1
|
Sallam M, Al-Mahzoum K, Eid H, Assaf AM, Abdaljaleel M, Al-Abbadi M, Mahafzah A. Attitude towards HPV Vaccination and the Intention to Get Vaccinated among Female University Students in Health Schools in Jordan. Vaccines (Basel) 2021; 9:vaccines9121432. [PMID: 34960177 PMCID: PMC8707789 DOI: 10.3390/vaccines9121432] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [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] [Received: 11/08/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 12/28/2022] Open
Abstract
Cervical cancer is a leading cause of morbidity and mortality in women worldwide. The availability of prophylactic vaccines for high-risk types of human papillomavirus (HPV) infection represents an important advancement in the prevention of cervical cancer. In Jordan, the availability of the HPV vaccination is restricted to individuals who are willing to pay. The aim of the current study was to evaluate the willingness and attitude of female university students in health schools/faculties in Jordan to get HPV vaccination and their knowledge about the virus. A self-administered online questionnaire was distributed in October 2021, which comprised 27 items to evaluate HPV knowledge, history of HPV vaccination, intentions to get the HPV vaccine, and the reason(s) behind vaccine refusal for those who rejected vaccination. The study sample comprised 836 participants: medical students (39.7%), pharmacy students (26.0%), dental students (21.2%), and nursing students (13.2%). Only 524 participants had heard of HPV prior to the study (62.7%), of which 48.7% knew about the availability of HPV vaccines. The lowest level of HPV knowledge was observed among nursing students. Only 19/524 students reported a history of HPV vaccination (3.6%). The overall willingness to receive HPV vaccination if provided freely was 75.0%, while only 16.0% were willing to pay for the vaccine. The most common reason for HPV vaccine rejection was the perceived low risk to get HPV infection. Significantly higher intentions to get HPV vaccination were found among older participants and medical students. The embrace of vaccine conspiracy beliefs was associated with a significantly less willingness to get the HPV vaccination (p < 0.001). Dependence on the internet/social media as the source of HPV knowledge was associated with a significantly lower intention to get HPV vaccination (p = 0.002). The coverage of the HPV vaccination among female university students in health schools in Jordan appeared extremely low; however, three-fourths of the students who had heard of HPV were willing to receive the HPV vaccination if provided freely. Complacency appeared as a major factor for HPV vaccine rejection. Increasing the levels of knowledge and awareness of HPV infection and its association with cervical cancer through reliable sources is recommended. This can be helpful for the individual benefit of the students besides the potentially positive role they can play in community education. Countering vaccine conspiracy beliefs with proper education and awareness programs can be helpful to appraise the role of HPV vaccines in cancer prevention.
Collapse
Affiliation(s)
- Malik Sallam
- Department of Pathology, Microbiology and Forensic Medicine, School of Medicine, The University of Jordan, Amman 11942, Jordan; (M.A.); (M.A.-A.); (A.M.)
- Department of Clinical Laboratories and Forensic Medicine, Jordan University Hospital, Amman 11942, Jordan
- Department of Translational Medicine, Faculty of Medicine, Lund University, 22184 Malmö, Sweden
- Correspondence: ; Tel.: +962-791845186
| | | | - Huda Eid
- School of Dentistry, The University of Jordan, Amman 11942, Jordan;
| | - Areej M. Assaf
- Department of Biopharmaceutics and Clinical Pharmacy, School of Pharmacy, The University of Jordan, Amman 11942, Jordan;
| | - Maram Abdaljaleel
- Department of Pathology, Microbiology and Forensic Medicine, School of Medicine, The University of Jordan, Amman 11942, Jordan; (M.A.); (M.A.-A.); (A.M.)
- Department of Clinical Laboratories and Forensic Medicine, Jordan University Hospital, Amman 11942, Jordan
| | - Mousa Al-Abbadi
- Department of Pathology, Microbiology and Forensic Medicine, School of Medicine, The University of Jordan, Amman 11942, Jordan; (M.A.); (M.A.-A.); (A.M.)
- Department of Clinical Laboratories and Forensic Medicine, Jordan University Hospital, Amman 11942, Jordan
| | - Azmi Mahafzah
- Department of Pathology, Microbiology and Forensic Medicine, School of Medicine, The University of Jordan, Amman 11942, Jordan; (M.A.); (M.A.-A.); (A.M.)
