Integrated cervical cancer screening in Mayuge District Uganda (ASPIRE Mayuge): a pragmatic sequential cluster randomized trial protocol

Evolution and Recent Radiation Therapy Advancement in Uganda: A Precedent on How to Increase Access to Quality Radiotherapy Services in Low- and Middle-Income Countries

The evolution of radiation therapy in Uganda has been a journey marked by significant milestones and persistent challenges. Since the inception of radiotherapy services in 1988-1989, there has been a concerted effort to enhance cancer treatment services. The early years were characterized by foundational developments, such as the installation of the first teletherapy units, low-dose-rate brachytherapy units, and conventional simulators, and the recognition of radiation oncologists and medical physicist professionals laid the groundwork for radiotherapy treatment modalities. With more support from the International Atomic Energy Agency, the acquisition of dosimetry equipment, treatment planning systems, and additional professional training signaled a new era in the fight against cancer. As we entered the second decade of the millennium, the Uganda Cancer Institute (UCI) witnessed a progression in sophisticated radiotherapy services, including high-dose-rate brachytherapy, initiation of intensity modulated radiation therapy (IMRT)/volumetric modulated arc therapy (VMAT), and use of artificial intelligence. These advancements improved the efficiency/precision of treatments and the time patients spent undergoing therapy. Around the second decade of radiotherapy services, about 600 new patients with cancer were annually treated compared with about 2,600 in 2023. Currently, an average of 1,440 brachytherapy insertions are done annually compared with 300 insertions for the first 20 years. Despite the technological strides, the UCI faced numerous obstacles, including limited equipment, knowledge gaps in appropriate tumor/organs at risk segmentations, treatment planning, and protocols. However, international support and collaboration efforts have led to significant improvement in the precision and effectiveness of treatments. Currently, about 51% of all patients are treated with image-guided techniques-IMRT/VMAT (42%) and three-dimensional conformal radiation treatment (10%). The Government has commenced the decentralization of radiotherapy services to other regions. This review can be a learning lesson for the more than 25 countries in Africa and other low-middle-income countries globally that do not have access to radiotherapy and/or are in the process of starting such facilities.

Role of lncRNA TPRG1-AS1 in the development of cervical squamous cell carcinoma and its prognostic value

OBJECTIVE

Cervical squamous cell carcinoma (CSCC) has a poor prognosis due to persistent HPV infection. LncRNA TPRG1-AS1 is linked to regulating the development of many cancers, so the regulatory mechanism and prognostic value of TPRG1-AS1 in CSCC were explored.

METHODS

138 patients with cervical cancer were included. TPRG1-AS1 expression and miR-590-3p were analyzed by qRT-PCR. The association between TPRG1-AS1 and clinicopathological features was investigated. Independent prognostic factors of CSCC were analyzed by multifactorial Cox regression. Patient survival was analyzed using Kaplan-Meier plotter curves. CCK-8 was employed to evaluate the proliferative capacity of the cells. Transwell assays were performed to evaluate the effects of TPRG1-AS1 and miR-590-3p on cell migration and invasion performance, and the target of both was reported by DLR assay.

RESULTS

TPRG1-AS1 levels were ascended in CSCC, and miR-590-3p levels were reduced. TPRG1-AS1 and miR-590-3p target binding and expression correlated negatively. Knockdown of TPRG1-AS1 expression could facilitate high miR-590-3p expression, which reduced cell proliferation, migration, and invasion ability. TPRG1-AS1 is an independent prognostic factor.

CONCLUSION

TPRG1-AS1 has potential as a prognostic marker for CSCC. Silencing the expression of TPRG1-AS1 could contribute to the high miR-590-3p expression thereby slowing down the progression of CSCC.

AUP1 transcriptionally activated by KDM5B reprograms lipid metabolism to promote the malignant progression of cervical cancer

Cervical cancer is one of the reproductive malignancies threatening women's lives worldwide. In the present study, it was aimed to explore the role and mechanism of ancient ubiquitous protein 1 (AUP1) in cervical cancer. Through bioinformatics analysis, AUP1 expression in cervical cancer tissues and the correlation between AUP1 and the prognosis of patients were analyzed. AUP1 expression in several cervical cancer cell lines was detected. Following the co‑transfection of short hairpin RNA specific to AUP1 with or without lysine demethylase 5B (KDM5B) overexpression plasmids in SiHa cells, the proliferation and apoptosis of SiHa cells were detected. Additionally, wound healing and Transwell assays were used to detect SiHa cell migration and invasion. Cellular lipid droplets level was detected using the Oil red O staining. Meantime, the levels of triglyceride, cholesterol, oxygen consumption rates and expression of lipid metabolism‑related proteins were detected to assess the lipid metabolism in SiHa cells. Then, the luciferase reporter assay and ChIP assay were used to verify the binding between KDM5B and AUP1. Finally, the effects of AUP1 and KDM5B on the growth and lipid metabolism in SiHa tumor‑bearing mice were measured. AUP1 was significantly upregulated in cervical cancer tissues and cells. AUP1 interference inhibited the malignant biological behaviors and lipid metabolism reprogramming of SiHa cells, which was blocked by KDM5B overexpression. Moreover, KDM5B could transcriptionally activate AUP1 and upregulate AUP1 expression. Furthermore, AUP1 knockdown transcriptionally regulated by KDM5B limited the tumor growth and suppressed the lipid metabolism reprogramming in vivo. Collectively, AUP1 could be transcriptionally activated by KDM5B to reprogram lipid metabolism, thereby promoting the progression of cervical cancer. These findings reveal possible therapeutic strategies in targeting metabolic pathways.

