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Luckett R, Ramogola-Masire D, Gompers A, Moraka N, Moyo S, Sedabadi L, Tawe L, Kashamba T, Gaborone K, Mathoma A, Noubary F, Kula M, Grover S, Dreyer G, Botha MH, Makhema J, Shapiro R, Hacker MR. Triage of HPV positivity in a high HIV prevalence setting: A prospective cohort study comparing visual triage methods and HPV genotype restriction in Botswana. Int J Gynaecol Obstet 2024; 165:507-518. [PMID: 37950533 PMCID: PMC11021160 DOI: 10.1002/ijgo.15225] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/08/2023] [Accepted: 10/12/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE Guidelines for effective triage following positive primary high-risk human papillomavirus (HPV) screening in low- and middle-income countries with high human immunodeficiency virus (HIV)-prevalence have not previously been established. In the present study, we evaluated the performance of three triage methods for positive HPV results in women living with HIV (WLHIV) and without HIV in Botswana. METHODS We conducted baseline enrollment of a prospective cohort study from February 2021 to August 2022 in South-East District, Botswana. Non-pregnant women aged 25 or older with an intact cervix and no prior diagnosis of cervical cancer were systematically consented for enrollment, with enrichment of the cohort for WLHIV. Those who consented completed a questionnaire and then collected vaginal self-samples for HPV testing. Primary HPV testing for 15 individual genotypes was conducted using Atila AmpFire® HPV assay. Those with positive HPV results returned for a triage visit where all underwent visual inspection with acetic acid (VIA), colposcopy, and biopsy. Triage strategies with VIA, colposcopy and 8-type HPV genotype restriction (16/18/31/33/35/45/52/58), separately and in combination, were compared using histopathology as the gold standard in diagnosing cervical intraepithelial neoplasia (CIN) 2 or worse (CIN2+). RESULTS Among 2969 women enrolled, 1480 (50%) tested HPV positive. The cohort included 1478 (50%) WLHIV; 99% were virologically suppressed after a mean of 8 years on antiretroviral therapy. In total, 1269 (86%) women had histopathology data for analysis. Among WLHIV who tested positive for HPV, 131 (19%) of 688 had CIN2+ compared with 71 (12%) of 581 in women without HIV. Screening by 8-type HPV genotype restriction was more sensitive as triage to detect CIN2+ in WLHIV 87.79% (95% CI: 80.92-92.85) and women without HIV 85.92% (95% CI: 75.62-93.03) when compared with VIA (WLHIV 62.31% [95% CI: 53.39-70.65], women without HIV 44.29% [95% CI: 32.41-56.66]) and colposcopy (WLHIV 70.77% [95% CI: 62.15-78.41], women without HIV 45.71% [95% CI: 33.74-58.06]). However, 8-type HPV genotype restriction had low specificity in WLHIV of 30.88% (95% CI: 27.06-34.90) and women without HIV 37.06% (95% CI: 32.85-41.41). These results were similar when CIN3+ was used as the outcome. When combining 8-type HPV genotype restriction with VIA as the triage strategy, there was improved specificity to detect CIN2+ in WLHIV of 81.65% (95% CI: 78.18-84.79) but dramatically reduced sensitivity of 56.15% (95% CI: 47.18-64.84). CONCLUSIONS Eight-type HPV genotype restriction is a promising component of effective triage for HPV positivity. However, novel triage strategies in LMICs with high HIV prevalence may be needed to avoid the trade-off between sensitivity and specificity with currently available options. CLINICAL TRIALS REGISTRATION This study is registered on Clinicaltrials.gov no. NCT04242823, https://clinicaltrials.gov/ct2/show/NCT04242823.
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Affiliation(s)
- Rebecca Luckett
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, USA
- Botswana Harvard Health Partnership, Gaborone, Botswana
- Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
- Harvard Medical School, Boston, USA
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
- Department of Obstetrics & Gynaecology, University of Pretoria, Pretoria, South Africa
| | - Annika Gompers
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, USA
| | | | - Sikhulile Moyo
- Botswana Harvard Health Partnership, Gaborone, Botswana
- Harvard T.H. Chan School of Public Health, Boston, USA
- School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
- Department of Pathology, University of Botswana, Gaborone, Botswana
| | - Leatile Sedabadi
- Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
| | - Leabaneng Tawe
- Department of Pathology, University of Botswana, Gaborone, Botswana
| | - Thanolo Kashamba
- Department of Pathology, University of Botswana, Gaborone, Botswana
| | | | - Anikie Mathoma
- Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
| | - Farzad Noubary
- Department of Health Sciences, Northeastern University, Boston, USA
| | - Maduke Kula
- National Cervical Cancer Prevention Program, Ministry of Health and Wellness Botswana, Gaborone, Botswana
| | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA
| | - Greta Dreyer
- Department of Obstetrics & Gynaecology, University of Pretoria, Pretoria, South Africa
| | - Matthys H Botha
- Department of Obstetrics & Gynaecology, Stellenbosch University, Cape Town, South Africa
| | - Joseph Makhema
- Botswana Harvard Health Partnership, Gaborone, Botswana
- Harvard T.H. Chan School of Public Health, Boston, USA
| | - Roger Shapiro
- Botswana Harvard Health Partnership, Gaborone, Botswana
- Harvard Medical School, Boston, USA
- Harvard T.H. Chan School of Public Health, Boston, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, USA
| | - Michele R Hacker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, USA
- Harvard Medical School, Boston, USA
- Harvard T.H. Chan School of Public Health, Boston, USA
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2
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Meghani K, Puri P, Bazzett-Matabele L, Vuylsteke P, Luckett R, Monare B, Chiyapo S, Ketlametswe R, Ralefala TB, Bvochora-Nsingo M, Zetola N, Ramogola-Masire D, Grover S. Significance of HIV status in cervical cancer patients receiving curative chemoradiation therapy, definitive radiation alone, or palliative radiation in Botswana. Cancer 2024. [PMID: 38529676 DOI: 10.1002/cncr.35289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 02/10/2024] [Accepted: 02/13/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Cervical cancer associated with human papillomavirus has the highest cancer incidence and mortality for women in Botswana because of a high HIV prevalence and limited screening. This study investigates the significance of HIV on the overall survival (OS) of patients with locally advanced cervical cancer by various treatment categories (curative chemoradiation, definitive radiation [RT] alone, or palliative RT alone). METHODS This study included patients diagnosed with cervical cancer between 2013 and 2020, prospectively enrolled in the Botswana Prospective Cancer Cohort. OS based on HIV status and completion of planned treatment regimen was estimated by the Kaplan-Meier method. Comparisons of 2-year OS by HIV status was performed by the log-rank test, univariate and multivariable Cox analyses adjusting for cancer stage, RT dose, number of chemotherapy cycles, and baseline hemoglobin levels. RESULTS Of 1131 patients diagnosed with stage IB-IVB cervical cancer, 69.8% were women living with HIV (n = 789). For patients receiving curative chemoradiation, HIV status was not significantly associated with OS in unadjusted (p = .987) and adjusted (p = .578) analyses. For RT only treatment and definitive (high-dose) RT alone, HIV status was significantly associated with OS in unadjusted analysis (HR = 1.77, p = .002; HR = 1.95, p = .014), but not in adjusted analysis (p = .227, p = .73). For patients receiving palliative (low-dose) RT, HIV status was not associated with OS in unadjusted (p = .835) or adjusted analysis (p = .359). CONCLUSIONS In Botswana, a resource-limited setting, HIV status had no significant effect on 2-year OS in patients with cervical cancer with well-managed HIV receiving chemoradiation, RT alone, or palliative RT. This demonstrates that patients living with HIV receiving antiretroviral treatment can receive clinically appropriate treatment with no evidence that HIV may lead to poorer outcomes.
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Affiliation(s)
- Kinza Meghani
- School of Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Priya Puri
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Peter Vuylsteke
- Department of Oncology, Gaborone Private Hospital, Gaborone, Botswana
| | - Rebecca Luckett
- Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
| | - Barati Monare
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | - Sebathu Chiyapo
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | | | - Tlotlo B Ralefala
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
- Department of Oncology, Princess Marina Hospital, Gaborone, Botswana
| | - Memory Bvochora-Nsingo
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
- Department of Oncology, Princess Marina Hospital, Gaborone, Botswana
| | - Nicola Zetola
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Oncology, Princess Marina Hospital, Gaborone, Botswana
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
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3
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George J, Tuli S, Patel PP, Monare B, Ramogola-Masire D, Bazzett-Matabele L, Bvochora-Nsingo M, Chiyapo S, Ralefala T, Vuylsteke P, Rendle KA, Grover S. Delays in Cervical Cancer Treatment Initiation for Patients Living With or Without HIV in Botswana: An Observational Cohort Analysis (2015-2019). Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00354-7. [PMID: 38462016 DOI: 10.1016/j.ijrobp.2024.02.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 02/04/2024] [Accepted: 02/18/2024] [Indexed: 03/12/2024]
Abstract
PURPOSE To assess delays in treatment initiation of chemoradiation or radiation alone for patients with advanced stage cervical cancer in Botswana. METHODS AND MATERIALS Females with locally advanced cervical cancer (stages IB2-IVB) were prospectively enrolled in an observational cohort study from 2015 to 2019. We evaluated delays at 30, 60, 90, 120, 150, and 180 or greater days between the date of diagnosis and treatment initiation. Factors associated with overall survival were modeled with multivariable Cox proportional hazards regression (aHR). Associations between delays in cervical cancer treatment initiation were evaluated via univariable logistic regression. RESULTS Among the 556 patients included (median age = 47.9 years), 386 (69.4%) were females living with HIV with a median CD4 count of 448.0 cells/μL (IQR, 283.0-647.5 cells/μL) at diagnosis. Most patients had stages 2 (38.1%) or 3 (34.5%) cervical cancer. Early-stage patients experienced longer delays in treatment initiation compared to late-stage patients (P = .033). Early-stage patients with delays ≥90 days and pathology diagnosis between 2016 and 2019 (aHR, 0.34; P < .001) versus <90 days had a decreased risk of mortality, and those with delays ≥90 days and pathology diagnosis before 2016 (aHR, 5.67; P = .022) versus <90 days had an increased risk of mortality. Late-stage patients with delays ≥120 days and pathology diagnosis between 2018 and 2019 (aHR, 1.98; P = .025) versus <120 days had an increased risk of mortality. Early-stage patients with pathology diagnosis between 2016 and 2019 (odds ratio, 2.32; P = .043) versus before 2016 were more likely to experience delays ≥90 days, and late-stage patients who traveled >100 km to the treatment facility (odds ratio, 2.83; P < .001) versus <100 km were more likely to experience delays ≥120 days. CONCLUSIONS Delays in care are common in Botswana, particularly for those living farther from the treatment clinic and at advanced stages. This paper is among the first to show an association between treatment delays and worsened overall survival at advanced stages of cervical cancer, highlighting the need for interventions to help patients receive timely care in global settings.
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Affiliation(s)
- Jessica George
- Donald Bren School of Information and Computer Sciences, University of California, Irvine, Irvine, California
| | - Shawna Tuli
- Donald Bren School of Information and Computer Sciences, University of California, Irvine, Irvine, California
| | - Palak P Patel
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Barati Monare
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | | | - Lisa Bazzett-Matabele
- Department of Obstetrics & Gynecology, University of Botswana, Gaborone, Botswana; Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, Connecticut
| | | | | | | | - Peter Vuylsteke
- CHU Namur, Site Sainte-Elisabeth, UCLouvain, Namur, Belgium; Department of Internal Medicine, University of Botswana, Gaborone, Botswana
| | - Katharine A Rendle
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana; Department of Family Medicine & Community Health, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Surbhi Grover
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana; Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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Luckett R, Ramogola-Masire D, Harris DA, Gompers A, Gaborone K, Mochoba L, Ntshese L, Mathoma A, Kula M, Shapiro R, Larson E. Feasibility and acceptability of an HPV self-testing strategy: lessons from a research context to assess for ability to implement into primary care at a national level in Botswana. Front Glob Womens Health 2024; 4:1300788. [PMID: 38259634 PMCID: PMC10800890 DOI: 10.3389/fgwh.2023.1300788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 12/08/2023] [Indexed: 01/24/2024] Open
Abstract
Background The WHO strategy for cervical cancer elimination strives to achieve 70% coverage with high-performance cervical screening. While few low- and middle-income countries have achieved this, high-risk human papillomavirus (hrHPV) self-testing creates the possibility to rapidly upscale access to high-performance cervical screening across resource settings. However, effective hrHPV screening requires linkage to follow-up, which has been variable in prior studies. This study developed and tested an implementation strategy aimed at improving screening and linkage to follow-up care in South East District in Botswana. Methods This study performed primary hrHPV self-testing; those with positive results were referred for a triage visit. Withdrawals for any reason, loss-to follow-up between hrHPV test and triage visit, and number of call attempts to give hrHPV results were also documented. Acceptability of the program to patients was measured as the proportion of patients who completed a triage visit when indicated, meeting the a priori threshold of 80%. Feasibility was defined as the proportion of participants receiving the results and attending follow-up. To assess the associations between participant characteristics and loss-to-follow-up we used log-binomial regressions to estimate risk ratios and 95% confidence intervals (CI). Results Enrollment of 3,000 women occurred from February 2021 to August 2022. In total, 10 participants withdrew and an additional 33 were determined ineligible after consent, leaving a final cohort of 2,957 participants who underwent self-swab hrHPV testing. Half (50%) of participants tested positive for hrHPV and nearly all (98%) of participants received their hrHPV results, primarily via telephone. Few calls to participants were required to communicate results: 2,397 (82%) required one call, 386 (13%) required 2 calls, and only 151 (5%) required 3-5 calls. The median time from specimen collection to participant receiving results was 44 days (IQR, 27-65). Of all hrHPV positive participants, 1,328 (90%) attended a triage visit. Discussion In a large cohort we had low loss-to-follow-up of 10%, indicating that the strategy is acceptable. Telephonic results reporting was associated with high screening completion, required few calls to participants, and supports the feasibility of hrHPV self-testing in primary care followed by interval triage.