- Department of Clinical Laboratories and Forensic Medicine, Jordan University Hospital, Amman 11942, Jordan
| |
Collapse
|
2
|
Devine A, Vahanian A, Sawadogo B, Zan S, Bocoum FY, Kelly H, Gilham C, Nagot N, Ong JJ, Legood R, Meda N, Miners A, Mayaud P. Costs and cost-effectiveness of cervical cancer screening strategies in women living with HIV in Burkina Faso: The HPV in Africa Research Partnership (HARP) study. PLoS One 2021; 16:e0248832. [PMID: 33765011 PMCID: PMC7993811 DOI: 10.1371/journal.pone.0248832] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 02/11/2020] [Accepted: 03/05/2021] [Indexed: 12/24/2022] Open
Abstract
Introduction This study estimated the costs and incremental cost per case detected of screening strategies for high-grade cervical intraepithelial neoplasia (CIN2+) in women living with HIV (WLHIV) attending HIV clinics in Burkina Faso. Methods The direct healthcare provider costs of screening tests (visual inspection with acetic acid (VIA), VIA combined visual inspection with Lugol’s iodine (VIA/VILI), cytology and a rapid HPV DNA test (careHPV)) and confirmatory tests (colposcopy, directed biopsy and systematic four-quadrant (4Q) biopsy) were collected alongside the HPV in Africa Research Partnership (HARP) study. A model was developed for a hypothetical cohort of 1000 WLHIV using data on CIN2+ prevalence and the sensitivity of the screening tests. Costs are reported in USD (2019). Results The study enrolled 554 WLHIV with median age 36 years (inter-quartile range, 31–41) and CIN2+ prevalence of 5.8%. The average cost per screening test ranged from US$3.2 for VIA to US$24.8 for cytology. Compared to VIA alone, the incremental cost per CIN2+ case detected was US$48 for VIA/VILI and US$814 for careHPV. Despite higher costs, careHPV was more sensitive for CIN2+ cases detected compared to VIA/VILI (97% and 56%, respectively). The cost of colposcopy was US$6.6 per person while directed biopsy was US$33.0 and 4Q biopsy was US$48.0. Conclusion Depending on the willingness to pay for the detection of a case of cervical cancer, decision makers in Burkina Faso can consider a variety of cervical cancer screening strategies for WLHIV. While careHPV is more costly, it has the potential to be cost-effective depending on the willingness to pay threshold. Future research should explore the lifetime costs and benefits of cervical cancer screening to enable comparisons with interventions for other diseases.
Collapse
Affiliation(s)
- Angela Devine
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Victoria, Australia
- * E-mail:
| | - Alice Vahanian
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Bernard Sawadogo
- Centre de Recherche Internationale pour la Santé, Université de Ouagadougou, Ouagadougou, Burkina Faso
| | - Souleymane Zan
- Centre Hospitalier Universitaire Yalgado Ouédraogo, Ouagadougou, Burkina Faso
| | - Fadima Yaya Bocoum
- Institut de Recherche en Sciences de la Santé, Ouagadougou, Burkina Faso
| | - Helen Kelly
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Clare Gilham
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Nicolas Nagot
- Pathogenesis and control of chronic infections, INSERM, Etablissement Francais du Sang, University of Montpellier, Montpellier, France
| | - Jason J. Ong
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Rosa Legood
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Nicolas Meda
- Centre de Recherche Internationale pour la Santé, Université de Ouagadougou, Ouagadougou, Burkina Faso
| | - Alec Miners
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Philippe Mayaud
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | |
Collapse
|
3
|
