Experiences of cervical cancer screening in HIV-positive women in Zimbabwe

A comparative analysis of somatic mutational profiles according to HIV status among women with cervical intraepithelial neoplasia 3 (CIN3): a focus on hotspots in TP53, PIK3CA, PTEN, and EGFR

BACKGROUND

Despite the success of antiretroviral therapy in HIV treatment, cervical cancer remains a leading malignancy in HIV-infected women. Additionally, co-infection by HIV and HPV further accelerates cervical cancer development. There are limited studies on the role of host somatic variations in HIV infected and HIV-negative women with cervical cancer. Therefore, this study aimed to investigate and compare host somatic genetic variation in cervical biopsies obtained from HIV infected and HIV-negative women with cervical intraepithelial neoplasia 3 to understand the genomic landscape. The distribution of HPV types was also investigated between HIV infected and HIV-negative women.

METHODS

The project used an age-matched case-control study utilizing archived cervical biopsies from 88 women (44 HIV infected, 44 HIV-negative) attending Groote Schuur Hospital Cancer Clinic between 2020 and 2022. HPV infection and type were confirmed using the Anyplex™ II HPV28 Detection kit. Six hotspot regions in the four commonly mutated genes (TP53, PIK3CA, PTEN, and EGFR) in cervical cancer were genotyped using PCR and Sanger Sequencing. Variant pathogenicity was assessed using SIFT, Polyphen-2, and ClinVar tools.

RESULTS

The median age was 37 years (IQR: 34-41) for HIV infected women and 35 years (IQR:32- 43) for HIV-negative women. Significantly more HIV-negative women (51% vs. 12%) reported tobacco smoking (p < 0.0001), menstruation irregularities (74% vs. 35%; p = 0.005), and contraception usage (77% vs. 59%; p = 0.019), when compared to their HIV-infected counterparts. Common HPV types identified were HPV16 (n = 43/88, 49%), HPV35 (n = 12/88, 14%), and HPV58 (n = 10/88, 11%). A total of 232 genetic variants were reported. HIV infected women had a significantly higher (p = 0.0406) burden of pathogenic variants (31%) compared to the HIV-negative (15%). The spectrum of observed mutations included stop-gain, missense, synonymous, and intronic changes. Most of the stop gain mutations in TP53 and PIK3CA were reported among HIV infected women (n = 4/5), compared to HIV-negative women (n = 1/5). Damaging variants were more prevalent in women under 50 in both cohorts. We also report on rare HPV subtypes currently not included in the diagnostic HPV test kits in this cohort (HPV 82, 42, 43 and 53).

CONCLUSION

HIV-infection status and age appear to be risk factors for higher burden of pathogenic mutations in genes that predispose to cervical cancer. Mutation profiles in PIK3CA and TP53 genes could be biomarkers of cervical cancer progression but more studies are needed.

Integration of cervical cancer screening into healthcare facilities in low- and middle-income countries: A scoping review

Cervical cancer is a prevalent disease among women, especially in low- and middle-income countries (LMICs), where most deaths occur. Integrating cervical cancer screening services into healthcare facilities is essential in combating the disease. Thus, this review aims to map evidence related to integrating cervical cancer screening into existing primary care services and identify associated barriers and facilitators in LMICs. The scoping review employed a five-step framework as proposed by Arksey and O'Malley. Five databases (MEDLINE, Maternity Infant Care, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science) were systematically searched. Data were extracted, charted, synthesized, and summarised. A total of 28 original articles conducted in LMICs from 2000 to 2023 were included. Thirty-nine percent of the reviewed studies showed that cervical cancer screening (CCS) was integrated into HIV clinics. The rest of the papers revealed that CCS was integrated into existing reproductive and sexual health clinics, maternal and child health, family planning, well-baby clinics, maternal health clinics, gynecology outpatient departments, and sexually transmitted infections clinics. The cost-effectiveness of integrated services, promotion, and international initiatives were identified as facilitators while resource scarcity, lack of skilled staff, high client loads, lack of preventive oncology policy, territorial disputes, and lack of national guidelines were identified as barriers to the services. The evidence suggests that CCS can be integrated into healthcare facilities in LMICs, in various primary care services, including HIV clinics, reproductive and sexual health clinics, well-baby clinics, maternal health clinics, and gynecology OPDs. However, barriers include limited health system capacity, workload, waiting times, and lack of coordination. Addressing these gaps could strengthen the successful integration of CCS into primary care services and improve cervical cancer prevention and treatment outcomes.

Effectiveness of a culturally tailored text messaging program for promoting cervical cancer screening in accra, Ghana: a quasi-experimental trial

INTRODUCTION

Despite breakthroughs in cervical cancer detection, resource-constrained countries continue to have a disproportionately high incidence and death rate. Mhealth has been identified as an important tool for increasing cervical cancer screening rates in Sub-Saharan Africa. We determined whether sending Ghanaian women culturally tailored one-way mobile phone SMS text messages about cervical cancer would encourage the uptake of the human papillomavirus (HPV) test.