eHealth Communication Intervention to Promote Human Papillomavirus Vaccination Among Middle-School Girls: Development and Usability Study

BACKGROUND

As the age of initiating sexual intercourse has gradually decreased among South Korean adolescents, earlier vaccination of adolescents for human papillomavirus (HPV) is necessary before their exposure to HPV. Health communication includes "cues to action" that lead to preventive health behaviors, and recently, social networking services, which operate with fewer time and space constraints, have been used in various studies as a form of eHealth communication.

OBJECTIVE

This study aims to investigate the feasibility and usability of an eHealth communication intervention for HPV vaccination in middle-school girls aimed at the girls and their mothers.

METHODS

The eHealth communication intervention for HPV vaccination was developed using a 6-step intervention mapping process: needs assessments, setting program outcomes, selection of a theory-based method and practical strategies, development of the intervention, implementation plan, and testing the validity of the intervention.

RESULTS

A review of 10 studies identified effective health communication messages, delivery methods, and theories for HPV vaccination among adolescents. Barriers including low knowledge, perceived threat, and the inconvenience of taking 2 doses of the vaccine were identified through focus groups, suggesting a need for youth-friendly and easy-to-understand information for adolescents delivered via mobile phones. The expected outcomes and the performance objectives are specifically tailored to reflect the vaccination intention. Behavior change techniques were applied using trusted sources and a health belief model. Health messages delivered through a KakaoTalk chatbot improved awareness and self-efficacy. Quality control was ensured with the use of a log system. The experts' chatbot usability average score was 80.13 (SD 8.15) and the average score of girls was 84.06 (SD 7.61).

CONCLUSIONS

Future studies need to verify the effectiveness of health communication strategies in promoting HPV vaccination and the effectiveness of scientific intervention using a chatbot as a delivery method for the intervention.

Barriers and facilitators of retention in care after cervical cancer screening: patients' and healthcare providers' perspectives

BACKGROUND

Cervical cancer continues to threaten women's health, especially in low-resource settings. Regular follow-up after screening and treatment is an effective strategy for monitoring treatment outcomes. Consequently, understanding the factors contributing to patient non-attendance of scheduled follow-up visits is vital to providing high-quality care, reducing morbidity and mortality, and unnecessary healthcare costs in low-resource settings.

METHODS

A descriptive qualitative study was done among healthcare providers and patients who attended the cervical cancer screening clinic at Mbarara Regional Referral Hospital in southwestern Uganda. In-depth interviews were conducted using a semi-structured interview guide. Interviews were audio-recorded, transcribed verbatim, and thematically analysed in line with the social-ecological model to identify barriers and facilitators.

RESULTS

We conducted 23 in-depth interviews with 5 healthcare providers and 18 patients. Health system barriers included long waiting time at the facility, long turnaround time for laboratory results, congestion and lack of privacy affecting counselling, and healthcare provider training gaps. The most important interpersonal barrier among married women was lacking support from male partners. Individual-level barriers were lack of money for transport, fear of painful procedures, emotional distress, and illiteracy. Inadequate and inaccurate information was a cross-cutting barrier across the individual, interpersonal, and community levels of the socio-ecological model. The facilitators were social support, positive self-perception, and patient counselling.

CONCLUSIONS

Our study revealed barriers to retention in care after cervical cancer screening, including lack of partner support, financial and educational constraints, and inadequate information. It also found facilitators that included social support, positive self-perception, and effective counselling.

Positivity rates, trends and experiences of health workers on human papillomavirus screened using genexpert in Uganda: a three-year retrospective cohort study

INTRODUCTION

Cervical cancer is a major public health issue in Uganda, with high incidence due to limited screening especially in rural areas. In 2019, HPV DNA testing using GeneXpert was rolled out to improve screening access. Assessing progress and challenges since its introduction is important.

AIM

To determine genotype distribution and explore health worker experiences with HPV screening using GeneXpert in Uganda.

METHODS

We conducted a retrospective cohort study where HPV screening data from 66 GeneXpert labs from March 2021-May 2023 country wide was analyzed. We used descriptive statistics to provide percentages and proportions from the data. Seven focus group discussions and five interviews were done with health workers to understand experiences.