Kelly HA, Chikandiwa A, Sawadogo B, Gilham C, Michelow P, Lompo OG, Omar T, Zan S, Magooa P, Segondy M, Nagot N, Meda N, Delany-Moretlwe S, Mayaud P. Diagnostic accuracy of cervical cancer screening and screening-triage strategies among women living with HIV-1 in Burkina Faso and South Africa: A cohort study. PLoS Med 2021; 18:e1003528. [PMID: 33661957 PMCID: PMC7971880 DOI: 10.1371/journal.pmed.1003528] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 03/18/2021] [Accepted: 12/22/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Cervical cancer screening strategies using visual inspection or cytology may have suboptimal diagnostic accuracy for detection of precancer in women living with HIV (WLHIV). The optimal screen and screen-triage strategy, age to initiate, and frequency of screening for WLHIV remain unclear. This study evaluated the sensitivity, specificity, and positive predictive value of different cervical cancer strategies in WLHIV in Africa. METHODS AND FINDINGS WLHIV aged 25-50 years attending HIV treatment centres in Burkina Faso (BF) and South Africa (SA) from 5 December 2011 to 30 October 2012 were enrolled in a prospective evaluation study of visual inspection using acetic acid (VIA) or visual inspection using Lugol's iodine (VILI), high-risk human papillomavirus DNA test (Hybrid Capture 2 [HC2] or careHPV), and cytology for histology-verified high-grade cervical intraepithelial neoplasia (CIN2+/CIN3+) at baseline and endline, a median 16 months later. Among 1,238 women (BF: 615; SA: 623), median age was 36 and 34 years (p < 0.001), 28.6% and 49.6% ever had prior cervical cancer screening (p < 0.001), and 69.9% and 64.2% were taking ART at enrolment (p = 0.045) in BF and SA, respectively. CIN2+ prevalence was 5.8% and 22.4% in BF and SA (p < 0.001), respectively. VIA had low sensitivity for CIN2+ (44.7%, 95% confidence interval [CI] 36.9%-52.7%) and CIN3+ (56.1%, 95% CI 43.3%-68.3%) in both countries, with specificity for ≤CIN1 of 78.7% (95% CI 76.0%-81.3%). HC2 had sensitivity of 88.8% (95% CI 82.9%-93.2%) for CIN2+ and 86.4% (95% CI 75.7%-93.6%) for CIN3+. Specificity for ≤CIN1 was 55.4% (95% CI 52.2%-58.6%), and screen positivity was 51.3%. Specificity was higher with a restricted genotype (HPV16/18/31/33/35/45/52/58) approach (73.5%, 95% CI 70.6%-76.2%), with lower screen positivity (33.7%), although there was lower sensitivity for CIN3+ (77.3%, 95% CI 65.3%-86.7%). In BF, HC2 was more sensitive for CIN2+/CIN3+ compared to VIA/VILI (relative sensitivity for CIN2+ = 1.72, 95% CI 1.28-2.32; CIN3+: 1.18, 95% CI 0.94-1.49). Triage of HC2-positive women with VIA/VILI reduced the number of colposcopy referrals, but with loss in sensitivity for CIN2+ (58.1%) but not for CIN3+ (84.6%). In SA, cytology high-grade squamous intraepithelial lesion or greater (HSIL+) had best combination of sensitivity (CIN2+: 70.1%, 95% CI 61.3%-77.9%; CIN3+: 80.8%, 95% CI 67.5%-90.4%) and specificity (81.6%, 95% CI 77.6%-85.1%). HC2 had similar sensitivity for CIN3+ (83.0%, 95% CI 70.2%-91.9%) but lower specificity compared to HSIL+ (42.7%, 95% CI 38.4%-47.1%; relative specificity = 0.57, 95% CI 0.52-0.63), resulting in almost twice as many referrals. Compared to HC2, triage of HC2-positive women with HSIL+ resulted in a 40% reduction in colposcopy referrals but was associated with some loss in sensitivity. CIN2+ incidence over a median 16 months was highest among VIA baseline screen-negative women (2.2%, 95% CI 1.3%-3.7%) and women who were baseline double-negative with HC2 and VIA (2.1%, 95% CI 1.3%-3.5%) and lowest among HC2 baseline screen-negative women (0.5%, 95% CI 0.1%-1.8%). Limitations of our study are that WLHIV included in the study may not reflect a contemporary cohort of WLHIV initiating ART in the universal ART era and that we did not evaluate HPV tests available in study settings today. CONCLUSIONS In this cohort study among WLHIV in Africa, a human papillomavirus (HPV) test targeting 14 high-risk (HR) types had higher sensitivity to detect CIN2+ compared to visual inspection but had low specificity, although a restricted genotype approach targeting 8 HR types decreased the number of unnecessary colposcopy referrals. Cytology HSIL+ had optimal performance for CIN2+/CIN3+ detection in SA. Triage of HPV-positive women with HSIL+ maintained high specificity but with some loss in sensitivity compared to HC2 alone.