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Affiliation(s)
- Rebecca Luckett
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Botswana Harvard Health Partnership, Gaborone, Botswana
- Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, United States
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
- Department of Obstetrics and Gynaecology, University of Pretoria, Pretoria, South Africa
| | - Devon A. Harris
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, United States
| | - Annika Gompers
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | | | | | - Lapelo Ntshese
- Department of Obstetrics and Gynaecology, Bamalete Lutheran Hospital, Ramotswa, Botswana
| | - Anikie Mathoma
- Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
| | - Maduke Kula
- National Cervical Cancer Prevention Program, Ministry of Health and Wellness Botswana, Gaborone, Botswana
| | - Roger Shapiro
- Botswana Harvard Health Partnership, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Elysia Larson
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, United States
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5
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Bhatia R, Chen R, Monare B, Nsingo M, Ralefala T, Setlhako D, Martei Y, Ramogola-Masire D, Vuylsteke P, Ngwa W, Rendle K, Grover S. Trends in the Use of Hypofractionation in Treatment of Breast Cancer in Botswana. Int J Radiat Oncol Biol Phys 2023; 117:e568. [PMID: 37785735 DOI: 10.1016/j.ijrobp.2023.06.1894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Clinical trials have shown that moderate hypofractionation (HF) is clinically effective as adjuvant treatment to breast conserving surgery or following mastectomy with advanced disease. ASTRO issued updated guidelines in 2018, expanding the population eligible to receive HF to all patients, regardless of age and tumor stage. Use of HF can promote efficient resource utilization for over-burdened health care systems; however, global adoption of HF has been previously only reported via ESTRO survey of individual physicians. These data note that HF following lumpectomy is 40% in Africa vs. >90% in North America, with limited data on the uptake of HF within individual African countries. In this study, we characterize temporal trends and clinical, socio-demographic factors associated with the use of HF in breast cancer in Botswana. MATERIALS/METHODS We retrospectively analyzed a cohort of breast cancer patients receiving curative intent radiation between 2015 and 2022 at the only radiation clinic in Botswana. We compared patients' characteristics between those who received HF vs. standard fractionation (SF) and report chi-square statistics when appropriate. We fit a multilevel mixed-effects logistic regression model with a random intercept for district while adjusting for fixed effects such as HIV infection status, laterality, hormone receptor status, and marital status. RESULTS A total of 234 patients were prescribed curative intent radiation between 2015 and 2022 in Gaborone, Botswana. Median age at diagnosis was 51 years old, and the majority of patients presented with stage III disease (61.9%, 109/234). 26.9% of this population were women living with HIV (WLWH), and 71% lived >100km from the hospital. HF was utilized overall in 59.4% (139/234) of patients. Most common fractionation patterns included: 4005cGy/15fx and 4267cG/16fx. One patient received ultra-HF (2600cGy/5fx). In unadjusted chi-square analysis, a higher proportion of HF was seen in right vs left-sided breast cancer (65.8% vs. 50.9%, p = 0.02), increasing year of diagnosis from 2015 - 2022 (p<0.001), and among patients >/ = 40 years of age vs. those <40 years of age (62.8% vs 42.1%, p = 0.017). Temporal trends show a significant increase in the utilization of HF starting from 23.8% (5/21) in 2015, to 61.5% (32/52) in 2018, and finally 100% (11/11) of cases in 2022. Our regression analysis shows that there is no statistically significant between-district variance or patient-level factors that associate with the uptake of HF. The overall utilization rate for HF between 2015-2022 was 59.4% (95% CI: 53.0%-65.5%). CONCLUSION Based on recent survey results the uptake of HF among African countries is lower than that of North America. To our knowledge, this is the first quantitative analysis of the utilization of HF over 5 years in an African country. Further analysis on factors related to physician prescription of hypofractionation is warranted, including influence of breast laterality, age, and primary surgery type.
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Affiliation(s)
- R Bhatia
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - R Chen
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - B Monare
- Botswana -UPenn Partnership, Gaborone, Botswana
| | - M Nsingo
- Department of Oncology, Gaborone Private Hospital, Gaborone, Botswana
| | - T Ralefala
- Princess Marina Hospital, Gaborone, Botswana
| | - D Setlhako
- Princess Marina Hospital, Gaborone, Botswana
| | - Y Martei
- University of Pennsylvania, Philadelphia, PA
| | - D Ramogola-Masire
- Department of Obstetrics and Gynecology, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, PA
| | - P Vuylsteke
- Princess Marina Hospital, Gaborone, Botswana
| | - W Ngwa
- John Hopkins University Hospital, Baltimore, MD
| | - K Rendle
- Department of Family Medicine & Community Health & Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, PA
| | - S Grover
- Princess Marina Hospital, Gaborone, Botswana
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Bhatia R, Zhang S, Nsingo M, Chiyapo S, Balang D, Ralefala T, Zetola N, Ramogola-Masire D, Markovina S, Robertson ES, Grover S. SCCAg as a Biomarker of Advanced Stage and OS in Limited Resource Setting for Cervical Cancer. Int J Radiat Oncol Biol Phys 2023; 117:S80-S81. [PMID: 37784581 DOI: 10.1016/j.ijrobp.2023.06.399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Elevated serum squamous cell antigen (SCCAg) has been previously correlated with poor survival, extensive tumor involvement, and recurrence for cervical cancer. Failure of serum SCCAg to normalize after treatment completion has also been studied as a poor prognostic indicator. This is the first study describing the association of SCCAg with stage and outcomes in patients diagnosed with cervical cancer in Botswana, in a population with a majority of women who are living with HIV (WLWH). MATERIALS/METHODS Patients with histologically confirmed cervical cancer were enrolled in a prospective observational study between August 2016 and April 2020 in Botswana. Among all patients undergoing definitive chemoradiation, serum SCCAg was determined at pre-treatment baseline, end of treatment (EOT), and 3-month follow-up (normal reference range 0.3 -1.9 ng/ml). Normalization of SCCAg was defined as return to the reference range after treatment (SCCAg response), and was measured first at EOT; if EOT values were not available, 3-month values were utilized. Patients were staged according to FIGO 2009 criteria, early stage was defined as Stage I-II; while advanced stage was defined as Stage III-IV. Median follow-up was 44 months. A significant cut-off point for baseline and SCCAg response correlated with overall survival (OS) was calculated utilizing a log-rank test RESULTS: Among 234 patients who were diagnosed with histologically confirmed cervical cancer, 73.5% were WLWH (mean CD4 count 466 cells/mL). 92.9% of all cancers were squamous cell carcinoma. 68.8% of patients had elevated SCCAg at time of diagnosis. There was no significant difference in mean baseline SCCAg between WLWH (13.3 ng/mL) and women living without HIV (9.07 ng/mL), p = 0.1052. There was a significant difference seen in mean SCCAg between early (7.9 ng/mL ± SD 13.4) and advanced (18.9 ng/mL, ± SD 29.8) stage disease at diagnosis, p < 0.0001. Baseline SCCAg > 7.9 ng/mL was found to be associated with worse OS (p < 0.001). 5-year OS was significantly different among patients with SCCAg response < = 2.8 (5-year OS 66.2%), vs. SCCAg >2.8 ng/mL (5-year OS 42.4%). There was no significant difference in average SCCAg values between EOT (p = 0.68) and 3-month follow-up (p = 0.24). There was no difference in the proportion of patients who experienced normalized SCCAg by HIV status (p = 0.67). CONCLUSION There was no significant difference in SCCAg among WLWH and women living without HIV. Among patients with elevated SCCAg above normal at baseline, SCCAg was associated with early vs. advanced stage disease. Additionally, there was a significant difference seen in overall survival by two measurement points: baseline SCCAg >7.9 ng/mL and response SCCAg >2.8 ng/mL. SCCAg may be utilized as a biomarker in low-resource settings to refine prognosis. Further studies will be needed to determine utility and validation in predicting recurrence risk and/or lymph node metastases.
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Affiliation(s)
- R Bhatia
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - S Zhang
- Biostatistics Analysis Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - M Nsingo
- Department of Oncology, Gaborone Private Hospital, Gaborone, Botswana
| | - S Chiyapo
- Gaborone Private Hospital, Gaborone, Botswana
| | - D Balang
- Gaborone Private Hospital, Gaborone, Botswana
| | - T Ralefala
- Princess Marina Hospital, Gaborone, Botswana
| | - N Zetola
- School of Medicine, University of Botswana, Gaborone, Botswana; Augusta University School of Medicine, Augusta, GA
| | - D Ramogola-Masire
- Department of Obstetrics and Gynecology, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, PA
| | - S Markovina
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO
| | - E S Robertson
- Departments of Otorhinolaryngology-Head and Neck Surgery, and Microbiology, and the Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - S Grover
- Princess Marina Hospital, Gaborone, Botswana
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Grover S, MacDuffie E, Nsingo M, Lei X, Mehta P, Davey S, Urusaro S, Chiyapo S, Vuylsteke P, Monare B, Bazzett-Matabele L, Ralefala T, Luckett R, Ramogola-Masire D, Smith GL. Benchmarking of the Cervical Cancer Care Cascade and Survival Outcomes After Radiation Treatment in a Low- and Middle-Income Country Setting. JCO Glob Oncol 2023; 9:e2200397. [PMID: 37738538 PMCID: PMC10846778 DOI: 10.1200/go.22.00397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 04/13/2023] [Accepted: 07/28/2023] [Indexed: 09/24/2023] Open
Abstract
PURPOSE Timely radiation treatment (RT) is critical in cervical cancer treatment, but patients in low- and middle-income countries (LMICs) in sub-Saharan Africa often face barriers that delay care. Time to care was benchmarked in a multidisciplinary team (MDT) setting in Botswana. METHODS Time intervals between steps in care were recorded for 230 patients reviewed at MDT between January 2016 and July 2018. Associations between RT delay and overall survival (OS) were evaluated using Kaplan-Meier curves and multivariable Cox proportional hazards models. RESULTS For patients who received RT (n = 187; 81.3%), the median biopsy to pathology reporting interval was 25 (IQR, 19-36) days and was 57 (IQR, 28-68) days for patients who did not (P = .003). Intervals in care did not differ between patients who did and did not receive RT. Among treated patients, the uppermost quartile interval from pathology reporting to RT initiation was ≥111 days and that from RT simulation to initiation was ≥12 days. Among patients receiving a RT dose of ≥65 Gy (n = 100), the delay from RT simulation to initiation of >12 days was associated with worse median OS (2.0 v 4.6 years; P = .048); this association trended toward, although did not meet, statistical significance on multivariable analysis (hazard ratio, 2.35; 95% CI, 0.95 to 5.85; P = .07). CONCLUSION The MDT-coordinated care model allows for systematic benchmarking of the patient treatment cascade. Barriers to timely treatment exist for this cohort in Botswana, and RT delay may be associated with OS of patients receiving curative treatment. Interventions to accelerate the timing of the radiation oncology care cascade may improve clinical outcomes in this LMIC setting.