RESULTS

We extracted 24,497 HPV tests that were done, and 39.1% were HPV positive. Other high-risk HPV genotypes were the most common at 65%, followed by HPV 16 (17%) and HPV 18/45 (18%). 15% of the HPV positive cases had more than one genotype. Qualitative findings showed inconsistent health worker knowledge, high workload, and complex care seeking behaviors as main challenges. It also revealed low community awareness, care seeking from traditional healers, CONCLUSION: HPV DNA testing has been expanding since its rollout, but the yield of HPV cases is lower than expected, signaling need to address supply-side challenges. Limited information on HPV among health workers especially community health workers, demand-side barriers like myths, medical pluralism and social norms must also be tackled through trainings of health workers and awareness campaigns engaging communities. Although access to GeneXpert services has increased, health system weaknesses pose bottlenecks to screening HPV. Targeted interventions are required to strengthen HPV diagnosis, prevent cervical cancer and save lives.

Prevalence of genital high-risk human papillomavirus infections and associated factors among women living with human immunodeficiency virus in Uganda

BACKGROUND

Women living with HIV are at risk for cervical dysplasia and cancer worldwide. In 2015, the World Health Organization (WHO) recommended that testing for high-risk HPV (hrHPV) infection be incorporated into cervical cancer screening programs using molecular nucleic acid tests (NATs) but this has not previously been done in Uganda. The country's coverage for Human Papilloma Virus (HPV) screening remains low at less than 10% for women aged 25-49 years. This study determined the genital prevalence of hrHPV infection and the associated factors among women living with HIV in Uganda.

METHODS

A descriptive cross-sectional study was conducted in 15 selected health facilities among participants who were on Antiretroviral therapy (ART). Participants who consented to participate were instructed on how to collect their own high vaginal swabs using a cervical brush for HPV molecular testing (HPV DNA or HPV RNA) and their demographics data was collected using a standard questionnaire. Laboratory diagnosis for HPV molecular testing was done using Gene xpert machines and Hologic Aptima Machine. Modified Poisson regression analysis was conducted to determine the associated factors.

RESULTS

This study involved 5856 HIV positive participants on ART. A total of 2006 out of 5856 (34.3%) participants had high risk HPV infections. HPV infections by genotypes were: HPV16 317(15.8%), HPV 18/45 308 (15.4%) and other high-risk HPV 1381 (68.8%). The independent factors associated with all hrHPV were parity, education level, having more than one partner, and engaging in early sex. Smoking was associated with HPV 16, HPV 18/45 and other hrHPV. Age was associated with all hrHPV, marital status with HPV 16, and occupation with HPV 16.

CONCLUSIONS

The prevalence of genital high-risk HPV infections among HIV positive women attending ART clinics in public facilities in Uganda was high. Other hrHPV genotype was the commonest compared to 18/45 and HPV 16. The integration of cervical cancer screening in ART programmes remains paramount to support the early detection of cervical cancer and Non-invasive self-collected urine and vaginal sampling for cervical cancer screening present an opportunity.

Women's cellphone access and ownership in rural Uganda: implications for self-care interventions

BACKGROUND

The World Health Organization (WHO) call for cervical cancer elimination includes increasing global cervical screening coverage. HPV-based self-collection (HPV-SC) is a promising screening model for low- and middle-income countries (LMICs), and while digital technology, such as cellphones, can be used to streamline HPV-SC, there is limited data on digital technology penetration in LMICs. Determining women's cellphone access is critical to understanding the feasibility of using cellphones to support HPV-SC.

METHODS

This study is a secondary analysis of a larger clinical trial. Participants of a cluster-randomized trial comparing HPV-SC models in Uganda completed a survey, including questions about demographics, cellphone access/ownership, prior cervical cancer screening (CCS), and willingness to receive CCS information by text. A logistic regression model was used to determine adjusted rates of cellphone ownership using survey variables as factors.

RESULTS

Of 2019 participants, 76.1% owned a cellphone. In non-cellphone owners (n = 483), 82.4% had daily cellphone access and 7.3% had no access. Compared to non-cellphone owners, cellphone owners were significantly older, more educated, closer to major health centers, more likely to have prior CCS, and more willing to receive a CCS text. In the logistic regression model, the aforementioned variables were all significantly associated with the odds of owning a cellphone.

CONCLUSIONS

As health care systems consider adopting HPV-SC, it is imperative to understand digital technology penetration. The majority of participants were cellphone owners and were willing to receive CCS information by text; however, significant socioeconomic and demographic differences remain between cellphone owners and non-owners. Further investigation is needed to understand whether HPV-SC using cellphones is feasible in similar settings.

TRIAL REGISTRATION

ISRCTN, 12767014 .

CLINICALTRIALS

gov, NCT04000503 .

Acceptability of Integrated Community-Based HIV and Cervical Cancer Screening in Mayuge District, Uganda

PURPOSE

To assess the acceptability of integrated screening for cervical cancer and HIV in the community setting.

