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

High-risk human papillomavirus genotype distribution among women living with HIV; implication for cervical cancer prevention in a resource limited setting

BACKGROUND

For women living with HIV (WLHIV), the burden of persistent HPV infection, cervical pre-cancerous lesions and cancer have been demonstrated to be higher than among HIV-negative women. As Ghana and other lower-middle-income countries (LMIC) work toward developing national cervical cancer programmes, it is essential that local scientific evidence be provided to guide policy decisions, especially for such special populations. The objective of this study was to determine the distribution of high-risk HPV genotype and related factors among WLHIV and its implication for the prevention of cervical cancer prevention efforts.

METHODS

A cross-sectional study was conducted at the Cape Coast Teaching Hospital in Ghana. WLHIV, aged 25-65 years, who met the eligibility criteria were recruited through a simple random sampling method. An interviewer-administered questionnaire was used to gather socio-demographic, behavioural, clinical and other pertinent information. The AmpFire HPV detection system (Atila BioSystem, Mointain View, CA was used to detect 15 high-risk HPV genotypes from self-collected cervico-vaginal samples. The data collected were exported to STATA 16.0 for statistical analysis.

RESULTS

In all, 330 study participants, with mean age of 47.2 years (SD ± 10.7), were involved. Most (69.1%, n = 188/272) had HIV viral loads < 1000 copies/ml and 41.2% (n = 136) had ever heard of cervical screening. The overall hr-HPV prevalence was 42.7% (n = 141, 95% CI 37.4-48.1) and the five commonest hr-HPV types among screen positives were HPV59 (50.4%), HPV18 (30.5%), HPV35 (26.2%), HPV58 (17%) and HPV45 (14.9%). Most infected women (60.3%, n = 85) had multiple hr-HPV infections, with about 57.4% (n = 81) having 2-5 h-HPV types, while 2.8% (n = 4) had more than five hr-HPV types. A total of 37.6% (n = 53) had HPV16 and/or18, while 66.0% (n = 93) had the hr-HPV genotypes covered by the nonavalent vaccine. Women with HIV viral load ≥ 1000copies/ml (AOR = 5.58, 95% CI 2.89-10.78, p < 0.001) had a higher likelihood of being co-infected.

CONCLUSION

This study found out that the prevalence of hr-HPV still remains high in women with HIV, with a notable occurrence of multiple infections and infection with genotypes 16 and/or18. Additionally, an association was established between hr-HPV and infection HIV viral load.. Therefore, comprehensive HIV care for these women should include awareness of cervical cancer, consideration of vaccination and implementation of screening and follow-up protocols. National programmes in LMIC, such as Ghana, should consider using HPV-based screen-triage-treat approach with partial genotyping.

[Faible niveau de dépistage du cancer du col de l'utérus, disparités géographiques et déterminants sociodémographiques du dépistage chez les femmes adultes au Burkina Faso : résultats de la première enquête nationale en population générale]

OBJECTIVE

To explore the level, geographical disparities and sociodemographic determinants of cervical cancer screening uptake among adult women in Burkina Faso by using data from the first national population-based survey.

METHODS

This was a cross-sectional secondary analysis of primary data obtained by the 2013 World Health Organization (WHO) Stepwise Approach to Surveillance survey conducted in Burkina Faso. All 13 Burkinabè regions, with their different rates of urbanization, were surveyed. Lifetime cervical cancer screening uptake was explored. We included 2293 adult women for analyses and performed Student's t, chi-square and Fisher's exact tests, and logistic regression.

RESULTS

Only 6.2% (95% CI: 5.3-7.3) of women had ever been screened for cervical cancer. For two regions ("Centre" and "Hauts-Bassins"), the pooled frequency was 16.6% (95% CI: 13.5-20.1) while in the other eleven regions it was significantly lower, 3.3% (95% CI: 2.5-4.2). In urban and rural areas, the respective frequencies for the screening uptake were 18.5% and 2.8% (p < 0.001), and in educated and un-educated women, frequencies were 27.7% and 3.3% (p < 0.001) respectively. The sociodemographic factors associated with screening uptake were being educated (adjusted odd-ratio [aOR] = 4.3; 95% CI: 2.8-6.7), urban residence (aOR = 3.8, 95% CI: 2.5-5.8) and having an occupation providing income (aOR = 3.1, 95% CI: 1.8-5.4).

CONCLUSION

There was a significantly wide range in screening uptake between Burkina Faso regions, and the overall national as well as the region-specific levels were far below the WHO's target for cervical cancer elimination. Cervical cancer interventions should be tailored specifically for Burkinabè women with different educational levels, and prevention strategies based on community engagement integrating psychosocial considerations could be helpful.

A Descriptive Study of Different Methods of Cervical Cancer Screening among Ever-Married Women in 35-Year and 45-Year Cohorts in Kalutara District, Sri Lanka

OBJECTIVE

Screening for cervical cancer in Sri Lankan females with Pap smears (conventional cytology) has shown no marked reduction in cervical cancer incidence over the past two decades. The study aims to compare the efficacy of Pap smear, with other screening tools such as Liquid Based Cytology (LBC) and Human Papilloma Virus/deoxyribonucleic acid (HPV/DNA) (using cobas 4800) in detection of underlying cervical intraepithelial neoplasia (CIN) and cervical cancer among 35 and 45 year old ever married women in Kalutara districtin Sri Lanka.