Collapse
Affiliation(s)
- Helen A. Kelly
- Catalan Institute of Oncology, Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat, Barcelona, Spain
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Admire Chikandiwa
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Bernard Sawadogo
- Centre de Recherche Internationale en Santé, University of Ouagadougou, Burkina Faso
| | - Clare Gilham
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Pamela Michelow
- Department of Anatomical Pathology, University of the Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Service, Johannesburg, South Africa
| | - Olga Goumbri Lompo
- Centre de Recherche Internationale en Santé, University of Ouagadougou, Burkina Faso
| | - Tanvier Omar
- Department of Anatomical Pathology, University of the Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Service, Johannesburg, South Africa
| | - Souleymane Zan
- Department of Gynaecology, Centre Hospitalier Universitaire Yalgado, Ouagadougou, Burkina Faso
| | - Precious Magooa
- Sexually Transmitted Infections Reference Centre, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | | | - Nicolas Nagot
- UMR1058, Montpellier University, Montpellier, France
| | - Nicolas Meda
- Centre de Recherche Internationale en Santé, University of Ouagadougou, Burkina Faso
| | - Sinead Delany-Moretlwe
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Philippe Mayaud
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | |
Collapse
|
4
|
Megersa BS, Bussmann H, Bärnighausen T, Muche AA, Alemu K, Deckert A. Community cervical cancer screening: Barriers to successful home-based HPV self-sampling in Dabat district, North Gondar, Ethiopia. A qualitative study. PLoS One 2020; 15:e0243036. [PMID: 33306681 PMCID: PMC7732077 DOI: 10.1371/journal.pone.0243036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 11/15/2020] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To explore the barriers to successful home-based human papillomavirus (HPV) self-sampling in North Gondar, Ethiopia. METHODS The study participants were women who had previously participated in a community-wide home-based HPV self-sampling pilot study, community health workers, women's development army leaders, and the sample collectors of the home-based HPV self-sampling pilot study. A community based qualitative descriptive study was conducted. We applied purposive and convenience sampling. In total, 47 women participated in the study (in-depth interviews n = 22, four focus group discussions n = 25, 6-7 participants each). The study employed thematic analysis for clustering the emerged themes. RESULTS Husband disapproval was identified as the main barrier to the acceptance of home-based HPV self-sampling. Social influence, lack of knowledge about cervical cancer and screening, lack of health education on cervical cancer and HPV-based screening, feeling healthy, and religious influence were identified as additional barriers. Fear of using Evalyn brush® for self-sampling was found to be the main barrier to the provision of a quality sample. The inability of the sample collectors to check the proper utilization of Evalyn brush® and the difficulty in understanding the instructions did also contribute to the low-quality. Providing health education concerning cervical cancer and HPV self-sapling to women, male involvement in the screening program, and linking the screening service to existing local health facilities were suggested to guarantee the success of home-based HPV self-sampling. CONCLUSIONS Educating women regarding cervical cancer and HPV testing, providing clear instructions on how to collect self-sample, and male involvement in the screening program are prerequisites for a successful implementation of home-based HPV testing. Women empowerment should also be focused to overcome the identified sociocultural barriers. Furthermore, the screening program should guarantee the timely provision of the test results and offering women follow-up examinations and treatment for abnormal findings.