METHODS

We developed surveys for patients and community health workers (CHWs) who participated in the Advances in Screening and Prevention in Reproductive Cancers (ASPIRE) Mayuge trial that compared self-collected human papillomavirus testing at home versus community health meetings in Mayuge district, Uganda. Quantitative data were summarized using descriptive statistics. Open-ended questions were analyzed using an inductive approach with thematic content analysis.

RESULTS

We conducted 102 patient surveys and 31 CHW surveys between June and August 2021. Ninety-nine percent of patients and 100% of CHWs indicated that they would find the addition of an HIV test to their self-collected cervical cancer test acceptable. The most frequently stated reasons in favor of adding an HIV test to the ASPIRE Mayuge cervical cancer screening pathways were time-saving, privacy, and support from other women and CHWs. The most frequently stated reasons against integrated screening were related to concerns about confidentiality, most often in reference to women's family members and other women in their village.

CONCLUSION

Integrated community-based cervical cancer and HIV testing would be highly acceptable to both women and CHWs.

Evaluation of cervical cancer screening program in Gondar city administration public health facilities, Northwest Ethiopia, 2021: mixed method approach

BACKGROUND

Cervical cancer is one of the most malignancies in women all over the world. Over 90% of cases occurred in low and middle-income countries with limited resources. Even though cervical cancer is preventable, the Sub-Saharan countries are the most burdened. In Ethiopia 27.19 million women are at risk of acquiring cervical cancer. Although the prevalence of cervical cancer screening among women aged 18 to 69 was around 14%, due to COVID 19 and internal conflict the screening prevalence was lowered to 0.2% by 2022.

OBJECTIVE

This study aimed to evaluate cervical cancer screening program implementation at Gondar city administration public health facilities, Northwest Ethiopia.

METHODS

Single case study design with mixed method evaluation was employed in eight public health facilities of Gondar city administration from March 29 to May 30, 2021. The quantitative data were collected through exit interviews and resources inventory observations. While qualitative data were collected through Key informant interviews, non-participatory observation and document review. A total of 310 clients, 14 key informants, 30 non-participatory observations and six months retrospective document reviews were included in this evaluation. Quantitative data were entered into EPI-data version 4.6 and exported into SPSS version 20 for analysis. For qualitative data; records were transcribed, translated and analyzed in themes. Variables with P-value < 0.05 at 95% confidence interval and adjusted odds ratio were used to declare associated variables with client satisfaction.

RESULTS

The overall implementation of cervical cancer screening program with visual inspection with acetic acid was 64.5%. The availability of program resources, compliance of healthcare providers and satisfaction of mothers were 52.3%, 64.3% and 77.1% respectively. Being educated, having information on cervical cancer screening and the number of lifetime sexual partners were positively associated variables with client satisfaction.

CONCLUSION

The cervical cancer screening program was judged as partially-implemented and needs urgent improvement based on pre-determined judgment parameters. To implement the program properly and serve more women; human and material resources should be available, providers shall be trained and the health facilities should equip with full infrastructures like electric power supply and separate procedure rooms.

Understanding the cervical cancer self-collection preferences of women living in urban and rural Rwanda

Cervical cancer is a leading cause of cancer among women in low- and middle-income countries. Women in Rwanda have high rates of cervical cancer due to limited access to effective screening methods. Research in other low-resource settings similar to Rwanda has shown that HPV-based self-collection is an effective cervical cancer screening method. This study aims to compare the preferences of Rwandan women in urban and rural settings toward self-collection and to report on factors related to self-collection amenability. A cross-sectional survey was conducted from June 1-9, 2022. Women were recruited from one urban and one rural clinic in Rwanda. Women were eligible for the study if they were ≥ 18 years and spoke Kinyarwanda or English. The survey consisted of 51 questions investigating demographics and attitudes towards self-collection for cervical cancer screening. We reported descriptive statistics stratified by urban and rural sites. In total, 169 urban and 205 rural women completed the survey. The majority of respondents at both sites had a primary school or lower education and were in a relationship. Both urban and rural respondents were open to self-collection; however, rates were higher in the rural site (79.9% urban and 95.6% rural; p-value<0.001). Similarly, women in rural areas were more likely to report feeling unembarrassed about self-collection (65.3% of urban, 76.8% of rural; p-value<0.001). Notably, almost all urban and rural respondents (97.6% urban and 98.5% rural) stated they would go for a cervical cancer pelvic examination to a nearby health center if their self-collected results indicated any concern (p-value = 0.731). Rwandan women in both urban and rural areas largely support self-collection for cervical cancer screening. Further research is needed to better understand how to implement self-collection screening services in Rwanda.

Timeliness and completeness of monthly disease surveillance data reporting, Uganda, 2020-2021

Introduction

timely and complete reporting of routine public health information about diseases and public health events are important aspects of a robust surveillance system. Although data on the completeness and timeliness of monthly surveillance data are collected in the District Health Information System-2 (DHIS2), they have not been routinely analyzed. We assessed completeness and timeliness of monthly outpatient department (OPD) data, January 2020-December 2021.

