modalities have the potential to substantially improve women's access to cancer prevention, as well as to create much needed infrastructure for future molecular-based cervical screening and HPV vaccination programs. Additional data addressing the effectiveness of see-and-treat approaches for HIV-infected women are urgently needed. Studies informing best practice guidelines on when to start, when to stop, and how frequently to screen HIV-infected women within the see-and-treat paradigm would be of great value.
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Chi BH, Vwalika B, Killam WP, Wamalume C, Giganti MJ, Mbewe R, Stringer EM, Chintu NT, Putta NB, Liu KC, Chibwesha CJ, Rouse DJ, Stringer JSA. Implementation of the Zambia electronic perinatal record system for comprehensive prenatal and delivery care. Int J Gynaecol Obstet 2011; 113:131-6. [PMID: 21315347 DOI: 10.1016/j.ijgo.2010.11.013] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Revised: 11/12/2010] [Accepted: 01/12/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To characterize prenatal and delivery care in an urban African setting. METHODS The Zambia Electronic Perinatal Record System (ZEPRS) was implemented to record demographic characteristics, past medical and obstetric history, prenatal care, and delivery and newborn care for pregnant women across 25 facilities in the Lusaka public health sector. RESULTS From June 1, 2007, to January 31, 2010, 115552 pregnant women had prenatal and delivery information recorded in ZEPRS. Median gestation age at first prenatal visit was 23weeks (interquartile range [IQR] 19-26). Syphilis screening was documented in 95663 (83%) pregnancies: 2449 (2.6%) women tested positive, of whom 1589 (64.9%) were treated appropriately. 111108 (96%) women agreed to HIV testing, of whom 22% were diagnosed with HIV. Overall, 112813 (98%) of recorded pregnancies resulted in a live birth, and 2739 (2%) in a stillbirth. The median gestational age was 38weeks (IQR 35-40) at delivery; the median birth weight of newborns was 3000g (IQR 2700-3300g). CONCLUSION The results demonstrate the feasibility of using a comprehensive electronic medical record in an urban African setting, and highlight its important role in ongoing efforts to improve clinical care.
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Affiliation(s)
- Benjamin H Chi
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
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Dorton BJ, Mulindwa J, Li MS, Chintu NT, Chibwesha CJ, Mbewe F, Frenkel LM, Stringer JSA, Chi BH. CD4+ cell count and risk for antiretroviral drug resistance among women using peripartum nevirapine for perinatal HIV prevention. BJOG 2011; 118:495-9. [PMID: 21199294 DOI: 10.1111/j.1471-0528.2010.02835.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the association between the antenatal CD4(+) cell count and the development of viral drug resistance following the use of peripartum nevirapine (NVP) for perinatal HIV prevention. DESIGN Secondary analysis of data from a previously conducted randomised controlled trial. SETTING Lusaka, Zambia. POPULATION HIV-positive pregnant women. METHODS We analysed the data from a clinical trial of single-dose tenofovir/emtricitabine (TDF/FTC) to reduce viral drug resistance associated with peripartum NVP. The trial population was categorised according to antenatal CD4(+) cell count (200-350, 351-500 and >500 cells/μl). MAIN OUTCOME MEASURES The relative risk for acquiring drug resistance, determined by consensus sequencing and oligonucleotide ligation assay (OLA), was estimated using multivariable logistic regression. RESULTS Of the 397 study participants, 119 (30%) had a CD4(+) count of 200-350 cells/μl, 135 (34%) had a CD4(+) count of 351-500 cells/μl and 143 (36%) had a CD4(+) count of >500 cells/μl. Among women receiving no intervention, the risk for drug resistance appeared to increase as the CD4(+) cell count decreased. Participants with CD4(+) cell counts of 200-350 cells/μl randomised to the study arm had the lowest risk, suggesting a higher efficacy of the intervention within this stratum. These results were consistent at 2 and 6 weeks, regardless of how drug resistance was measured. CONCLUSIONS Women with CD4(+) cell counts of 200-350 cells/μl may be at increased risk for viral drug resistance following the use of peripartum NVP. Given the high prevalence of NVP resistance and the clear benefits of treatment, antiretroviral therapy should be initiated among pregnant women with CD4(+) cell counts of ≤350 cells/μl.
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Affiliation(s)
- B J Dorton
- Centre for Infectious Disease Research, Lusaka, Zambia.
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