Collapse
Affiliation(s)
- Bikila Soboka Megersa
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
- * E-mail:
| | - Hermann Bussmann
- Department of Applied Tumor Biology, Institute of Pathology, Heidelberg University, Heidelberg, Germany
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Achenef Asmamaw Muche
- Department of Epidemiology and Biostatistics, Institute of Public Health, University of Gondar, Gondar, Ethiopia
| | - Kassahun Alemu
- Department of Epidemiology and Biostatistics, Institute of Public Health, University of Gondar, Gondar, Ethiopia
| | - Andreas Deckert
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| |
Collapse
|
5
|
Orang'o EO, Were E, Rode O, Muthoka K, Byczkowski M, Sartor H, Vanden Broeck D, Schmidt D, Reuschenbach M, von Knebel Doeberitz M, Bussmann H. Novel concepts in cervical cancer screening: a comparison of VIA, HPV DNA test and p16 INK4a/Ki-67 dual stain cytology in Western Kenya. Infect Agent Cancer 2020; 15:57. [PMID: 33024449 PMCID: PMC7531147 DOI: 10.1186/s13027-020-00323-6] [Citation(s) in RCA: 8] [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: 07/03/2020] [Accepted: 09/21/2020] [Indexed: 12/12/2022] Open
Abstract
Background Screening of unvaccinated women remains essential to mitigate the high morbidity/mortality of cervical cancer. Here, we compared visual inspection with acetic acid (VIA), recommended by WHO as the most cost-effective screening approach in LMICs, with HPV-based screening, and usage of p16INK4a/Ki-67 dual stain cytology. Methods We prospectively enrolled women participating in a VIA-based cervical cancer screening program in two peri-urban health centers of Kenya. Consenting women had a VIA examination preceded by collection of a liquid-based cytology sample from the cervix stored in PreservCyt medium (Hologic®). Analysis of all samples included a hrHPV DNA test and evaluation of a p16INK4a /Ki-67 (CINtecPLUS®) dual stained slide that was prepared using the ThinPrep® 2000 Processor and evaluated by a pathologist trained in the methodology. Results In 701 of a total of 800 women aged 18–64 years, all three investigations were performed and data could be analyzed. The HPV, VIA and dual stain cytology positivity were 33%, 7%, and 2% respectively. The HPV positivity rate of VIA positive cases was 32%. The five most common HPV types were HPV16, 52, 68, 58 and 35. The OR among HIV infected women of an HPV infection, VIA positivity and positive dual stain cytology were 2.6 (95%CI 1.5–4.3), 1.9 (95%CI 0.89–4.4) and 3.4 (95%CI 1.07–10.9) respectively. The sensitivity of VIA to detect a p16INK4a/Ki-67 positive transforming infection was 13% (95%CI 2–38). Conclusions Primary HPV testing appears feasible and should be considered as a primary screening test also in LMICs. The poor sensitivity of VIA renders it unsuitable as a triage test for HPV positive women. The utility of p16INK4a/Ki-67 dual stain cytology as a triage test for HPV positive women in LMICs should be further studied.
Collapse
Affiliation(s)
- Elkanah Omenge Orang'o
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Department of Reproductive Health, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Edwin Were
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Department of Reproductive Health, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Oliver Rode
- Applied Tumor Biology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Kapten Muthoka
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | | | - Heike Sartor
- Applied Tumor Biology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Davy Vanden Broeck
- International Centre of Reproductive Health, Ghent University, Ghent, Belgium.,National Reference Centre for HPV, Brussels, Belgium.,Laboratory of Molecular Pathology, AML, Antwerp, Belgium
| | - Dietmar Schmidt
- MVZ of Histology, Cytology and Molecular Diagnostics, Department of Cytopathology, Trier, Germany
| | - Miriam Reuschenbach
- Applied Tumor Biology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Hermann Bussmann
- Applied Tumor Biology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| |
Collapse
|
6
|
Johnson LG, Saidu R, Mbulawa Z, Williamson A, Boa R, Tergas A, Moodley J, Persing D, Campbell S, Tsai W, Wright TC, Denny L, Kuhn L. Selecting human papillomavirus genotypes to optimize the performance of screening tests among South African women. Cancer Med 2020; 9:6813-6824. [PMID: 32706163 PMCID: PMC7520316 DOI: 10.1002/cam4.3329] [Citation(s) in RCA: 10] [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: 04/08/2020] [Revised: 06/05/2020] [Accepted: 06/29/2020] [Indexed: 12/14/2022] Open
Abstract