Methods

we analyzed secondary data from all the 15 regions and 146 districts of Uganda. Completeness was defined as the number of submitted reports divided by the number of expected reports. Timeliness was defined as the number of reports submitted by the deadline (15th day of the following month) divided by reports received. Completeness or timeliness score of <80% was regarded incomplete or untimely.

Results

overall, there was good general performance with the median completeness being high in 2020 (99.5%; IQR 97.8-100%) and 2021 (100%; IQR 98.7-100%), as was the median timeliness (2020; 82.8%, IQR 74.6-91.8%; 2021, 94.9%, IQR 86.5-99.1%). Kampala Region was the only region that consistently failed to reach ≥ 80% OPD timeliness (2020: 44%; 2021: 65%). Nakasongola was the only district that consistently performed poorly in the submission of timely reports in both years (2020: 54.4%, 2021: 58.3%).

Conclusion

there was an overall good performance in the submission of complete and timely monthly OPD reports in most districts and regions in Uganda. There is a need to strengthen the good reporting practices exhibited and offer support to regions, districts, and health facilities with timeliness challenges.

Effectiveness of Clinic-Based Patient-Led Human Papillomavirus DNA Self-Sampling among HIV-Infected Women in Uganda

In Uganda, the uptake of cervical cancer (CC) screening services is low, at 46.7%, among HIV-infected women, and only 9% of these women adhere to annual CC screening. Some studies have evaluated the possibility of community or home-based human papillomavirus (HPV) self-collected vaginal swabs, but not clinic-based HPV self-collected vaginal swabs. Therefore, we propose a study to determine the efficacy of clinic-based versus home-based HPV DNA self-sampling among HIV-infected women attending a rural HIV clinic in Uganda. We believe that a randomized, single-blinded trial would achieve this objective, and so we have chosen it to guide the study. Including a total of 382 participants from a rural HIV clinic, randomized into a ratio of 1:1 for clinic- and home-based HPV self-sampling, would allow us to appropriately ascertain the difference in the uptake of HPV self-sampling between the two arms. The Integrated Biorepository of H3 Africa Uganda Laboratory would be used as a reference laboratory for the HPV DNA extraction, typing, and sequencing. At baseline, modified Poisson regression models would be used to measure factors associated with the prevalence of HPV and uptake in both arms at baseline. Visual inspection under acetic acid (VIA), as a gold-standard test for CC to grade for CIN, would be performed at 0 and 6 months among a random sample of 75 women with a self-collected HPV sample. The difference in uptake could be determined using the intention-to-treat analysis. The difference in the groups by each variable would be summarized as the standardized mean difference (i.e., the mean difference divided by the pooled standard deviation). The predictors of the time for which participants would continue with HPV self-sampling in both arms, recovery, and Cox proportional hazards regression would be used. At the bivariate level, the associations between each independent variable and time, with the time of continuing HPV self-sampling, would be computed. Crude hazard ratios and their 95% confidence interval would be used in the presentation of the results, with p-values < 0.05 considered significant at the bivariate level. Incremental cost-effectiveness analysis (CEA) using a Markov model would be used to determine the cost of clinic-based HPV self-sampling. We believe that screening approaches to disease stratification could provide an insight into the merits and limitations of current approaches to the diagnosis of cervical cancer, and how these could eventually be implemented into HIV clinics in Uganda and other developing African countries. It is anticipated that the findings would guide the development of step-by-step guidelines for the HPV self-sampling approach.

Factors associated with uptake of human papilloma virus vaccine among school girls aged 9-14 years in Lira City northern Uganda: a cross-sectional study

BACKGROUND

Cervical cancer is the most common Human Papilloma Virus (HPV)-related disease among women. Since 2008, HPV vaccination has been routinely recommended for pre-adolescent and adolescent girls in Uganda as the primary preventive measure for cervical cancer. However, in Uganda, most especially in Lira district, there is limited literature on HPV vaccination uptake and associated factors among girls aged 9-14years. This study assessed the uptake of HPV vaccine and associated factors among in-school girls aged 9-14 years in Lira City, northern Uganda.

METHODS

A cross-sectional study was conducted among 245 primary school girls aged 9-14 years in Lira City, northern Uganda. Multistage sampling technique was used to sample eligible participants and data was collected using interviewer administered questionnaire. Data was analysed using SPSS version 23.0. Descriptive statistics and multivariate logistic regression at 95% level of significance were used to identify the level of HPV vaccine uptake and predictors respectively.

RESULTS

HPV vaccination uptake was at 19.6% (95% CI,14.8-25.1) among the school girls aged 9-14 years in Lira City, northern Uganda. The mean age of the girls was 12.11 (± 1.651) years. Predictors that were independently associated with HPV vaccine uptake included; recommendation from health worker [aOR 9.09, 95% CI (3.19-25.88), P ≤ 0.001], taught about cervical cancer at school [aOR,12.56, 95% CI (4.60-34.28), P ≤ 0.001], and exposure to outreach clinics [aOR, 4.41, 95% CI (1.37-14.19), P = 0.013].