METHODS

From August to November 2016, 88 women aged 18 to 39 living or working in an urban community (Accra, Ghana) participated in a quasi-experimental study. For 8 weeks, 32 SMS messages regarding cervical cancer were developed and sent to the personal phones of intervention arm participants (n = 42). Women in the control group (n = 46) received SMS texts with general health and lifestyle advice. Fischer's exact tests were performed to assess cervical cancer screening uptake and associated reasons for non-uptake between the intervention and control groups (p < 0.05).

RESULTS

At the baseline, women differed in terms of ethnicity and wealth. After the intervention, participants' self-reported risk factors for cervical cancer, such as early menarche, usual source of medical treatment, family history of cancer, smoking, and alcohol history, changed. None of the women in the intervention group sought cervical cancer screening after the intervention, but only one (2.2%) of the control arm participants did. Almost all the women (> 95%) agreed that an HPV test was essential and that regular healthcare check-ups could help prevent cervical cancer. Some women believed that avoiding particular foods could help prevent cervical cancer (23.8% intervention vs. 58.7% control, p < 0.001). Time constraints and out-of-pocket expenses were significant barriers to cervical cancer screening.

CONCLUSION

A one-way SMS delivered to urban women did not increase cervical cancer screening attendance. The time spent in screening facilities and the lack of coverage by the National Health Insurance Scheme limited screening uptake. We urge for the establishment of screening centers in all healthcare facilities, as well as the inclusion of cervical cancer screening in healthcare programs through cost-sharing.

Knowledge and Practice of Women With HIV on Cervical Cancer Prevention and Control and their Attributes to Utilize the Screening Services in Ethiopia: A Cross Sectional Study

BACKGROUND

Previous studies underscore the crucial link between awareness and timely cervical cancer screening and treatment, particularly among women of reproductive age. Yet, insights remain limited when it comes to women living with HIV in Addis Ababa. This study examined the knowledge and practices of these women regarding cervical cancer screening and treatment, illuminating the factors that both enable and hinder their uptake.

METHODS

This cross-sectional study took place in six public hospitals in Addis Ababa, Ethiopia, involving 578 women with HIV. The recruitment spanned 10 months, from January 1st to October 31st, 2021. Trained clinicians utilized the Open Data Kit for data collection, ensuring real-time submission to the server. Statistical analysis was performed using SPSS version 25, employing descriptive and inferential statistics. The logistic regression model identified predictors of outcome variables, and open-ended questions were thematically narrated for qualitative insights.

RESULTS

A notable 51.2% of women with HIV exhibited inadequate knowledge regarding cervical cancer prevention and control programs. Furthermore, a substantial 68.5% had never undergone cervical examination, citing reasons such as considering themselves healthy (49.6%), perceiving the examination as painful (28.4%), and feeling shy to undergo screening (23.3%). Notably, participants with non-formal education were 70% less likely to possess knowledge about cervical cancer prevention and control (AOR = 0.30; 95% CI = 0.13-0.71). Income emerged as an independent predictor for both knowledge and practice in women's approach to cervical cancer prevention and control (P < 0.05). Additionally, occupation and duration of HIV diagnosis independently predicted practice, even after adjusting for confounding factors.

CONCLUSION

Half of the participating HIV-positive women lacked adequate awareness about cervical cancer prevention and control, underscoring the urgent need for comprehensive awareness initiatives tailored to this population. Relevant ministries, health care providers, and advocacy groups must collaborate to implement targeted education programs, utilizing diverse channels like community outreach, health care settings, and media campaigns.

An audit of adherence to cervical cancer screening guidelines in a tertiary-level HIV clinic

Background

Cervical cancer is the most common malignancy affecting South African women aged 15-44 years, with a higher prevalence among women living with HIV (WLWH). Despite recommendations for a screening target of 70%, the reported rate of cervical cancer screening in South Africa is 19.3%.

Objectives

To investigate the adherence of healthcare workers to cervical cancer screening guidelines in a tertiary-level HIV clinic.

Method

A retrospective cross-sectional record audit of women attending the Charlotte Maxeke Johannesburg Academic Hospital HIV Clinic over a 1-month period.

Results

Out of 403 WLWH who attended the clinic, 180 (44.7%) were screened for cervical cancer in the 3 years prior to the index consultation. Only 115 (51.6%) of those women with no record of prior screening were subsequently referred for screening. Women who had undergone screening in the previous 3 years were significantly older (47 years vs 44 years, P = 0.046) and had a longer time since diagnosis of their HIV (12 years vs 10 years, P = 0.001) compared to women who had not undergone screening. There was no significant difference in CD4 count or viral suppression between women who had and had not undergone screening.

Conclusion

The rate of cervical cancer screening in our institution is below that recommended by the World Health Organization and the South African National Department of Health.