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Affiliation(s)
- Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
- Princess Marina Hospital, Gaborone, Botswana
- Botswana-UPenn Partnership, Gaborone, Botswana
- Department of Medicine, University of Botswana, Gaborone, Botswana
| | - Emily MacDuffie
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Memory Nsingo
- Department of Oncology, Gaborone Private Hospital, Gaborone, Botswana
| | - Xiudong Lei
- Department of Health Services Research, MD Anderson Cancer Center, Houston, TX
| | - Priyanka Mehta
- Department of Gynecology & Obstetrics, Emory University, Atlanta, GA
| | - Sonya Davey
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Sandra Urusaro
- Botswana-UPenn Partnership, Gaborone, Botswana
- School of Nursing, University of Pennsylvania, Philadelphia, PA
- Department of Global Health, University of Washington, Seattle, WA
| | | | - Peter Vuylsteke
- Department of Medicine, University of Botswana, Gaborone, Botswana
| | | | - Lisa Bazzett-Matabele
- Princess Marina Hospital, Gaborone, Botswana
- Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
- Department of Obstetrics and Gynecology, Yale University, New Haven, CT
| | | | - Rebecca Luckett
- Princess Marina Hospital, Gaborone, Botswana
- Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
- Department of Obstetrics and Gynecology, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, PA
| | - Grace L. Smith
- Department of Health Services Research, MD Anderson Cancer Center, Houston, TX
- Department of Gastrointestinal Radiation Oncology, MD Anderson Cancer Center, Houston, TX
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8
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Hofmeyr GJ, Black RE, Rogozińska E, Heuer A, Walker N, Ashorn P, Ashorn U, Bhandari N, Bhutta ZA, Koivu A, Kumar S, Lawn JE, Munjanja S, Näsänen-Gilmore P, Ramogola-Masire D, Temmerman M. Evidence-based antenatal interventions to reduce the incidence of small vulnerable newborns and their associated poor outcomes. Lancet 2023; 401:1733-1744. [PMID: 37167988 DOI: 10.1016/s0140-6736(23)00355-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/26/2023] [Accepted: 02/14/2023] [Indexed: 05/13/2023]
Abstract
A package of care for all pregnant women within eight scheduled antenatal care contacts is recommended by WHO. Some interventions for reducing and managing the outcomes for small vulnerable newborns (SVNs) exist within the WHO package and need to be more fully implemented, but additional effective measures are needed. We summarise evidence-based antenatal and intrapartum interventions (up to and including clamping the umbilical cord) to prevent vulnerable births or improve outcomes, informed by systematic reviews. We estimate, using the Lives Saved Tool, that eight proven preventive interventions (multiple micronutrient supplementation, balanced protein and energy supplementation, low-dose aspirin, progesterone provided vaginally, education for smoking cessation, malaria prevention, treatment of asymptomatic bacteriuria, and treatment of syphilis), if fully implemented in 81 low-income and middle-income countries, could prevent 5·202 million SVN births (sensitivity bounds 2·398-7·903) and 0·566 million stillbirths (0·208-0·754) per year. These interventions, along with two that can reduce the complications of preterm (<37 weeks' gestation) births (antenatal corticosteroids and delayed cord clamping), could avert 0·476 million neonatal deaths (0·181-0·676) per year. If further research substantiates the preventive effect of three additional interventions (supplementation with omega-3 fatty acids, calcium, and zinc) on SVN births, about 8·369 million SVN births (2·398-13·857) and 0·652 million neonatal deaths (0·181-0·917) could be avoided per year. Scaling up the eight proven interventions and two intrapartum interventions would cost about US$1·1 billion in 2030 and the potential interventions would cost an additional $3·0 billion. Implementation of antenatal care recommendations is urgent and should include all interventions that have proven effects on SVN babies, within the context of access to family planning services and addressing social determinants of health. Attaining high effective coverage with these interventions will be necessary to achieve global targets for the reduction of low birthweight births and neonatal mortality, and long-term benefits on growth and human capital.
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Affiliation(s)
- G Justus Hofmeyr
- Department of Obstetrics and Gynaecology, University of Botswana, Gaborone, Botswana; Effective Care Research Unit, University of the Witwatersrand, Johannesburg, South Africa; Department of Obstetrics and Gynaecology, Walter Sisulu University, East London, South Africa
| | - Robert E Black
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | | | - Austin Heuer
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Neff Walker
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Per Ashorn
- Center for Child, Adolescent, and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Ulla Ashorn
- Center for Child, Adolescent, and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Nita Bhandari
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Zulfiqar A Bhutta
- Centre of Excellence in Women and Child Health & Institute for Global Health & Development, Aga Khan University, Karachi, Pakistan; Centre for Child Global Health, Hospital for Sick Children, Toronto, ON, Canada
| | - Annariina Koivu
- Center for Child, Adolescent, and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | | | - Joy E Lawn
- MARCH Center, London School of Hygiene & Tropical Medicine, London, UK
| | - Stephen Munjanja
- Department of Obstetrics and Gynaecology, University of Zimbabwe, Harare, Zimbabwe
| | - Pieta Näsänen-Gilmore
- Center for Child, Adolescent, and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | | | - Marleen Temmerman
- Centre of Excellence in Women and Child Health-East Africa, Aga Khan University, Nairobi, Kenya
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9
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Grover S, Seckar T, Gao L, Bhatia R, Lin X, Zetola N, Ramogola-Masire D, Robertson E. Characterization of HPV subtypes in invasive cervical cancer in Botswana patients using a pan-pathogen microarray technology. Tumour Virus Res 2023; 15:200262. [PMID: 37209888 DOI: 10.1016/j.tvr.2023.200262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 03/21/2023] [Accepted: 05/10/2023] [Indexed: 05/22/2023] Open
Abstract
Human papillomavirus (HPV) plays a significant role in the development of cervical cancers in the setting of co-infection with HIV. Botswana has a high prevalence of HIV and cervical cancer. In this study, we investigated the distribution of HPV subtypes in cervical cancer biopsy samples from patients in Botswana using a highly sensitive pan-pathogen microarray technology, PathoChip, to detect both high- (HR-HPV) and low-risk HPV (LR-HPV) subtypes in women living with HIV (WLWH) and women living without HIV. We analyzed samples from 168 patients, of which 73% (n = 123) were WLWH with a median CD4 count of 479.5 cells/μL. Five HR-HPV subtypes were detected in the cohort: HPV 16, 18, 26, 34, and 53. The most prevalent subtypes were HPV 26 (96%) and HPV 34 (92%); 86% of WLWH (n = 106) had co-infection with four or more HR-HPV subtypes compared to 67% (n = 30) of women without HIV (p < 0.01). We detected 66 LR-HPV subtypes among all cervical cancer patients, with HPV 6b and 48 being most prevalent. Notably, signatures for LR-HPV subtypes 10, 41, 90, and 129 were only detected in WLWH. Signal intensity for HPV 18 was significantly weaker in WLWH with CD4 levels ≤200 cells/μL as compared to patients with >200 cells/μL and HIV-negative patients. Although the majority of cervical cancer specimens in this cohort were determined to have multiple HPV infections, the most prevalent HR-HPV subtypes (HPV 26 and HPV34) found in these cervical cancer samples are not covered in the current HPV vaccines. Though no conclusions can be made on the direct carcinogenicity of these subtypes the results do underlie the need for continued screening for prevention of cervical cancer.
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Affiliation(s)
- Surbhi Grover
- Department of Radiation Oncology, Perelman School of Medicine, USA.
| | - Tyler Seckar
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, USA
| | - Le Gao
- Department of Computer Sciences, New Jersey Institute of Technology, USA
| | - Rohini Bhatia
- Department of Radiation Oncology, Johns Hopkins School of Medicine, USA
| | - Xiang Lin
- Department of Computer Sciences, New Jersey Institute of Technology, USA
| | - Nicola Zetola
- Department of Pulmonary Medicine, Medical College of Georgia, USA
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, University of Botswana Medical School, South Africa
| | - Erle Robertson
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, USA
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10
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Moyo S, Ramogola-Masire D, Moraka NO, Tawe L, Noubary F, Motsumi K, Manowe G, Zuze B, Radibe B, Hungwe FTT, Mohammed T, Maphorisa C, Shapiro R, Gaseitsiwe S, Luckett R. Comparison of the AmpFire® Multiplex HPV Assay to the Xpert® HPV Assay for detection of human papillomavirus and cervical disease in women with human immunodeficiency virus: a pragmatic performance evaluation. Infect Agent Cancer 2023; 18:29. [PMID: 37165397 PMCID: PMC10170707 DOI: 10.1186/s13027-023-00504-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/14/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Low- and middle-income countries (LMICs) account for nearly 85% of the global cervical cancer burden, yet have the least access to high-performance screening. International guidelines recommend human papillomavirus testing (HPV) as primary screening, yet implementation is inhibited by the cost of HPV testing. Atila AmpFire® HPV Assay (AmpFire) is both affordable and easy to use, and offers individual genotyping. The objective of this study was to compare the performance of the AmpFire HPV assay to the Xpert® HPV assay in detection of both HPV and clinically significant cervical disease. METHODS We utilized stored cervical specimens from a prospective cohort study of women living with human immunodeficiency virus (HIV) in Botswana conducted from May to July 2018. Positive and negative percent agreement was calculated for the AmpFire and Xpert assays, as was detection of high-grade cervical dysplasia. RESULTS 63 stored cervical specimens had detectable DNA after thawing and were included in the analysis. The positive percent agreement was 91.2% (95%CI 76.3-98.1) and negative percent agreement was 79.3% (95% CI 60.3-92.0). Six cases positive by AmpFire but negative by Xpert were HPV genotypes 35, 52 (n = 2), 58, 68, and co-infection with HPV 45 and 68. Both Xpert and AmpFire assays detected HPV in all 10 samples of women who had high-grade cervical dysplasia. CONCLUSIONS The AmpFire HPV assay demonstrated excellent analytic performance in both detection of HPV and clinically significant cervical disease. AmpFire HPV is a promising option to increase access to affordable, type-specific HPV screening for cervical cancer in LMICs.
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Affiliation(s)
- Sikhulile Moyo
- Botswana Harvard Health Partnership, Gaborone, Botswana
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | | | - Leabaneng Tawe
- Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Farzad Noubary
- Department of Health Sciences, Northeastern University, Boston, MA, USA
| | | | | | | | | | - Faith T T Hungwe
- School of Engineering Sciences in Chemistry, Biotechnology and Health, KTH Royal Institute of Technology, Stockholm, Sweden
- Department of Molecular Medicine, Karolinska Institute, Stockholm, Sweden
- Department of Biochemistry and Chemistry, Stockholm University, Stockholm, Sweden
| | | | | | - Roger Shapiro
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Kirstein, 3Rd Floor, 330 Brookline Avenue, Boston, MA, 02215, USA
- Harvard Medical School, Boston, MA, USA
| | - Simani Gaseitsiwe
- Botswana Harvard Health Partnership, Gaborone, Botswana
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Rebecca Luckett
- Botswana Harvard Health Partnership, Gaborone, Botswana.
- Faculty of Medicine, University of Botswana, Gaborone, Botswana.
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Kirstein, 3Rd Floor, 330 Brookline Avenue, Boston, MA, 02215, USA.
- Harvard Medical School, Boston, MA, USA.
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11
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Moyo S, Ramogola-Masire D, Moraka N, Tawe L, Noubary F, Motsumi K, Manowe G, Zuze B, Radibe B, Hungwe FT, Mohammed T, Maphorisa C, Shapiro R, Gaseitsiwe S, Luckett R. Comparison of the AmpFire Multiplex HPV Assay to the Xpert HPV Assay for detection of human papillomavirus and cervical disease in women with human immunodeficiency virus: A pragmatic performance evaluation. Res Sq 2023:rs.3.rs-2606441. [PMID: 36909533 PMCID: PMC10002806 DOI: 10.21203/rs.3.rs-2606441/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Background: Low- and middle-income countries (LMICs) account for nearly 85% of the global cervical cancer burden, yet have the least access to high-performance screening. International guidelines recommend human papillomavirus testing (HPV) as primary screening, yet implementation is inhibited by the cost of HPV testing.Atila AmpFire HPV Assay (AmpFire) is both affordable and easy to use, and offers individual genotyping. The objective of this study was to compare the performance of the AmpFire HPV assay to the Xpert HPV assay in detection of both HPV and clinically significant cervical disease. Methods: We utilized stored cervical specimens from a prospective cohortstudy of women living with human immunodeficiency virus (HIV) in Botswana conducted from May to July 2018. Positive and negative percent agreement was calculated for the AmpFire and Xpert assays, as was detection of high-grade cervical dysplasia. Results : 63 stored cervical specimens haddetectable DNA after thawing and were included in the analysis. The positive percent agreement was 91.2% (95%CI: 76.3-98.1) and negative percent agreement was 79.3% (95% CI: 60.3-92.0). Six cases positive by AmpFire but negative by Xpert were HPV genotypes 35, 52 (n=2), 58, 68, and co-infection with HPV 45 and 68. Both Xpert and AmpFire assays detected HPV in all 10 samples of women who had high-grade cervical dysplasia. Conclusions : The AmpFire HPV assay demonstrated excellent analytic performance in both detection of HPV and clinically significant cervical disease. AmpFire HPV is a promising option to increase access to affordable, type-specific HPV screening for cervical cancer in LMICs.