CONCLUSION

The study found that one in five of the school girls in Lira City, northern Uganda. received HPV vaccine. Girls who were taught about cervical cancer at school, exposure to outreach clinics and received health worker recommendation had more odds of receiving HPV vaccine than their counter parts. The Ministry of Health should strengthen school based cervical cancer education, awareness raising about HPV vaccination and health worker recommendations to improve HPV vaccine uptake among school girls in Uganda.

Experiences with thermal ablation for cervical precancer treatment after self-collection HPV-based screening in the ASPIRE Mayuge randomized trial

Cervical cancer remains a significant public health burden in low-resourced countries. Thus, the WHO prioritized cervix screening, and recently recommended thermal ablation treatment for cervical precancer. However, there is limited information on side effects during treatment and recovery, and acceptability among those treated. The ASPIRE Mayuge trial recruited women to participate in self-collection cervix screening between 2019 and 2020 (N = 2019). Screen-positive women (N = 531, 26.3%) were referred for visual inspection with acetic acid and thermal ablation treatment, per Uganda Ministry of Health recommendations; 71.2% of those referred attended follow-up. Six months post-screening, a subset of trial participants were recontacted. Those who received thermal ablation completed a survey assessing side effects during and after the procedure, and willingness to recommend the treatment to others. We summarized the results to describe the side effects and acceptability of thermal ablation treatment. Of 2019 participants, 349 (17%) received thermal ablation. A subset of 135 completed the follow-up survey, where 90% reported pain during treatment; however, intensity and duration were low. Over a third of women reported problems with recovery for reasons including pain, discharge and bleeding. Regardless, 98% reported they would recommend the treatment to others. The use of thermal ablation to treat cervical precancer appears to be highly acceptable in this population. While many women reported side effects during the procedure and recovery, the majority said they would recommend the treatment to others. However, given the substantial proportion who reported problems with recovery, efforts should be made to provide additional resources to women after receiving thermal ablation treatment for cervical precancer.

Community-integrated self-collected HPV-based cervix screening in a low-resource rural setting: a pragmatic, cluster-randomized trial

Effective approaches to improve coverage of self-collected human papillomavirus (HPV)-based cervix screening (SCS) as well as attendance at treatment for HPV-positive participants are needed to inform policy on optimal integration of cervical cancer screening programs within existing infrastructure in low-resource settings. ASPIRE Mayuge was a pragmatic cluster-randomized trial in rural Mayuge district, Uganda, comparing the superiority of two recruitment implementation strategies for SCS: Door-to-Door versus Community Health Day. Villages were randomized (unblinded) to a strategy, and participants aged 25-49 years with no previous history of hysterectomy or treatment for cervical cancer or pre-cancer were eligible. Participants completed a survey and participated in SCS. The primary outcome was rate of attendance at treatment after a positive SCS. The trial randomized 31 villages and 2,019 participants included in these analyses (Door-to-Door: 16 clusters, 1,055 participants; Community Health Day: 15 clusters, 964 participants). Among HPV-positive participants, attendance at treatment rates were 75% (Door-to-Door) and 67% (Community Health Day) (P = 0.049). Participants in the Community Health Day intervention were less likely to attend treatment compared to Door-to-Door (risk ratio = 0.78, 95% confidence interval: 0.64-0.96). No adverse events were reported. Policymakers in low-resource settings can use these results to guide implementation of SCS programs. ISRCTN registration: 12767014 . ClinicalTrials.gov registration: NCT04000503 .

"We Shall Tell them with Love, Inform them what we have Learnt and then Allow them to go" - Men's Perspectives of Self-Collected Cervical Cancer Screening in Rural Uganda: A Qualitative Inquiry

Uganda has high incidence rates of cervical cancer (47.5/100,000/year) due to limited screening access. In settings where men hold most of the decision-making power, they play an important role in women's uptake of cervical cancer screening. We aimed to capture men's knowledge, beliefs and perspectives about cervical cancer, community-based screening and health system barriers. Focus group discussions were conducted with men in rural Uganda. Data were verbatim translated and transcribed into English. Transcripts were analysed in ATLAS.ti using a deductive approach of thematic content analysis and applied to an implementation research framework. Twenty-three men participated in focus groups. Men held poor knowledge of cervical cancer, its causes and treatment. Men felt screening would be acceptable by women if men and women were educated. Men highlighted health system barriers to accessing screening including: 1) poor-quality health services, 2) large distances to facilities/lack of affordable transportation and 3) lack of health workers/mistreatment by health workers. Men described supporting women through assisting with transportation, psychosocial support and sharing information. They requested services for men to be decentralized alongside community outreaches for cervical cancer screening. Engaging men in the implementation, education and planning of community-based cervical cancer screening programs is critical. Not engaging men is a missed opportunity to provide them with services and education. Concerted efforts must be made in educating men and reducing health system barriers to ensure rural women receive cervical cancer screening and follow-up care in low-income settings. Clinicaltrials.gov, NCT04000503; Registered 27 June 2019.