METHODS

Women from 35-year cohort and 45-year cohort were selected from all Public Health Midwife areas (n=413) in Kalutara district by random sampling. Pap smear, LBC, and HPV/DNA specimen were collected s from women who attended the Well Woman Clinics (WWC) . Women with positive results from any method were confirmed by colposcopy.  Results: Of the, 510 and 502 women in the 35-year cohort and 45-year cohort, respectively, included in the analysis, nine women among 35-year cohort (1.8%) and 7 women among 45-year cohort (1.4%) had cytological abnormality (positive results) with Pap smears. Thirteen women among 35-year cohort (2.5%) and 10 women among 45-year cohort (2%) age groups had cytological abnormality (positive results) with Liquid Based Cytology reports. Total of 32 women among 35-year cohort (6.2%) and 24 women among 45-year cohort (4.8%)  were positive for HPV/DNA test. Of  the women tested positive on screening, colposcopy revealed that HPV/DNA method was superior to Pap and LBC for detecting CIN while the results of latter two were comparable.

CONCLUSIONS AND RECOMMENDATIONS

The CIN detection rate by colposcopy was high with HPV/DNA screening with cobas 4800, whereas the detection rate by LBC was insignificantly higher than Pap smears.

Human papillomavirus testing using existing nucleic acid testing platforms to screen women for cervical cancer: implementation studies from five sub-Saharan African countries

OBJECTIVES

To demonstrate acceptability and operational feasibility of introducing human papillomavirus (HPV) testing as a principal cervical cancer screening method in public health programmes in sub-Saharan Africa.

SETTING

45 primary and secondary health clinics in Malawi, Nigeria, Senegal, Uganda and Zimbabwe.

PARTICIPANTS

15 766 women aged 25-54 years presenting at outpatient departments (Senegal only, general population) or at antiretroviral therapy clinics (all other countries, HIV-positive women only). Eligibility criteria followed national guidelines for cervical cancer screening.

INTERVENTIONS

HPV testing was offered to eligible women as a primary screening for cervical cancer, and HPV-positive women were referred for visual inspection with acetic acid (VIA), and if lesions identified, received treatment or referral.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes were the proportion of HPV-positive women who received results and linked to VIA and the proportion of HPV-positive and VIA-positive women who received treatment.

RESULTS

A total of 15 766 women were screened and tested for HPV, among whom 14 564 (92%) had valid results and 4710/14 564 (32%) were HPV positive. 13 837 (95%) of valid results were returned to the clinic and 3376 (72%) of HPV-positive women received results. Of women receiving VIA (n=2735), 715 (26%) were VIA-positive and 622 (87%) received treatment, 75% on the same day as VIA.

CONCLUSIONS

HPV testing was found to be feasible across the five study countries in a public health setting, although attrition was seen at several key points in the cascade of care, namely results return to women and linkage to VIA. Once women received VIA, if eligible, the availability of on-site cryotherapy and thermal ablation allowed for same-day treatment. With sufficient resources and supportive infrastructure to ensure linkage to treatment, use of HPV testing for cervical cancer screening as recommended by WHO is a promising model in low-income and middle-income countries.

Mathematical Models for Evaluating Effectiveness and Cost-Effectiveness of Cervical Cancer Control Policies in Populations Including Women Living With Human Immunodeficiency Virus: A Scoping Review

OBJECTIVES

Mathematical modeling is increasingly used to inform cervical cancer control policies, and model-based evaluations of such policies in women living with human immunodeficiency virus (HIV) are an emerging research area. We did a scoping review of published literature to identify research gaps and inform future work in this field.

METHODS

We systematically searched literature up to April 2022 and included mathematical modeling studies evaluating the effectiveness or cost-effectiveness of cervical cancer prevention strategies in populations including women living with HIV. We extracted information on prevention strategies and modeling approaches.

RESULTS

We screened 1504 records and included 22 studies, almost half of which focused on South Africa. We found substantial between-study heterogeneity in terms of strategies assessed and modeling approaches used. Fourteen studies evaluated cervical cancer screening strategies, 7 studies assessed human papillomavirus vaccination (with or without screening), and 1 study evaluated the impact of HIV control measures on cervical cancer incidence and mortality. Thirteen conducted cost-effectiveness analyses. Markov cohort state-transition models were used most commonly (n = 12). Most studies (n = 17) modeled the effect of HIV by creating HIV-related health states. Thirteen studies performed model calibration, but 11 did not report the calibration methods used. Only 1 study stated that model code was available upon request.

CONCLUSIONS

Few model-based evaluations of cervical cancer control strategies have specifically considered women living with HIV. Improvements in model transparency, by sharing information and making model code publicly available, could facilitate the utility of these evaluations for other high disease-burden countries, where they are needed for assisting policy makers.

Knowledge, perception of HIV symptom severity and cervical cancer screening behaviour among women living with HIV in China

OBJECTIVE

This study aimed to examine the previous uptake of cervical cancer screening and intention to be screened and its associated factors among women living with HIV in China.

METHODS

We conducted a cross-sectional survey of 213 women living with HIV to collect information about cervical cancer screening behaviour, demographics, knowledge about cervical cancer and screening, and perception of HIV symptom severity.

RESULTS

Seventy-eight women living with HIV (36.6%) had undergone cervical cancer screening, and 83 (61.5%) of the nonscreened women had the intention to be screened in the future. Using multivariate analysis, women who had more knowledge about cervical cancer screening (OR = 2.373, 95% CI = 1.593-3.534, p = 0.000) and had at least one nongynecological symptom (OR = 0.446, 95% CI = 0.204-0.978, p = 0.044) were more likely to have received screening previously.

CONCLUSION

This study emphasised that knowledge, as a salient factor, was crucial to promoting cervical cancer screening behaviour among women living with HIV. Effective measures should be taken to promote the knowledge about cervical cancer prevention. A new healthcare model, including preventive healthcare in addition to HIV/AIDS care, may be needed to address the complex needs of women living with HIV in China.