Human papillomavirus (HPV) testing is highly sensitive compared to cytology, with the trade-off of being less specific. We investigated whether select combinations of HPV genotypes, ascertained by Linear Array (LA) and Xpert HPV (GX), can optimize sensitivity/specificity trade-offs to detect high-grade cervical intraepithelial neoplasia (CIN2+). In a study in Cape Town, South Africa, 586 women living without and 535 living with HIV, aged 30-65 years, were recruited. Each woman underwent a pelvic exam to collect cervical samples (tested by LA and GX for 14 high-risk HPV genotypes) and underwent colposcopy with histological sampling to determine CIN2+. In multivariable logistic regression of LA results, only HPV genotypes 16, 18, 31, 33, 35, 52, 58 were significantly associated with CIN2+ (P < .05). Xpert includes these seven types along with HPV 45 within three of the test's five channels and we defined these eight types as restricted genotyping (ie 16, 18, 31, 33, 35, 45, 52, 58). Full genotyping was defined as all 14 high-risk types. Sensitivity estimates for full genotyping using LA were similar to that of restricted genotyping: 83.9% (full) vs 79.0% (restricted) in women without HIV and 93.0% (full) vs 88.9% (restricted) in women living with HIV. Specificity estimates improved for restricted vs full genotyping: 87.4% (full) vs 90.8% (restricted) in women without HIV and 63.7% (full) vs 71.4% (restricted) in women living with HIV. To optimize the performance of HPV testing for cervical cancer screening in high-burden, under-resourced settings like South Africa, only HPV 16, 18, 31, 33, 35, 45, 52, 58 could be included to define screen-positive. We recommend the inclusion of HPV45 for its known link to adenocarcinoma.
Collapse
Affiliation(s)
- Lauren G. Johnson
- Department of EpidemiologyMailman School of Public HealthColumbia University Irving Medical CenterNew YorkNYUSA
- School of NursingColumbia University Irving Medical CenterNew YorkNYUSA
| | - Rakiya Saidu
- Department of Obstetrics and GynecologyUniversity of Cape TownCape TownSouth Africa
- South African Medical Research Council Gynaecologic Cancer Research Centre (SAMRC GCRC)University of Cape TownCape TownSouth Africa
| | - Zizipho Mbulawa
- South African Medical Research Council Gynaecologic Cancer Research Centre (SAMRC GCRC)University of Cape TownCape TownSouth Africa
- Department of PathologyInstitute of Infectious Disease and Molecular MedicineUniversity of Cape TownCape TownSouth Africa
- Department of Laboratory Medicine and PathologyNational Health Laboratory ServicesWalter Sisulu UniversityMthathaSouth Africa
| | - Anna‐Lise Williamson
- South African Medical Research Council Gynaecologic Cancer Research Centre (SAMRC GCRC)University of Cape TownCape TownSouth Africa
- Department of PathologyInstitute of Infectious Disease and Molecular MedicineUniversity of Cape TownCape TownSouth Africa
| | - Rosalind Boa
- Department of Obstetrics and GynecologyUniversity of Cape TownCape TownSouth Africa
- South African Medical Research Council Gynaecologic Cancer Research Centre (SAMRC GCRC)University of Cape TownCape TownSouth Africa
| | - Ana Tergas
- Department of EpidemiologyMailman School of Public HealthColumbia University Irving Medical CenterNew YorkNYUSA
- Department of Obstetrics and GynecologyVagelos College of Physicians and SurgeonsColumbia University Irving Medical CenterNew YorkNYUSA
| | - Jennifer Moodley
- South African Medical Research Council Gynaecologic Cancer Research Centre (SAMRC GCRC)University of Cape TownCape TownSouth Africa
- Women’s Health Research UnitSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | | | | | - Wei‐Yann Tsai
- Department of BiostatisticsMailman School of Public HealthColumbia University Irving Medical CenterNew YorkNYUSA
| | - Thomas C. Wright
- Department of PathologyVagelos College of Physicians and SurgeonsColumbia University Irving Medical CenterNew YorkNYUSA
| | - Lynette Denny
- Department of Obstetrics and GynecologyUniversity of Cape TownCape TownSouth Africa
- South African Medical Research Council Gynaecologic Cancer Research Centre (SAMRC GCRC)University of Cape TownCape TownSouth Africa
| | - Louise Kuhn
- Department of EpidemiologyMailman School of Public HealthColumbia University Irving Medical CenterNew YorkNYUSA
- Gertrude H. Sergievsky CenterVagelos College of Physicians and SurgeonsColumbia University Irving Medical CenterNew YorkNYUSA
| |
Collapse
|
7
|
Abstract