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12
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Koobotse MO, Zachariah M, Senabye B, Gobe I, Kadimo K, Nthontho KC, Mokomane M, Koto G, Phuthego T, Lekgetho H, Ndlovu A, Motswaledi M, Mbwinja A, Tawe L, Ramatlho P, Paganotti GM, Kyokunda L, Vuylsteke P, Grover S, Ramogola-Masire D, Kasvosve I. Bibliometric analysis of cancer research outputs in Botswana between 2009 and 2021. J Cancer Policy 2023; 35:100405. [PMID: 36690157 PMCID: PMC10066854 DOI: 10.1016/j.jcpo.2023.100405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 01/13/2023] [Accepted: 01/19/2023] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Cancer research is critical for cancer control policies; however, the state of cancer research activities in Botswana is largely unknown. The goal of this review was to describe trends and patterns of cancer research outputs in Botswana. METHODS PubMed, Web of Science, EBSCOhost, African Journals Online, and African Index Medicus databases were systematically searched for peer-reviewed, primary cancer-related research articles published on the Botswana population or by Botswana institutions between January 2009 and June 2021. RESULTS Of the 86 publications included, 39 (45 %) were about cervical cancer, followed by breast cancer (10 %) and Kaposi sarcoma (7 %). The remainder (27 %) were not focused on any specific cancer type. The research activities were skewed towards three main areas of scientific interest: early detection, diagnosis, and prognosis; cancer control, survivorship, and outcomes; and treatment. Botswana was represented by authors in the first (54 %), last (53 %), and any authorship (53 %) positions. The United States of America had the strongest collaborative partnerships with Botswana, followed by the United Kingdom and South Africa. The majority of funding institutions were American (76 %) and the National Institutes of Health was the most mentioned funding organization, accounting for 33 % of all financial acknowledgments. Only 9 % of the funding acknowledgments came from Botswana. CONCLUSION AND POLICY SUMMARY Although cancer research in Botswana is expanding because of substantial foreign assistance, it is also hampered by a lack of local funding, minimal participation by Botswana-affiliated researchers, and research that is not aligned with disease burden. Our study highlights the need to strengthen local research capacity in Botswana.
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Affiliation(s)
- Moses O Koobotse
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana.
| | - Matshediso Zachariah
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
| | - Bonolo Senabye
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
| | - Irene Gobe
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
| | - Khutsafalo Kadimo
- Department of Library Services, University of Botswana, Gaborone, Botswana
| | - Keneuoe C Nthontho
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana; Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | - Margaret Mokomane
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
| | - Garesego Koto
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
| | - Thato Phuthego
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
| | - Henry Lekgetho
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
| | - Andrew Ndlovu
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
| | - Modisa Motswaledi
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
| | - Alfred Mbwinja
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
| | - Leabaneng Tawe
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana; Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | - Pleasure Ramatlho
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana; Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | - Giacomo M Paganotti
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana; Department of Biomedical Sciences, Faculty of Medicine, University of Botswana, Gaborone, Botswana; Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lynnete Kyokunda
- Department of Pathology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Peter Vuylsteke
- Department of Internal Medicine, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Surbhi Grover
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana; Department of Radiation Oncology, University of Pennsylvania, PA, USA
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana; Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | - Ishmael Kasvosve
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
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13
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Hammad N, Ndlovu N, Carson LM, Ramogola-Masire D, Mallick I, Berry S, Olapade-Olaopa EO. Competency-Based Workforce Development and Education in Global Oncology. Curr Oncol 2023; 30:1760-1775. [PMID: 36826097 PMCID: PMC9955139 DOI: 10.3390/curroncol30020136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/14/2023] [Accepted: 01/29/2023] [Indexed: 02/05/2023] Open
Abstract
The healthcare workforce plays a pivotal role in cancer care delivery, leadership, policy, education, and research in complex cancer systems. To ensure quality and relevance, health professionals must have the necessary competencies to deliver patient-centered and efficient care, coupled with the ability to work in teams and manage health resources wisely. This paper aims to review the concept of competency-based medical education (CBME) in the context of oncology to provide insights and guidance for those interested in adopting or adapting competency-based education in training programs. The results of a scoping review of CBME in oncology are presented here to describe the current status of CBME in oncology. The literature describing the implementation and evaluation of CBME in oncology training programs for medical professionals internationally is summarized and key themes identified to provide practical guidance for educators. Further, the paper identifies critical competencies for oncology education and training globally and presents recommendations and opportunities for collaboration in competency-based education and training in oncology. The authors argue for increased global collaboration and networking in the realm of CBME to facilitate the establishment of a competent global cancer care workforce.
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Affiliation(s)
- Nazik Hammad
- Department of Oncology, Queen’s University, Kingston, ON K7L 3N6, Canada
- Correspondence:
| | - Ntokozo Ndlovu
- Department of Oncology, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare P.O. Box MP 167, Zimbabwe
- Division of Radiotherapy and Oncology, Parirenyatwa Group of Hospitals, Harare P.O. Box CY 198, Zimbabwe
| | - Laura Mae Carson
- Department of Oncology, Queen’s University, Kingston, ON K7L 3N6, Canada
| | - Doreen Ramogola-Masire
- Department of ObGYN, Faculty of Medicine, University of Botswana, Private Bag UB 0022, Gaborone, Botswana
| | - Indranil Mallick
- Department of Radiation Oncology, Tata Medical Center, Kolkata 700 160, West Bengal, India
| | - Scott Berry
- Department of Oncology, Queen’s University, Kingston, ON K7L 3N6, Canada
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14
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Grover S, Bhatia R, Friebel-Klingner TM, Mathoma A, Vuylsteke P, Khan S, Ralefala T, Tawe L, Bazzett-Matabele L, Monare B, Luckett R, Ramogola-Masire D. Cervical cancer screening in HIV-endemic countries: An urgent call for guideline change. Cancer Treat Res Commun 2023; 34:100682. [PMID: 36682141 PMCID: PMC9999385 DOI: 10.1016/j.ctarc.2023.100682] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 12/29/2022] [Accepted: 01/09/2023] [Indexed: 01/14/2023]
Abstract
Women living with HIV (WLWH) are at an increased risk of developing HPV-related high grade cervical dysplasia and cervical cancer. Prior World Health Organization (WHO) screening guidelines recommended starting screening at age 30. We assessed characteristics of women diagnosed with cervical cancer to further inform and refine screening guidelines. We prospectively enrolled women diagnosed with cervical cancer from January 2015 to March 2020 at two tertiary hospitals in Gaborone, Botswana. We performed chi-square and ANOVA analyses to evaluate the association between age upon diagnosis and HIV status, CD4 count, viral load, and other sociodemographic and clinical factors. Data were available for 1130 women who were diagnosed with cervical cancer and 69.3% were WLWH. The median age overall was 47.9 (IQR 41.2-59.1), 44.6 IQR: 39.8 - 50.9) among WLWH, and 61.2 (IQR 48.6-69.3) among women living without HIV. There were 1.3% of women aged <30 years old, 19.1% were 30-39 and 37.2% were 40-49. Overall, 20.4% (n = 231) of cancers were in women <40 years. Age of cervical cancer diagnosis is younger in countries with higher HIV prevalence, like Botswana. Approximately 20% of the patients presented with cancer at <40 years of age and would have likely benefited from screening 10 years prior to cancer diagnosis to provide an opportunity for detection and treatment of pre-invasive disease.
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Affiliation(s)
- Surbhi Grover
- Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Rohini Bhatia
- Johns Hopkins University, Department of Radiation Oncology and Molecular Sciences, Baltimore, MD,USA
| | - Tara M Friebel-Klingner
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD,USA
| | - Anikie Mathoma
- Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Peter Vuylsteke
- Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Salman Khan
- Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tlotlo Ralefala
- Department of Oncology, Princess Marina Hospital,Gaborone, Botswana
| | | | - Lisa Bazzett-Matabele
- Department of Obstetrics & Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana; Department of Obstetrics & Gynecology, Yale University School of Medicine, New Haven, CT, United States of America
| | | | - Rebecca Luckett
- Department of Obstetrics & Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana; Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Doreen Ramogola-Masire
- Department of Obstetrics & Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
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15
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Tawe L, Ramatlho P, Ketlametswe R, Koobotse M, Robertson ES, Grover S, Ramogola-Masire D, Paganotti GM. Cervical human papillomavirus genotypes in a high HIV setting: A scoping review of a decade of human papillomavirus epidemiological research in Botswana. Front Med (Lausanne) 2022; 9:1020760. [PMID: 36507502 PMCID: PMC9729273 DOI: 10.3389/fmed.2022.1020760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 11/09/2022] [Indexed: 11/25/2022] Open
Abstract
Cervical cancer burden is still high in low- and middle-income countries, including Botswana. Persistent human papillomavirus (HPV) infection is the leading cause of cervical cancer. Accurate knowledge of HPV diversity associated to cervical cancer in sub-Saharan Africa may provide accurate understanding of the natural history of HPV infection in these contexts. The goal of this review was to consolidate existing evidence on cervical HPV infection and to conduct a pooled analysis of data from all eligible Botswana studies. After a successful review of twelve studies on cervical HPV genotypes that met the inclusion criteria, HPV-16 genotype was the most frequently discovered in women with pre-cancerous and cancer lesions, followed by HPV-18. HPV-16 in HIV-positive women with precancerous lesions to cancer is between 45% and 47.7%, and between 4.5% and 26.1% for HPV-18. With reference to other HPV genotypes, the proportion of HPV-35 and HPV-58 (13-16%) seems relatively consistent among the studies, however HPV-58 appears to be more common in HIV-positive subjects compared to HIV-negative women. Indeed, HPV-45 seems to be frequently detected in women with cervical cancer compared to women with precancerous lesions. Regarding the low-risk HPV genotypes, an appropriate breakdown has been provided. In conclusion, the current prophylactic vaccines against HPV-16 and HPV-18, which have demonstrated good immunogenicity in HIV-infected populations, may still prevent infection and ultimately cancer.
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Affiliation(s)
- Leabaneng Tawe
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana,Office of Research and Graduate Studies, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Pleasure Ramatlho
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana,School of Allied Health Professions, University of Botswana, Gaborone, Botswana
| | | | - Moses Koobotse
- School of Allied Health Professions, University of Botswana, Gaborone, Botswana
| | - Erle S. Robertson
- Department of Otorhinolaryngology - Head and Neck Surgery, The Tumor Virology Program, Abramson Comprehensive Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Surbhi Grover
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana,Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Doreen Ramogola-Masire
- Office of Research and Graduate Studies, Faculty of Medicine, University of Botswana, Gaborone, Botswana,Department of Obstetrics and Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Giacomo M. Paganotti
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana,Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States,Department of Biomedical Sciences, Faculty of Medicine, University of Botswana, Gaborone, Botswana,*Correspondence: Giacomo M. Paganotti,
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16
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Friebel-Klingner TM, Bazzett-Matabele L, Ramogola-Masire D, Monare B, Ralefala TB, Seiphetlheng A, Ramontshonyana G, Vuylsteke P, Mitra N, Wiebe DJ, Rebbeck TR, McCarthy AM, Grover S. Distance to Multidisciplinary Team Clinic in Gaborone, Botswana, and Stage at Cervical Cancer Presentation for Women Living With and Without HIV. JCO Glob Oncol 2022; 8:e2200183. [PMID: 36395437 PMCID: PMC10166426 DOI: 10.1200/go.22.00183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/20/2022] [Accepted: 09/16/2022] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Cervical cancer is the leading cause of cancer death for women in Botswana. Barriers in access to cancer care can lead to later stages at diagnosis and increased mortality. This study evaluated access, defined as travel time from a patient's residential village to a multidisciplinary team clinic in Gaborone, with stage of cervical cancer at presentation. In addition, because of the high HIV prevalence in Botswana, we explored the association between travel time and HIV status. METHODS Eligible patients with cervical cancer presenting to the multidisciplinary team between 2015 and 2020 were included. Data were abstracted from questionnaires and hospital records. Google Maps was used to calculate travel time. Multinomial regression was used to examine travel time and cancer stage, and multivariable logistic regression was used to investigate travel time and HIV status. RESULTS We identified 959 patients with cervical cancer of which 70.1% were women living with HIV. The median travel time was approximately 2 hours. Using a reference group of stage I disease and a travel time of < 1 hour, the odds of presenting with stage II increased for patients traveling 3-5 hours (adjusted odds ratio [OR], 2.00; 95% CI, 1.14 to 3.52) and > 5 hours (OR, 2.19; 95% CI, 1.15 to 4.19). There were no significant associations for stage III. For stage IV disease, the odds were increased for patients traveling 3-5 hours (OR, 2.93; 95% CI, 1.26 to 6.79) and > 5 hours (adjusted OR, 4.05; 95% CI, 1.62 to 10.10). In addition, the odds of patients presenting living with HIV increased with increasing travel time (trend test = 0.004). CONCLUSION This study identified two potential factors, travel time and HIV status, that influence access to comprehensive cervical cancer care in Botswana.