MINI: A high-throughput point-of-care device for performing hundreds of nucleic acid tests per day

There are a variety of infectious diseases with a high incidence and mortality in limited resource settings that could benefit from rapid point of care molecular diagnosis. Global health efforts have sought to implement mass-screening programs to provide earlier detection and subsequent treatment in an effort to control transmission and improve health outcomes. However, many of the current diagnostic technologies under development are limited to fewer than 10 samples per run, which inherently restricts the screening throughput of these devices. We have developed a high throughput device called "MINI" that is capable of testing hundreds of samples per day at the point-of-care. MINI can utilize multiple energy sources - electricity, flame, or solar - to perform loop-mediated isothermal amplification (LAMP) in a portable and robust device which is ideal for use in limited resource settings. The unique opto-electronic design of MINI minimizes the energy and space requirements of the device and maximizes the optical isolation and signal clarity, enabling point-of-care analysis of 96 unique samples at once. We show comparable performance to a commercial instrument using two different LAMP assays for Kaposi's sarcoma-associated herpesvirus and a common housekeeping gene, GAPDH. With a single device capable of running hundreds of samples per day, increased access to modern molecular diagnostics could improve health outcomes for a variety of diseases common in limited resource settings.

LncRNA SFTA1P promotes cervical cancer progression by interaction with PTBP1 to facilitate TPM4 mRNA degradation

Long non-coding RNAs (lncRNAs) play key roles in cancer development and progression. However, the biological function and clinical significance of most lncRNAs in cervical cancer remain elusive. In this study, we explore the function and mechanism of lncRNA surfactant associated 1 (SFTA1P) in cervical cancer. We firstly identified SFTA1P by analyzing the RNA sequencing data of cervical cancer from our previous study and from The Cancer Genome Atlas (TCGA). We then verified SFTA1P expression by qRT-PCR. The cell proliferation and migration capacity of SFTA1P was assessed by using CCK-8, colony formation, transwell and wound healing assays. RNA pull-down, RNA immunoprecipitation (RIP), RNA stability and western blot assays were used to reveal potential mechanisms. Athymic nude mice were used to evaluate tumorigenicity and metastasis in vivo. SFTA1P is upregulated in cervical tumor tissues and its high expression is associated with poor prognosis. Biologically, knockdown of SFTA1P inhibited the proliferation, migration, and invasion of cervical cancer cells in vitro, as well as tumorigenesis and metastasis in vivo. Mechanistically, SFTA1P was shown to interact with polypyrimidine tract binding protein 1 (PTBP1) to regulate the stability of tropomyosin 4 (TPM4) mRNA, thereby resulting in malignant cell phenotypes. TPM4 knockdown could attenuate the suppression of cell progression induced by either SFTA1P or PTBP1 knockdown. Our findings demonstrate that SFTA1P can promote tumor progression by mediating the degradation of TPM4 mRNA through its interaction with PTBP1 protein. This provides a potential therapeutic strategy to target the SFTA1P-PTBP1-TPM4 axis in cervical cancer.

Multiple High-Risk HPV Types Contribute to Cervical Dysplasia in Ugandan Women Living With HIV on Antiretroviral Therapy

BACKGROUND

Cervical cancer mortality remains high in sub-Saharan Africa, especially among women living with HIV (WLWH). Characterization of prevalent high-risk human papillomavirus (hrHPV) types and immune function in WLWH with cervical abnormalities despite antiretroviral therapy (ART) can inform prevention strategies.

SETTING

Kampala, Uganda.

METHODS

From 2017 to 2020, we enrolled Ugandan women with cervical dysplasia detected with visual inspection with acetic acid (VIA). WLWH were required to be on ART >3 months with plasma HIV RNA <1000 copies/mL. Biopsies from VIA-positive lesions underwent histopathologic grading and cervical swab specimens were tested for hrHPV. Clinical correlations were evaluated with Poisson regression to estimate adjusted prevalence ratios (aPR).

RESULTS

One hundred eighty-eight WLWH and 116 HIV-seronegative women participated. Among WLWH, median ART duration was 6 years and median CD4 667 cells/µL. Cervical intraepithelial neoplasia (CIN) grade 2/3 was found in 29% of WLWH versus 9% of HIV-seronegative women. In women with CIN1 or without histopathology-confirmed dysplasia, hrHPV (aPR [95% confidence interval]: 2.17 [1.43 to 3.29]) and multiple hrHPV (aPR 3.73 [1.07 to 13.1]) were more common in WLWH, as were vaccine-targeted and vaccine-untargeted hrHPVtypes. Differences in hrHPV prevalence by HIV serostatus were not observed in women with CIN2/3 (interaction P < 0.01). Among WLWH, low CD4/8 ratio was associated with hrHPV while detectable plasma HIV RNA (20-1000 copies/mL) was associated with CIN2/3 or invasive cancer.