Cervical cancer is the fourth most common cancer among women globally, with approximately 580,000 new diagnoses in 2018. Approximately, 90% of deaths from this disease occur in low- and middle-income countries, especially in areas of high HIV prevalence, and largely due to limited prevention and screening opportunities and scarce treatment options. In this overview, we describe the opportunities and challenges faced in many low- and middle-income countries in delivery of cervical cancer detection, treatment and complete pathways of care. In particular, drawing on our experience and that of colleagues, we describe cervical screening and pathways of care provision in Malawi, as a case study of a low-resource country with high incidence and mortality rates of cervical cancer. Screening methods such as cytology – although widely used in high-income countries – have limited relevance in many low-resource settings. The World Health Organization recommends screening using human papillomavirus testing wherever possible; however, although human papillomavirus primary testing is more sensitive and detects precancers and cancers earlier than cytology, there are currently costs, infrastructure considerations and specificity issues that limit its use in low- and middle-income countries. The World Health Organization accepts the alternative screening approach of visual inspection with acetic acid as part of ‘screen and treat’ programmes as a simple and inexpensive test that can be undertaken by trained health workers and hence give wider screening coverage; however, subjectivity and variability in interpretation of findings between providers raise issues of false positives and overtreatment. Cryotherapy using either nitrous oxide or carbon dioxide is an established treatment for precancerous lesions within ‘screen and treat’ programmes; more recently, thermal ablation has been recognized as suitable to low-resource settings due to lightweight equipment, short treatment times, and hand-held battery-operated and solar-powered models. For larger lesions and cancers, complete clinical pathways (including loop excision, surgery, radiotherapy, chemotherapy and palliative care) are required for optimal care of women. However, provision of each of these components of cancer control is often limited due to limited infrastructure and lack of trained personnel. Hence, global initiatives to reduce cervical mortality need to adopt a holistic approach to health systems strengthening.
Collapse
Affiliation(s)
- Heather A Cubie
- Global Health Academy and Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Christine Campbell
- Global Health Academy and Usher Institute, The University of Edinburgh, Edinburgh, UK
| |
Collapse
|
8
|
Jede F, Brandt T, Gedefaw M, Wubneh SB, Abebe T, Teka B, Alemu K, Tilahun B, Azemeraw T, Gebeyehu A, Schmidt D, Pesic A, Kaufmann AM, Abebe B, Ayichew Z, Byczkowski M, Vaucher T, Sartor H, Andargie G, Bärnighausen T, von Knebel Doeberitz M, Bussmann H. Home-based HPV self-sampling assisted by a cloud-based electronic data system: Lessons learnt from a pilot community cervical cancer screening campaign in rural Ethiopia. Papillomavirus Res 2020; 9:100198. [PMID: 32416283 PMCID: PMC7240728 DOI: 10.1016/j.pvr.2020.100198] [Citation(s) in RCA: 8] [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] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/23/2020] [Accepted: 04/27/2020] [Indexed: 01/01/2023]
Abstract
Primary HPV testing and triage of HPV-positive women is an effective cervical cancer screening strategy. Such a multi-visit screening algorithm is also promising for community-based screening in resource-poor communities, provided a robust tracking system is in place. A cervical cancer screening campaign was conducted in a rural community in Ethiopia. All women aged 25–65 years were offered genital self-sampling using the Evalyn Brush®. Samples were HPV-DNA-tested at a central laboratory. Key indicators were captured on tablet computers and linked by a cloud-based information system. HPV-positive women were examined at the local clinic using portable colposcopy, p16/Ki-67 dual stain cytology and biopsy examination. CIN2+ women were referred for LEEP to the referral hospital. Of 749 enumerated age-eligible women 634 (85%, (95% CI 82–88)) consented to screening, 429 samples were adequate for HPV testing, giving a total testing coverage of 57% (95% CI 53–62). The hrHPV prevalence was 14% (95% CI 5–22), 72% (95% CI 60–84) attended the clinic for a triage examination. Home-based HPV-DNA self-sampling and clinic-based triage assisted by cloud-based information technology is feasible in rural Ethiopia. Key components of such strategy are broad community awareness, high competency of community workers, and establishment of an adequate self-sampling and HPV-DNA testing platform.