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Affiliation(s)
- Tara M. Friebel-Klingner
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | - Lisa Bazzett-Matabele
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
- Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, CT
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Barati Monare
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | | | | | | | | | - Nandita Mitra
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Douglas J. Wiebe
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | - Timothy R. Rebbeck
- Dana-Farber Cancer Institute and Harvard TH Chan School of Public Health, Boston, MA
| | - Anne Marie McCarthy
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Surbhi Grover
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
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17
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Friebel-Klingner TM, Iyer HS, Ramogola-Masire D, Bazzett-Matabele L, Monare B, Seiphetlheng A, Ralefala TB, Mitra N, Wiebe DJ, Rebbeck TR, Grover S, McCarthy AM. Evaluating the geographic distribution of cervical cancer patients presenting to a multidisciplinary gynecologic oncology clinic in Gaborone, Botswana. PLoS One 2022; 17:e0271679. [PMID: 35925976 PMCID: PMC9352107 DOI: 10.1371/journal.pone.0271679] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 07/29/2021] [Accepted: 07/05/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE In Botswana, cervical cancer is the leading cause of cancer death for females. With limited resources, Botswana is challenged to ensure equitable access to advanced cancer care. Botswana's capital city, Gaborone, houses the only gynecologic oncology multi-disciplinary team (MDT) and the one chemoradiation facility in the country. We aimed to identify areas where fewer women were presenting to the MDT clinic for care. METHODS This cross-sectional study examined cervical cancer patients presenting to the MDT clinic between January 2015 and March 2020. Patients were geocoded to residential sub-districts to estimate age-standardized presentation rates. Global Moran's I and Anselin Local Moran's I tested the null hypothesis that presentation rates occurred randomly in Botswana. Community- and individual-level factors of patients living in sub-districts identified with higher (HH) and lower (LL) clusters of presentation rates were examined using ordinary least squares with a spatial weights matrix and multivariable logistic regression, respectively, with α level 0.05. RESULTS We studied 990 patients aged 22-95 (mean: 50.6). Presentation rates were found to be geographically clustered across the country (p = 0.01). Five sub-districts were identified as clusters, two high (HH) sub-district clusters and three low (LL) sub-district clusters (mean presentation rate: 35.5 and 11.3, respectively). Presentation rates decreased with increased travel distance (p = 0.033). Patients residing in LL sub-districts more often reported abnormal vaginal bleeding (aOR: 5.62, 95% CI: 1.31-24.15) compared to patients not residing in LL sub-districts. Patients in HH sub-districts were less likely to be living with HIV (aOR: 0.59; 95% CI: 0.38-0.90) and more likely to present with late-stage cancer (aOR: 1.78; 95%CI: 1.20-2.63) compared to patients not in HH sub-districts. CONCLUSIONS This study identified geographic clustering of cervical cancer patients presenting for care in Botswana and highlighted sub-districts with disproportionately lower presentation rates. Identified community- and individual level-factors associated with low presentation rates can inform strategies aimed at improving equitable access to cervical cancer care.
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Affiliation(s)
- Tara M. Friebel-Klingner
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | - Hari S. Iyer
- Dana-Farber Cancer Institute and Harvard TH Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
- Department of Obstetrics and Gynecology, Yale University, New Haven, Connecticut, United States of America
| | - Lisa Bazzett-Matabele
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
- Department of Obstetrics and Gynecology, Yale University, New Haven, Connecticut, United States of America
| | - Barati Monare
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | | | | | - Nandita Mitra
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Douglas J. Wiebe
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | - Timothy R. Rebbeck
- Dana-Farber Cancer Institute and Harvard TH Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Surbhi Grover
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Anne Marie McCarthy
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
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18
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Grover S, Luckett R, Bhatia RK, Ralefala T, Seiphetlheng A, Ramogola-Masire D, Monare B, Bazzett-Matabele L, Schmeler K, Gaolebale PA. Neoadjuvant chemotherapy and less invasive surgery for the management of early stage cervical cancer: A brief report from Botswana. Gynecol Oncol Rep 2022; 42:101032. [PMID: 35782102 PMCID: PMC9240358 DOI: 10.1016/j.gore.2022.101032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/05/2022] [Accepted: 06/08/2022] [Indexed: 02/04/2023] Open
Abstract
The majority of deaths from cervical cancer occur in low- and middle- income countries (LMICs). The standard of care for early-stage cervical cancer (FIGO 2018 IA2-IB1) is radical hysterectomy, a procedure performed by trained gynecologic oncologists. However, the lack of gynecologic oncologists in LMICs has required exploration into other methods of treatment for early-stage cervical cancer. A potential course of treatment for early-stage cervical cancer is neoadjuvant chemotherapy followed by simple hysterectomy and pelvic lymph node sampling, which can be performed by a general gynecologist. We gathered data for 8 women who underwent this method of treatment and found that cause-specific survival was 100% over a 3.5-year median follow-up. These findings support the exploration for this method of treatment for early-stage cervical cancer in LMICs, which would improve access to treatment for these women and hopefully reduce the high burden of cervical cancer related deaths in LMICs.
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Affiliation(s)
- Surbhi Grover
- Department of Radiation Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, University of Botswana, Gaborone, Botswana
- Corresponding author at: Department of Radiation Oncology, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia 19104, PA, USA.
| | - Rebecca Luckett
- Beth Israel Deaconess Medical Center, Boston, MA, USA
- Botswana Harvard AIDS Partnership, Gaborone, Botswana and Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
| | - Rohini K. Bhatia
- Johns Hopkins University, Department of Radiation Oncology, Baltimore, MD, USA
| | - Tlotlo Ralefala
- Department of Oncology, Princess Marina Hospital, Gaborone, Botswana
| | | | - Doreen Ramogola-Masire
- University of Botswana, Gaborone, Botswana, Department of Obstetrics and Gynecology, Botswana
| | | | - Lisa Bazzett-Matabele
- University of Botswana, Gaborone, Botswana, Department of Obstetrics and Gynecology, Botswana
- Yale University School of Medicine, Department of Obstetrics and Gynecology, New Haven, CT, USA
| | - Kathleen Schmeler
- The University of Texas MD Anderson Cancer Center, Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, Houston, TX, USA
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19
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Rendle KA, Friebel-Klingner T, Puri PM, Gopakumar GM, Monare B, Ralefala T, Luckett R, Ramogola-Masire D, Bazzett-Matabele L, Vuylsteke P, Grover S. Impact of the COVID-19 pandemic on cervical cancer diagnosis and treatment in Botswana. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e17518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e17518 Background: The COVID-19 pandemic rapidly altered cancer care delivery globally, providing a compelling opportunity to empirically study how these changes impacted persistent disparities in care. Cervical cancer is one of the most common female cancers worldwide, with approximately 90% of cases and deaths occurring in low- and middle-income countries (LMICs). In Botswana, a LMIC with a particularly high prevalence of HIV and cervical cancer, delays in cervical cancer diagnosis and treatment have been documented but is unknown how these delays may have been mitigated or exacerbated since the pandemic. Methods: The objective of this analysis is to evaluate patterns of cervical cancer diagnosis and treatment initiation before (January 2015-March 2020) and during the pandemic (April 2020-July 2021) using longitudinal clinical and patient-reported data from a cohort of over 1,000 patients receiving care for gynecologic cancers in Botswana. The primary outcome is timeliness of treatment defined by the number of days between first clinical visit and initiation of first-line treatment and categorized dichotomously (> 30 days classified as delay). Primary exposure is the time period (pre-pandemic and pandemic) defined by the month of first visit. We calculated unadjusted proportion of delays and covariates stratified by time period and used bivariate analysis to examine factors associated with each time period. We used multivariable logistic regression models to examine the association between delay and time period, adjusting for all covariates (age, stage, HIV status, rurality, screening history, and partner status). Results are presented as unadjusted proportions, adjusted odds ratios (AOR), and 95% confidence intervals. Results: Of the 1,200 patients treated for cervical cancer at the multidisciplinary clinic, 990 (82.5%) were diagnosed pre-pandemic and 210 (17.5%) during the pandemic. Among all patients with gynecologic cancers (n = 1,568), the proportion of patients with cervical cancer significantly decreased from 78.6% pre-pandemic to 68.0% during the pandemic (p < 0.001). In comparison to pre-pandemic, patients with cervical cancer during the pandemic were significantly less likely to have attended a screening clinic prior to their treatment (57.6% vs 15.3%; p < 0.001) and significantly more likely to experience treatment delays (61.6% vs 92.9%; p < 0.001). In the multivariable model, patients diagnosed during the pandemic had a 7-fold higher likelihood of treatment delays than those patients diagnosed pre-pandemic (AOR: 7.95; 95% CI: 4.45-14.19). Conclusions: The pandemic significantly increased delays in treatment for nearly all patients with cervical cancer in Botswana. Given persistent global disparities in cervical cancer, there is a great need to implement evidence-based strategies for improving screening and timeliness of care in Botswana and other LMICs.
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20
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Mutebi MC, Aryeetey NA, Carson LM, Mwanzi SA, Lombe DC, Woldetsadik ES, Msadabwe SC, Lasebikan N, Mohamed Z, Ramogola-Masire D, Alemu HK, Jalink M, Jagsi R, Vanderpuye VD, Hammad N. Challenges faced by female oncologists in sub-Saharan Africa. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.11001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
11001 Background: Recent articles by ASCO and ESMO have identified challenges facing female oncologists in western contexts. The challenges female oncologists face in sub-Saharan Africa (SSA) have yet to be explored. This study was launched by the AORTIC Education and Training Committee to determine the most common and substantial challenges faced by female oncologists in SSA and identify potential solutions. Methods: A diverse panel of 32 female oncologists from 20 countries in SSA was recruited through professional and personal networks. Following an initial meeting to review terminology, a modified three-round Delphi process took place. Participants iteratively reviewed a list of previously identified challenges facing women in oncology in SSA and identified new challenges. The survey was conducted via REDCap, a secure-web-based software platform. Participants reflected on personal experiences or those of colleagues, and were asked to indicate their agreement with each listed challenge, as well as propose solutions. Descriptive statistics identified the most common challenges. Following the third survey, a focus group was held to enrich study data. A thematic analysis is being conducted on the focus group transcript to identify key themes, and a subsequent modified Delphi process is being executed to build consensus around potential solutions to identified challenges. Results: Response rates for the 3 modified Delphi rounds were 66%, 66%, and 53%. The challenge with the greatest agreement was, “pressure to maintain a work-family life balance and meet social obligations”. These were felt to be unique to women in SSA due to an extended family network with several responsibilities beyond the nuclear family. The next two top-scored challenges were “lack of female support and networks”, and “micro-aggressions” (Table). Conclusions: Female oncologists in SSA experience many of the challenges that have been previously identified by similar studies in other regions, with different degrees of perceived importance. Some challenges have a different lived experience for female oncologists in SSA. The second part of this study will include thematic analysis of the recent focus group and explore potential solutions to mitigate these challenges, which will add insight and potential paths forward to optimizing a diverse workforce in SSA.[Table: see text]
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Affiliation(s)
| | | | | | | | | | | | | | - Nwamaka Lasebikan
- Department of Radiation Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | | | | | | | | | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | | | - Nazik Hammad
- Department of Oncology, Cancer Center of Southeastern Ontario, Queen's University, Kingston, ON, Canada
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21
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Rendle KA, Ramogola-Masire D, Monare B, Ogden SN, Toneff HK, Saia CA, Wainwright JV, Friebel-Klingner TM, Bazzett-Matabele L, Bhatia R, Bonner N, Ralefala TB, Vuylsteke P, Luckett R, Grover S. Patient perspectives on delays in cervical cancer screening and follow-up care in Botswana: a mixed methods study. BMC Womens Health 2022; 22:195. [PMID: 35643491 PMCID: PMC9148477 DOI: 10.1186/s12905-022-01777-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/19/2022] [Indexed: 11/10/2022] Open
Abstract
Background Delays in screening and timely diagnosis contribute significantly to global disparities in cervical cancer mortality in Botswana and other low- and middle-income countries, particularly those with high rates of HIV. Little is known about the modifiable factors shaping these delays from the perspectives of women themselves and how these perspectives may differ between those living with and without HIV. Methods From March–May 2019, we conducted a concurrent, mixed methods study of women receiving treatment for cervical cancer at a multidisciplinary oncology clinic in Botswana. Enrolled participants completed a one-time, concurrent semi-structured interview and structured questionnaire assessing patient characteristics, screening and HIV-related beliefs and knowledge, and barriers and facilitators to screening and follow-up care. Qualitative data were analyzed using directed content analysis guided by the Model of Pathways to Treatment and triangulated with quantitative questionnaire data to identify areas of convergence and divergence. Fisher’s exact tests were used to explore associations between questionnaire data (e.g., screening knowledge) and HIV status. Results Forty-two women enrolled in the study, 64% of whom were living with HIV and 26% were diagnosed with stage III cervical cancer. Median age was 45 years (IQR 54–67) in those living with HIV and 64 years (IQR 42–53) in those living without. Overall screening rates before symptomatic disease were low (24%). Median time from most proximal screen to diagnosis was 52 median days (IQR 15–176), with no significant differences by HIV status. General screening knowledge was higher among those living with HIV versus those without (100% vs 73%; p < 0.05), but knowledge about HPV and other risk factors was low in both groups. Similar to questionnaire results, qualitative results indicate limited awareness of the need to be screened prior to symptoms as a central barrier to timely screening. Some participants also noted that delays in the receipt of screening results and fear also contributed to treatment delays. However, many participants also described myriad sources of social and tangible support that helped them to overcome some of these challenges. Conclusion Interventions focused on increasing routine screening and supporting timely awareness and access to care are needed to reduce global disparities in cervical cancer.