CONCLUSION

Despite ART, WLWH with cervical VIA abnormalities remain at elevated risk for multiple hrHPV and high-grade dysplasia. Cervical cancer prevention and research tailored for WLWH are warranted in the ART era.

Encouraging improvement in HPV vaccination coverage among adolescent girls in Kampala, Uganda

Introduction

WHO recommends vaccination against HPV for girls before sexual debut. Uganda started HPV vaccination in 2008 as pilot programs in 2 districts, followed by national roll out in 2015. Despite the availability of vaccines against human papillomavirus (HPV) in Uganda in the period covered by the study, there was reported low HPV vaccine uptake and completion especially of the second dose in Uganda; with little information available on timely completion of HPV vaccine and the associated factors in Uganda. This study was therefore done to determine the HPV vaccine dose 2 completion and describe the possible factors associated with timely HPV vaccine completion and non-completion among girls of age 9–14 years attending the adolescent clinic at Mulago hospital.

Methods

A retrospective mixed methods study was conducted in Mulago National Referral hospital adolescent clinic. Data were mainly collected through review of charts and folders for clinic attendance by eligible girls and focus group discussions with eligible girls that completed the 2 doses of HPV vaccine on recommended/scheduled time.

Results

Out of the 201 girls studied, 87 girls (43.3%) had timely completion of the HPV vaccination. Knowledge about HPV infection and HPV vaccine benefits, positive peer influence and healthcare worker recommendation to get vaccinated at health facility level positively influenced timely completion of HPV vaccine. Among barriers to completion of HPV vaccine identified were: inadequate information about HPV infection and HPV vaccine, concerns about HPV vaccine efficacy and safety, unclear communication with adolescents/caregivers from healthcare workers and -stock out of the HPV vaccine.

Conclusion

Timely completion of the second dose of HPV vaccine among girls attending the adolescent clinic of Mulago hospital was low (at 43.3%) but higher when compared to earlier published reports. Interventions around improved social mobilization, enhanced outreach and static vaccination approach and education of eligible girls on HPV vaccination can help increase vaccine uptake.

Human papillomavirus self-sampling for cervical cancer screening among women in sub-Saharan Africa: a scoping review protocol

INTRODUCTION

Evidence shows that women in sub-Saharan Africa have high rates of cervical cancer (CC) mortality compared with women in high-income countries. Effective screening programmes have significantly reduced the burden of CC in high-income countries. Self-sampling for human papillomavirus testing (HPVSS) has been reported to increase the participation and engagement of women in CC screening. Before HPVSS can be introduced for CC screening there is a need to establish its acceptability among end-users to ensure the increase in CC screening rates. Here, we outline a protocol for a scoping review aimed at mapping literature on the use and acceptability of HPVSS for screening CC in sub-Saharan Africa to reveal gaps to guide future research and practice.

METHOD

The scoping review protocol was developed according to Arksey and O'Malley and Levac et al, and guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. We will search Scopus, PubMed, Medline Ovid, Cochrane and Web of Science databases for evidence on the use and acceptability of HPVSS published between January 2011 and July 2021. We will also search grey literature in the form of dissertations/theses, conference proceedings, websites of international organisations such as the WHO, and relevant government reports reporting evidence on HPVSS programmes for screening CC among women in sub-Saharan Africa.

ETHICS AND DISSEMINATION

No ethical approval is needed for the study as it will not include animals or human participants. The results of the proposed scoping review will be disseminated electronically in peer-reviewed journals, in print and through conference presentations.

Acceptability and preferences for self-collected screening for cervical cancer within health systems in rural Uganda: A mixed-methods approach

OBJECTIVE

To understand the knowledge, preferences, and barriers for self-collected cervical cancer screening (SC-CCS) and follow-up care at the individual and health system level to inform the implementation of community-based SC-CCS.

METHODS

Surveys and focus group discussions (FGDs) with women and FGDs with healthcare providers were conducted in Uganda. Survey data were analyzed using frequencies and FGD data were analyzed using thematic content analysis. Data were triangulated between methods.

RESULTS

Sixty-four women were surveyed and 58 participated in FGDs. Facilitators to screening access included decentralization, convenience, privacy, confidentiality, knowledge, and education. Barriers to accessing screening included lack of transportation and knowledge, long wait times, difficulty accessing health care, and lack of trust in the health system. Additional implementation challenges included insufficiently trained human resources and lack of infrastructure.

CONCLUSION

Integrating SC-CCS within rural health systems in low-resource settings has been under-evaluated. Community-based SC-CSS could prevent high cervical cancer-related mortalities while working within the human and financial resource limitations of rural health systems. SC-CCS is acceptable to women and healthcare providers. By addressing rural women's preferences and barriers to care, decision-makers can build health systems that provide community-centered care close to women's homes across the care continuum.