Collapse
Affiliation(s)
- Felix Jede
- Applied Tumor Biology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany.
| | - Theresa Brandt
- Applied Tumor Biology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany.
| | | | - Solomon Berhe Wubneh
- Department of Obstetrics and Gynecology, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Tamrat Abebe
- Department of Microbiology, Immunology and Parasitology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Brhanu Teka
- Department of Microbiology, Immunology and Parasitology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Kassahun Alemu
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Binyam Tilahun
- Department of Health Informatics, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Temesgen Azemeraw
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | | | - Dietmar Schmidt
- Department of Cytopathology, Institute of Pathology, Viersen, Germany.
| | - Aleksandra Pesic
- Clinic for Gynecology, Charité - Berlin Institute of Health, Charite - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Benjamin Franklin, Berlin, Germany.
| | - Andreas M Kaufmann
- Clinic for Gynecology, Charité - Berlin Institute of Health, Charite - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Benjamin Franklin, Berlin, Germany.
| | - Bewketu Abebe
- Department of Pathology, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Zelalem Ayichew
- Department of Obstetrics and Gynecology, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | | | - Timoté Vaucher
- École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland.
| | - Heike Sartor
- Applied Tumor Biology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany.
| | - Gashaw Andargie
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Till Bärnighausen
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany; Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA; Africa Health Research Institute (AHRI), Somkhele and Durban, South Africa.
| | | | - Hermann Bussmann
- Applied Tumor Biology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany.
| |
Collapse
|
9
|
Johnson LG, Ramogola-Masire D, Teitelman AM, Jemmott JB, Buttenheim AM. Assessing Nurses' Adherence to the See-and-Treat Guidelines of Botswana's National Cervical Cancer Prevention Programme. Cancer Prev Res (Phila) 2019; 13:329-336. [PMID: 31852663 DOI: 10.1158/1940-6207.capr-19-0348] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/05/2019] [Accepted: 12/12/2019] [Indexed: 01/23/2023]
Abstract
The see-and-treat approach for cervical cancer screening [visual inspection with acetic acid (VIA) followed by immediate cryotherapy] was first pilot tested in Botswana in 2009. Botswana's Ministry of Health and the Botswana-UPenn Partnership collaborated to expand see-and-treat to five additional sites throughout the country in 2014. The purpose of this study was to evaluate whether nurses' adherence to guideline-based screening was maintained during scale-up. Therefore, we compared nurses' adherence between the pilot and scaled-up sites and determined main drivers of nonadherence across all sites. We conducted a retrospective review of 6,644 medical charts from Botswana's National Cervical Cancer Prevention Programme between February 2014 and October 2015. Using multivariable regression modeled with generalized estimating equations, we determined whether nurses' adherence to the see-and-treat guideline differed between the pilot and scale-up sites after controlling for significant covariates. Overall, adherence to the guideline was high (88.4%). Although the scaled-up sites had higher adherence compared with the pilot site (90.9% vs. 80.2%, respectively), the difference between sites was not statistically significant in the multivariable model (P = 0.221). Of the nonadherent clinical encounters, the three most frequent visit types were VIA not performed (178, 23.3%), VIA negative: HIV unknown (163, 21.3%), and VIA negative: HIV negative (144, 18.9%). The most common reason for nonadherence was misspecification of follow-up times. Despite known challenges of scaling-up health innovations in resource-limited settings, our study shows that nurses maintained guideline-adherent care in Botswana's national see-and-treat program. The successful scale-up may have been attributable to the program's intensive quality assurance monitoring.
Collapse
Affiliation(s)
- Lauren G Johnson
- School of Nursing, Columbia University, New York, New York. .,Office of Nursing Research, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Anne M Teitelman
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John B Jemmott
- Annenberg School for Communication, University of Pennsylvania, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alison M Buttenheim
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
10
|
|