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Affiliation(s)
- Katharine A Rendle
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology and Office of Research and Graduate Studies, University of Botswana, Gaborone, Botswana
| | - Barati Monare
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | - Shannon N Ogden
- Department of Health Law, Policy, and Management, Boston University, Boston, MA, USA
| | - Hannah K Toneff
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, PA, USA
| | - Chelsea A Saia
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, PA, USA
| | - Jocelyn V Wainwright
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, PA, USA
| | - Tara M Friebel-Klingner
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Rohini Bhatia
- Department of Radiation Oncology and Molecular Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Tlotlo B Ralefala
- Department of Oncology, Princess Marina Hospital, Gaborone, Botswana
| | - Peter Vuylsteke
- Department of Internal Medicine, University of Botswana, Gaborone, Botswana
| | - Rebecca Luckett
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana.,Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA.
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22
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Ramatlho P, Grover S, Mathoma A, Tawe L, Matlhagela K, Ngoni K, Molebatsi K, Chilisa B, Zetola NM, Robertson ES, Paganotti GM, Ramogola-Masire D. Human papillomavirus prevalence among unvaccinated young female college students in Botswana: A cross-sectional study. S Afr Med J 2022; 112:335-340. [PMID: 35587246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Human papillomavirus (HPV) is a sexually transmitted infection and a causative agent of cervical cancer. It is common in adolescent girls and young women, and the majority of infections are transient and asymptomatic. In Botswana, there are currently no data on the HPV prevalence against which the impact of prophylactic HPV vaccines can be measured. OBJECTIVES To establish a baseline HPV prevalence in an unvaccinated cohort of young women. METHODS Women aged ≥18 years were recruited from the University of Botswana between September 2016 and May 2020. Demographic and behavioural characteristics of participants were collected. Subsequently, cervicovaginal swabs were obtained and tested for HPV using polymerase chain reaction-restriction fragment length polymorphism. We determined the prevalent HPV types, and evaluated the risk factors associated with HPV positivity. RESULTS A total of 978 young women were recruited. Overall, there were 589 (60.2%) participants with HPV infection and 12 (1.2%) with HIV. The median (interquartile range) age of the study participants was 19 (18 - 20) years. Multivariate logistic regression analysis showed that significant factors associated with HPV positivity were sexual activity (adjusted odds ratio (aOR) 2.06; 95% confidence interval (CI) 1.49 - 2.63; p<0.001), number of sex partners ≥3 (aOR 2.10; 95% CI 1.39 - 3.18; p<0.001), and smoking (aOR 2.00; 95% CI 1.26 - 3.20; p=0.004). CONCLUSION Our results demonstrate for the first time the prevalence of HPV in unvaccinated young women in Botswana. We found a high prevalence of HPV infection, with statistical differences with different risk factors. This finding supports the need for HPV vaccination strategies for females prior to sexual debut to reduce the future burden of cervical cancer in Botswana.
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Affiliation(s)
- P Ramatlho
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana; Botswana-University of Pennsylvania Partnership, Gaborone, Botswana.
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23
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Ramogola-Masire D, McClung N, Mathoma A, Gargano JW, Nyepetsi NG, Querec TD, Onyekwuluje J, Mine M, Morroni C, Luckett R, Markowitz LE. Human papillomavirus prevalence in male and female university students in Gaborone, Botswana. Epidemiol Infect 2022; 150:1-25. [PMID: 35382907 PMCID: PMC9102060 DOI: 10.1017/s0950268822000619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 02/13/2022] [Accepted: 03/13/2022] [Indexed: 11/29/2022] Open
Abstract
In 2015, Botswana introduced the quadrivalent human papillomavirus (HPV) vaccine as a two-dose schedule in girls aged 9–13 years. We sought to establish a baseline HPV prevalence in unvaccinated young adults in Botswana. HIV-uninfected men and women aged 18–22 years were recruited from the University of Botswana in Gaborone during October 2019–February 2021. Demographic and behavioural characteristics were self-reported during structured interviews. Self-collected vaginal and penile swabs were tested for 28 HPV types using Seegene Anyplex II HPV28. We compared any HPV type, quadrivalent vaccine (HPV 6, 11, 16, 18)-type and non-quadrivalent vaccine-type prevalence in men and women and evaluated the risk factors for prevalence of any HPV type. A total of 493 men and 500 women were included in the analysis. Compared to men, women had higher prevalence of any HPV type (63.0% versus 31.4%, P < 0.001), vaccine-type HPV (21% versus 9.7%, P < 0.001) and non-vaccine-type HPV (60.4% versus 28.4%, P < 0.001). Higher prevalence of any HPV type in men and women was associated with having ≥2 sex partners in the past 12 months; always using condoms in the past 3 months was associated with a lower HPV prevalence. These data provide baseline information for future evaluation of the population impact of the HPV vaccination programme, including potential herd effects in men.
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Affiliation(s)
- Doreen Ramogola-Masire
- Faculty of Medicine, Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
| | - Nancy McClung
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Anikie Mathoma
- Faculty of Medicine, Office of Research and Graduate Studies, University of Botswana, Gaborone, Botswana
| | - Julia W. Gargano
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Naledi Gape Nyepetsi
- Faculty of Medicine, Office of Research and Graduate Studies, University of Botswana, Gaborone, Botswana
- Botswana-University of Maryland School of Medicine, BUMMHI, Gaborone, Botswana
| | - Troy D. Querec
- National Center for Emerging, Zoonotic, and Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Juanita Onyekwuluje
- National Center for Emerging, Zoonotic, and Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Madisa Mine
- National Health Laboratory, Botswana Ministry of Health and Wellness, Gaborone, Botswana
| | - Chelsea Morroni
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, Scotland
| | - Rebecca Luckett
- Faculty of Medicine, Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Beth Israel Deaconess Medical Center, Department of Obstetrics and Gynecology, Boston, MA, USA
| | - Lauri E. Markowitz
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Ramogola-Masire D, Grover S, Mathoma A, Monare B, Gabaitiri L, Bazzett-Matabele L, Hofmeyr GJ, Morroni C, Luckett R. Support for lowering cervical cancer screening age to 25 for women living with HIV: retrospective cross-sectional programmatic data from Botswana. BMC Womens Health 2022; 22:100. [PMID: 35366863 PMCID: PMC8976959 DOI: 10.1186/s12905-022-01680-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 03/21/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Women living with human immunodeficiency virus (HIV) tend to develop cervical cancer at a younger age than women without HIV. The World Health Organization's (WHO) 2021 guidelines for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention include a conditional recommendation for initiating screening at age 25 for women living with HIV (WLWH). This recommendation is based on low-certainty evidence, and WHO calls for additional data. We describe the association of age and HIV status with visual inspection with acetic acid (VIA) positivity and cervical intraepithelial neoplasia grade two or higher (CIN2+) in Botswana. METHODS This was a retrospective cross-sectional study of 5714 participants aged 25 to 49 years who underwent VIA screening in a clinic mainly serving WLWH. VIA-positive women received cryotherapy if eligible or were referred for colposcopy and excisional treatment. Known cervical cancer risk factors, screening outcome, and histological results were extracted from the program database. We compared the proportions and association of VIA positivity and CIN2+ by age and HIV status. RESULTS The median age was 35 years [IQR 31-39], and 18% of the women were aged 25-29. Ninety percent were WLWH; median CD4 count was 250 cells/µL [IQR 150-428], and 34.2% were on anti-retroviral treatment (ART). VIA-positivity was associated with younger age (OR 1.48, CI 1.28, 1.72 for 25-29 years vs. 30-49 years), and HIV-positivity (OR 1.85, CI 1.51, 2.28). CIN2+ was only associated with HIV-positivity (OR 6.12, CI 3.39, 11.10), and proportions of CIN2+ were similar for both age groups in WLWH (69.1% vs. 68.3%). CONCLUSIONS Younger WLWH in Botswana had a significant burden of CIN2+. This finding further supports lowering the screening age for WLWH from 30 to 25.
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Affiliation(s)
- Doreen Ramogola-Masire
- grid.7621.20000 0004 0635 5486Department of Obstetrics and Gynecology and Office of Research and Graduate Studies, University of Botswana, Corner of Notwane and Mabuto Road, Gaborone, Botswana
| | - Surbhi Grover
- grid.25879.310000 0004 1936 8972Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA ,Botswana U-Penn Partnership, Gaborone, Botswana
| | - Anikie Mathoma
- grid.7621.20000 0004 0635 5486Office of Research, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | | | - Lesego Gabaitiri
- grid.7621.20000 0004 0635 5486Department of Statistics, Faculty of Social Sciences, University of Botswana, Gaborone, Botswana
| | - Lisa Bazzett-Matabele
- grid.7621.20000 0004 0635 5486Department of Obstetrics and Gynecology and Office of Research and Graduate Studies, University of Botswana, Corner of Notwane and Mabuto Road, Gaborone, Botswana
| | - GJustus Hofmeyr
- grid.7621.20000 0004 0635 5486Department of Obstetrics and Gynecology and Office of Research and Graduate Studies, University of Botswana, Corner of Notwane and Mabuto Road, Gaborone, Botswana
| | - Chelsea Morroni
- grid.462829.3Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana ,grid.4305.20000 0004 1936 7988MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Rebecca Luckett
- grid.7621.20000 0004 0635 5486Department of Obstetrics and Gynecology and Office of Research and Graduate Studies, University of Botswana, Corner of Notwane and Mabuto Road, Gaborone, Botswana ,grid.462829.3Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana ,grid.239395.70000 0000 9011 8547Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA USA
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25
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Wynn A, Mussa A, Ryan R, Hansman E, Simon S, Bame B, Moreri-Ntshabele B, Ramogola-Masire D, Klausner JD, Morroni C. Evaluating the diagnosis and treatment of Chlamydia trachomatis and Neisseria gonorrhoeae in pregnant women to prevent adverse neonatal consequences in Gaborone, Botswana: protocol for the Maduo study. BMC Infect Dis 2022; 22:229. [PMID: 35255814 PMCID: PMC8899784 DOI: 10.1186/s12879-022-07093-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/26/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are extremely common sexually transmitted infections (STIs) that are associated with adverse birth and neonatal outcomes, and the risk of vertical transmission of CT and NG during delivery is high. The majority of CT and NG infections are asymptomatic and missed by the standard of care in most countries (treatment based on symptoms). Thus, it is likely that missed maternal CT and NG infections contribute to preventable adverse health outcomes among women and children globally. This study aims to assess the effectiveness of CT and NG testing for asymptomatic pregnant women to prevent adverse neonatal outcomes, understand the inflammatory response linking CT and NG infections to adverse neonatal outcomes, and conduct an economic analysis of the CT and NG testing intervention. METHODS The Maduo ("results" in Setswana) is a prospective, cluster-controlled trial in Gaborone, Botswana to compare a near point-of-care CT and NG testing and treatment intervention implemented in "study clinics" with standard antenatal care (World Health Organization-endorsed "syndromic management" strategy based on signs and symptoms without laboratory confirmation) implemented in "standard of care clinics" among asymptomatic pregnant women. The primary outcome is vertical transmission of CT/NG infection. Secondary outcomes include preterm birth (delivery < 37 completed weeks of gestation) and/or low birth weight (< 2500 g). The trial will also evaluate immunological and inflammatory markers of adverse neonatal outcomes, as well as the costs and cost-effectiveness of the intervention compared with standard care. DISCUSSION The Maduo study will improve our understanding of the effectiveness and cost-effectiveness of CT and NG testing among asymptomatic pregnant women. It will also increase knowledge about the CT/NG-related immune responses that might drive adverse neonatal outcomes. Further, results from this study could encourage expansion of STI testing during antenatal care in low resource settings and improve maternal and neonatal health globally. TRIAL REGISTRATION This trial is registered with ClinicalTrials.gov (Identifier NCT04955717, First posted: July 9, 2021)).
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Affiliation(s)
- Adriane Wynn
- University of California, San Diego, USA. .,Botswana Sexual and Reproductive Health Initiative, Gaborone, Botswana.
| | - Aamirah Mussa
- Botswana Sexual and Reproductive Health Initiative, Gaborone, Botswana.,Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Rebecca Ryan
- Botswana Sexual and Reproductive Health Initiative, Gaborone, Botswana.,Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | - Selebaleng Simon
- Botswana Sexual and Reproductive Health Initiative, Gaborone, Botswana.,Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Bame Bame
- Botswana Sexual and Reproductive Health Initiative, Gaborone, Botswana.,Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | | | | | - Chelsea Morroni
- Botswana Sexual and Reproductive Health Initiative, Gaborone, Botswana.,Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana.,University of Edinburgh, Edinburgh, UK
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Abstract
PURPOSE OF REVIEW Although cervical cancer is preventable, it is the leading cancer among women in southern Africa. The association of high-risk human papillomavirus (HR-HPV) with almost all invasive cervical cancers has led to the development of effective primary and secondary prevention measures. This review focuses on updated and new evidence of the epidemiology of HPV and HPV-based secondary prevention in southern Africa. RECENT FINDINGS HR-HPV prevalence in southern Africa differs between regions, and varies most by HIV prevalence and age. HR-HPV prevalence among women living with HIV (WLWH) is reported between 29 and 59.7%, and between 16.2 and 25.2% among women without HIV. HPV16 is the most common HR-HPV type present in invasive cervical cancers in the region; and vaccination may potentially prevent approximately 80% of these cancers. Concerning preliminary data suggests faster development of new cervical precancer within a short follow-up period. SUMMARY We need tools that identify the small number of women with precancer from the many with transient HR-HPV infection in southern Africa. The high-volume of test-positive women leads to challenges in managing triage in a HR-HPV-based screening program. Longitudinal data from the entire region is urgently needed to guide effective implementation of HPV-based screening programs.
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Affiliation(s)
- Doreen Ramogola-Masire
- Department of Obstetrics & Gynecology, University of Botswana, Gaborone, Botswana
- Gynaecologic Oncology Unit, Department of Obstetrics & Gynaecology, University of Pretoria, Pretoria, South Africa
| | - Rebecca Luckett
- Department of Obstetrics & Gynecology, University of Botswana, Gaborone, Botswana
- Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Greta Dreyer
- Gynaecologic Oncology Unit, Department of Obstetrics & Gynaecology, University of Pretoria, Pretoria, South Africa
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27
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Tawe L, Choga WT, Paganotti GM, Bareng OT, Ntereke TD, Ramatlho P, Ditshwanelo D, Gaseitsiwe S, Kasvosve I, Ramogola-Masire D, Orang'o OE, Robertson E, Zetola N, Moyo S, Grover S, Ermel AC. Genetic diversity in L1 ORF of human papillomavirus in women with cervical cancer with and without human immunodeficiency virus in Botswana and Kenya. BMC Infect Dis 2022; 22:95. [PMID: 35086475 PMCID: PMC8796425 DOI: 10.1186/s12879-022-07081-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 01/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The variation of human papillomavirus (HPV) genotypes shapes the risks of cervical cancer and these variations are not well defined in Africa. Nucleotide changes within the L1 gene, nucleotide variability, and phylogeny were explored in relation to HIV in samples from Botswana and Kenya. METHODS A total of 98 HPV-positive cervical samples were sequenced to identify different HPV variants. Phylogenetic inferences were used to determine HPV genotypes and investigate the clustering of sequences between women living with HIV (WLWHIV) and -women not living with HIV (WNLWHIV). RESULTS Out of 98 generated sequences, 83.7% (82/98) participants had high-risk (HR) HPV genotypes while 16.3% (16/98) had low-risk (LR) HPV genotypes. Among participants with HR-HPV genotypes, 47.6% (39/82) were coinfected with HIV. The prevalence of HR-HPV genotypes was statistically higher in the Botswana population compared to Kenya (p-value < 0.001). Multiple amino acid mutations were identified in both countries. Genetic diversity differed considerably among WLWHIV and WNLWHIV. The mean pairwise distances between HPV-16 between HIV and HIV/HPV as well as for HPV-18 were statistically significant. Six (6) new deleterious mutations were identified in the HPV genotypes based on the sequencing of the L1 region, HPV-16 (L441P, S343P), HPV-18 (S424P), HPV-45 (Q366H, Y365F), and HPV-84 (F458L). The majority of the patients with these mutations were co-infected with HIV. CONCLUSIONS Genomic diversity and different genomic variants of HPV sequences were demonstrated. Candidate novel mutations within the L1 gene were identified in both countries which can be further investigated using functional assays.
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Affiliation(s)
- Leabaneng Tawe
- Department of Medical Laboratory Sciences, Faculty of Health Sciences, University of Botswana, Private Bag 00712, Gaborone, Botswana. .,Botswana-University of Pennsylvania Partnership, Gaborone, Botswana. .,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.
| | - Wonderful T Choga
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Giacomo M Paganotti
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana.,Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Biomedical Sciences, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Ontlametse T Bareng
- Department of Medical Laboratory Sciences, Faculty of Health Sciences, University of Botswana, Private Bag 00712, Gaborone, Botswana.,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | - Pleasure Ramatlho
- Department of Medical Laboratory Sciences, Faculty of Health Sciences, University of Botswana, Private Bag 00712, Gaborone, Botswana.,Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | | | - Simani Gaseitsiwe
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, MA, USA
| | - Ishmael Kasvosve
- Department of Medical Laboratory Sciences, Faculty of Health Sciences, University of Botswana, Private Bag 00712, Gaborone, Botswana
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | | | - Erle Robertson
- Department of Otorhinolaryngology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nicola Zetola
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | - Sikhulile Moyo
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, MA, USA
| | - Surbhi Grover
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana.,Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Aaron C Ermel
- Indiana University School of Medicine, Indianapolis, IN, USA
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28
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Wynn A, Moucheraud C, Martin NK, Morroni C, Ramogola-Masire D, Klausner JD, Leibowitz A. Bridging the Gap Between Pilot and Scale-Up: A Model of Antenatal Testing for Curable Sexually Transmitted Infections From Botswana. Sex Transm Dis 2022; 49:59-66. [PMID: 34310524 PMCID: PMC8663512 DOI: 10.1097/olq.0000000000001517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 10/06/2019] [Accepted: 07/13/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are common sexually transmitted infections (STIs) associated with adverse outcomes, yet most countries do not test and conduct syndromic management, which lacks sensitivity and specificity. Innovations allow for expanded STI testing; however, cost is a barrier. METHODS Using inputs from a pilot program in Botswana, we developed a model among a hypothetical population of 50,000 pregnant women to compare 1-year costs and outcomes associated with 3 antenatal STI testing strategies: (1) point-of-care, (2) centralized laboratory, and (3) a mixed approach (point of care at high-volume sites, and hubs elsewhere), and syndromic management. RESULTS Syndromic management had the lowest delivery cost but was associated with the most infections at delivery, uninfected women treated, CT/NG-related low-birth-weight infants, disability-adjusted life years, and low birth weight hospitalization costs. Point-of-care CT/NG testing would treat and cure the most infections but had the highest delivery cost. Among the testing scenarios, the mixed scenario had the most favorable cost per woman treated and cured ($534/cure). Compared with syndromic management, the mixed approach resulted in a mean incremental cost-effectiveness ratio of $953 per disability-adjusted life years averted, which is cost-effective under World Health Organization's one-time per-capita gross domestic product willingness-to-pay threshold. CONCLUSIONS As countries consider new technologies to strengthen health services, there is an opportunity to determine how to best deploy resources. Compared with point-of-care, centralized laboratory, and syndromic management, the mixed approach offered the lowest cost per infection averted and is cost-effective if policy makers' willingness to pay is informed by the World Health Organization's gross domestic product/capita threshold.
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Affiliation(s)
- Adriane Wynn
- From the Division of Infectious Diseases and Global Health, Department of Medicine, University of California, San Diego, La Jolla
| | - Corrina Moucheraud
- Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA
| | - Natasha K. Martin
- From the Division of Infectious Diseases and Global Health, Department of Medicine, University of California, San Diego, La Jolla
| | - Chelsea Morroni
- Botswana-Harvard AIDS Institute Partnership
- Botswana-UPenn Partnership, Gaborone, Botswana
- Women's Health Research Unit, Division of Social/Behavioural Sciences, School of Public Health, UCT, Cape Town, South Africa
- International Sexual and Reproductive Health, Liverpool School of Tropical Medicine, Liverpool
- UK Faculty of Sexual and Reproductive Health Care Clinical Effectiveness Unit, Edinburgh, United Kingdom
| | - Doreen Ramogola-Masire
- Research and Graduate Studies, Faculty of Medicine, School of Medicine, University of Botswana, Gaborone, Botswana
| | | | - Arleen Leibowitz
- School of Public Policy, University of California, Los Angeles, Los Angeles, CA
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Schriger S, Binagwaho A, Keetile M, Kerry V, Mubiligi JM, Ramogola-Masire D, Roland M, Barg FK, Cancedda C. Hierarchy of qualities in global health partnerships: a path towards equity and sustainability. BMJ Glob Health 2022; 6:bmjgh-2021-007132. [PMID: 34969686 PMCID: PMC8718486 DOI: 10.1136/bmjgh-2021-007132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 12/03/2021] [Indexed: 11/03/2022] Open
Abstract
Despite the exponential growth of global health partnerships (GHPs) over the past 20 years, evidence for their effectiveness remains limited. Furthermore, many partnerships are dysfunctional as a result of inequitable partnership benefits, low trust and accountability and poor evaluation and quality improvement practices. In this article, we describe a theoretical model for partnerships developed by seven global health experts. Through semistructured interviews and an open-coding approach to data analysis, we identify 12 GHP pillars spanning across three interconnected partnership levels and inspired by Maslow's hierarchy of needs. The transactional pillars are governance, resources and expertise, power management, transparency and accountability, data and evidence and respect and curiosity. The collaborative pillars (which build on the transactional pillars) are shared vision, relationship building, deep understanding and trust. The transformational pillars (which build on the collaborative pillars and allow partnerships to achieve their full potential) are equity and sustainability. The theoretical model described in this article is complemented by real-life examples, which outline both the cost incurred when GHPs fail to live up to these pillars and the benefits gained when GHPs uphold them. We also provide lessons learnt and best practices that GHPs should adopt to further increase their strength and improve their effectiveness in the future. To continue improving health outcomes and reducing health inequities globally, we need GHPs that are transformational, not just rhetorically but de facto. These actualised partnerships should serve as a catalyst for the greater societal good and not simply as a platform to accrue and exchange organisational benefits.
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Affiliation(s)
- Simone Schriger
- Department of Psychology, School of Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | - Vanessa Kerry
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Doreen Ramogola-Masire
- University of Botswana, Gaborone, Botswana.,For Frances Barg: Department of Family Medicine and Community Health; For Corrado Cancedda and Doreen Ramogola Masire: Center for Global Health; For Corrado Cancedda only: Division of Infectious Diseases/Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michelle Roland
- Sutter Medical Group, An Affiliate of Sutter Medical Foundation, Jackson, California, USA
| | - Frances K Barg
- For Frances Barg: Department of Family Medicine and Community Health; For Corrado Cancedda and Doreen Ramogola Masire: Center for Global Health; For Corrado Cancedda only: Division of Infectious Diseases/Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Corrado Cancedda
- For Frances Barg: Department of Family Medicine and Community Health; For Corrado Cancedda and Doreen Ramogola Masire: Center for Global Health; For Corrado Cancedda only: Division of Infectious Diseases/Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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30
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Gutin SA, Harper GW, Moshashane N, Ramontshonyana K, Stephenson R, Shade SB, Harries J, Mmeje O, Ramogola-Masire D, Morroni C. Relationship, partner factors and stigma are associated with safer conception information, motivation, and behavioral skills among women living with HIV in Botswana. BMC Public Health 2021; 21:2231. [PMID: 34879845 PMCID: PMC8653588 DOI: 10.1186/s12889-021-12268-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 11/16/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND A significant proportion (20-59%) of people living with HIV in sub-Saharan Africa desire childbearing, are of reproductive age, and are in sero-different relationships (~50%). Thus it is plausible that some portion of new HIV transmissions are due to attempts to become pregnant. Safer conception (SC) methods that effectively reduce the risk of HIV transmission exist and can be made available in resource-constrained settings. Few studies in the region, and none in Botswana, have quantitatively examined the correlates of information, motivation, and behavioral skills for SC uptake. METHODS We surveyed 356 women living with HIV from 6/2018 to 12/2018 at six public-sector health clinics in Gaborone, Botswana. Participants were 18-40 years old, not pregnant, and desired future children or were unsure about their childbearing plans. We examined correlates of SC information, motivation, and behavioral skills using nested linear regression models, adjusting for socio-demographic, interpersonal, and structural variables. RESULTS Knowledge of SC methods varied widely. While some SC methods were well known (medical male circumcision by 83%, antiretroviral therapy for viral suppression by 64%), most other methods were known by less than 40% of participants. Our final models reveal that stigma as well as relationship and partner factors affect SC information, motivation, and behavioral skills. Both internalized childbearing stigma (ß=-0.50, 95%CI:-0.17, -0.02) and perceived community childbearing stigma were negatively associated with SC information (ß=-0.09, 95%CI:-0.80, -0.21). Anticipated (ß=-0.06, 95%CI:-0.12, -0.003) and internalized stigma (ß=-0.27, 95%CI:-0.44; -0.10) were associated with decreased SC motivation, while perceived community childbearing stigma was associated with increased SC motivation (ß=0.07, 95%CI:0.02, 0.11). Finally, internalized childbearing stigma was associated with decreased SC behavioral skills (ß=-0.80, 95%CI: -1.12, -0.47) while SC information (ß=0.24, 95%CI:0.12, 0.36), motivation (ß=0.36, 95%CI:0.15, 0.58), and perceived partner willingness to use SC (ß=0.47, 95%CI:0.36, 0.57) were positively associated with behavioral skills CONCLUSIONS: Low SC method-specific information levels are concerning since almost half (47%) of the study participants reported they were in sero-different relationships and desired more children. Findings highlight the importance of addressing HIV stigma and partner dynamics in interventions to improve SC information, motivation, and behavioral skills.
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Affiliation(s)
- Sarah A Gutin
- Center for AIDS Prevention Studies, Division of Prevention Science, University of California, San Francisco, 550 16th Street, 3rd Floor, 94143, San Francisco, CA, USA.
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, 1415 Washington Heights, MI, 48109, Ann Arbor, USA.
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, 7925, Observatory, Cape Town, South Africa.
| | - Gary W Harper
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, 1415 Washington Heights, MI, 48109, Ann Arbor, USA
| | - Neo Moshashane
- Botswana Harvard AIDS Institute Partnership Princess Marina Hospital, Private Bag BO 320, Gaborone, Botswana
| | - Kehumile Ramontshonyana
- Botswana Harvard AIDS Institute Partnership Princess Marina Hospital, Private Bag BO 320, Gaborone, Botswana
| | - Rob Stephenson
- Department of Systems, Population and Leadership, School of Nursing, University of Michigan, MI, Ann Arbor, USA
- The Center for Sexuality and Health Disparities, School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Starley B Shade
- Department of Epidemiology & Biostatistics School of Medicine, University of California, San Francisco, CA, San Francisco, USA
| | - Jane Harries
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, 7925, Observatory, Cape Town, South Africa
| | - Okeoma Mmeje
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, 1415 Washington Heights, MI, 48109, Ann Arbor, USA
- Department of Obstetrics and Gynecology, University of Michigan Medical School, MI, Ann Arbor, USA
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Chelsea Morroni
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, 7925, Observatory, Cape Town, South Africa
- Botswana Harvard AIDS Institute Partnership Princess Marina Hospital, Private Bag BO 320, Gaborone, Botswana
- MRC Centre for Reproductive Health, University of Edinburgh, 47 Little France Crescent, EH16 4TJ, Edinburgh, United Kingdom
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31
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Howett R, Krogstad EA, Badubi O, Gertz AM, Bawn C, Mussa A, Kgaswanyane T, Malima S, Maotwe T, Mokganya L, Ramogola-Masire D, Morroni C. Experiences of Accessing and Providing Contraceptive Implant Removal Services in Gaborone, Botswana: A Qualitative Study Among Implant Users and Healthcare Providers. Front Glob Womens Health 2021; 2:684694. [PMID: 34816231 PMCID: PMC8593984 DOI: 10.3389/fgwh.2021.684694] [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] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/03/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction: This study explored implant user and healthcare provider experiences of accessing and providing contraceptive implant removal services in Gaborone, Botswana, following introduction of the implant in the public sector in 2016. We sought to understand reasons for satisfaction and dissatisfaction with services and their potential impact on wider perceptions of the implant, including influence on future uptake. Methods: Qualitative data were collected through in-depth interviews. Participants comprised ten women who had previously undergone implant removal, and ten providers whose work included provision of implant insertion and removal. Data were analyzed using thematic content analysis. Results: Seven of the ten users in this study had experienced a delay between initial request and undergoing implant removal. This interval ranged from <1 week to 3 months. Users identified the principal barriers to accessing implant removal services as lack of access to trained removal providers, inconvenient appointment times, and provider resistance to performing removal. Nine of the ten providers in this study had experienced barriers to providing implant removal, including insufficient training, lack of equipment, lack of time, and lack of a referral pathway for difficult removals. Despite experiencing barriers in accessing removal, users' perceptions of the implant remained generally positive. Providers were concerned that ongoing negative user experiences of removal services would damage wider perceptions of the implant. Conclusion: Introduction of the contraceptive implant in Botswana has been an important strategy in increasing contraceptive choice. Following an initial focus on provision of insertion services, the development of comparable, accessible removal services is critical to ensuring that the implant remains a desirable contraceptive option and is vital to upholding women's reproductive health rights. The experiences of users and providers in this study can inform the ongoing development of services for implant insertion and removal in Botswana and other lower-resource settings.
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Affiliation(s)
| | - Emily A Krogstad
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Opelo Badubi
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Alida M Gertz
- Botswana-UPenn Partnership, Gaborone, Botswana.,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Caitlin Bawn
- Sexual and Reproductive Health Department, Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom.,Research Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Aamirah Mussa
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Tiroyaone Kgaswanyane
- Botswana Family Welfare Association, Gaborone, Botswana.,Botswana Training and Education Center for Health, Gaborone, Botswana
| | - Sifelani Malima
- Botswana Ministry of Health and Wellness, Gaborone, Botswana
| | - Tshego Maotwe
- Botswana Ministry of Health and Wellness, Gaborone, Botswana
| | - Lesego Mokganya
- Botswana Ministry of Health and Wellness, Gaborone, Botswana
| | | | - Chelsea Morroni
- Botswana-UPenn Partnership, Gaborone, Botswana.,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Liverpool School of Tropical Medicine, Liverpool, United Kingdom.,Medical Research Council Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom
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32
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Bhatia R, Ramogola-Masire D, Friebel-Klingner T, Monare B, Grover S. Cervical Cancer Screening in Botswana: An Urgent Call for Guideline Change. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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33
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George J, Tuli S, Monare B, Lichter K, Ramogola-Masire D, Ralefala T, Seiphetlheng A, Zetola N, Shin S, Bazzett-Matabele L, Grover S. Stage and Outcomes of Cervical Cancer With or Without HIV Infection in Botswana 2013-2020. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.1632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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34
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Carveth-Johnson T, Dunin De Skrzynno S, Wynn A, Moshashane N, Ramontshonyana K, Lebelonyane R, Mussa A, Ramogola-Masire D, Klausner J, Morroni C. Integrating Sexually Transmitted Infection Testing and Treatment With Routine HIV Care in Gaborone, Botswana. Sex Transm Dis 2021; 48:887-894. [PMID: 34174039 PMCID: PMC8505143 DOI: 10.1097/olq.0000000000001492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 05/04/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sexually transmitted infection (STI) testing is not routinely offered in many countries, and management is symptoms based. Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are associated with an increased risk of HIV transmission. We assess the feasibility and acceptability of integrating CT/NG testing into routine HIV care in Botswana, as well as the prevalence and correlates of CT/NG infections. METHOD A prospective study was conducted at an HIV clinic in Gaborone between February and October 2019. Eligibility criteria included the following: ≥18 years, HIV infected, and not treated for CT/NG in the past month. Participants self-collected samples and responded to a questionnaire on sociodemographic and health characteristics. Samples were processed using the GeneXpert. Patients were offered same-day results in person or by telephone. Those who tested positive were treated. RESULTS Of 806 patients informed of the study, 526 (65%) expressed interest and 451 (60%) were enrolled. The median age was 48 years, and 66% were women. All participants provided self-collected samples, were successfully tested, and received results. Almost all reported sample self-collection was easy. The prevalence of CT/NG was 5%. Most participants (73%) with a positive result were asymptomatic. Among infected, 20 (91%) received same-day results and all were treated. Younger age, female sex, and pain during sex were associated with having CT/NG. CONCLUSIONS Integrating STI testing into routine HIV care was feasible, self-collecting specimens was highly acceptable, but uptake of testing was low. Where blanket screening to the entire clinic population may not be feasible because of resource limitation, one strategy could be to prioritize sexually active patients, younger patients, and women.
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Affiliation(s)
| | | | - Adriane Wynn
- From the Botswana-UPenn Partnership (BUP), Gaborone, Botswana
- Division of Infectious Diseases and Global Health, Department of Medicine, University of California, Los Angeles, California
| | - Neo Moshashane
- Botswana Harvard AIDS Institute Partnership (BHP), Gaborone, Botswana
| | | | | | - Aamirah Mussa
- Botswana Harvard AIDS Institute Partnership (BHP), Gaborone, Botswana
| | | | - Jeffrey Klausner
- Department of Medicine, University of California, Los Angeles, California
| | - Chelsea Morroni
- From the Botswana-UPenn Partnership (BUP), Gaborone, Botswana
- Botswana Harvard AIDS Institute Partnership (BHP), Gaborone, Botswana
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom
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35
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MacDuffie E, Sakamuri S, Luckett R, Wang Q, Bvochara-Nsingo M, Monare B, Bazzett-Matabele L, Moloi T, Ralefala T, Ramogola-Masire D, Shin SS, Zetola NM, Grover S. Vulvar cancer in Botswana in women with and without HIV infection: patterns of treatment and survival outcomes. Int J Gynecol Cancer 2021; 31:1328-1334. [PMID: 34493586 DOI: 10.1136/ijgc-2021-002728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 07/28/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Vulvar cancer is a rare gynecological malignancy. However, the incidence of human papillomavirus (HPV)-associated vulvar disease is increasing, particularly in low- and middle-income countries. HIV infection is associated with an increased risk of HPV-associated vulvar cancer. We evaluated treatment patterns and survival outcomes in a cohort of vulvar cancer patients in Botswana. The primary objective of this study was to determine overall survival and the impact of treatment modality, stage, and HIV status on overall survival. METHODS Women with vulvar cancer who presented to oncology care in Botswana from January 2015 through August 2019 were prospectively enrolled in this observational cohort study. Demographics, clinical characteristics, treatment, and survival data were collected. Factors associated with survival including age, HIV status, stage, and treatment were evaluated. RESULTS Our cohort included 120 women with vulvar cancer. Median age was 42 (IQR 38-47) years. The majority of patients were living with HIV (89%, n=107) that was well-controlled on antiretroviral treatment. Among women with HIV, 54.2% (n=58) were early stage (FIGO stage I/II). In those without HIV, 46.2% (n=6) were early stage (stage I/II). Of the 95 (79%) patients who received treatment, 20.8% (n=25) received surgery, 67.5% (n=81) received radiation therapy, and 24.2% (n=29) received chemotherapy, either alone or in combination. Median follow-up time of all patients was 24.7 (IQR 14.2-39.1) months and 2- year overall survival for all patients was 74%. Multivariate analysis demonstrated improved survival for those who received surgery (HR 0.26; 95% CI 0.08 to 0.86) and poor survival was associated with advanced stage (HR 2.56; 95% CI 1.30 to 5.02). Survival was not associated with HIV status. CONCLUSIONS The majority of women with vulvar cancer in Botswana are young and living with HIV infection. Just under half of patients present with advanced stage, which was associated with worse survival. Improved survival was seen for those who received surgery.
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Affiliation(s)
- Emily MacDuffie
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sruthi Sakamuri
- Department of Obstetrics and Gynecology, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rebecca Luckett
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana.,Princess Marina Hospital, Gaborone, Botswana
| | - Qiao Wang
- Sue and Bill Gross School of Nursing, University of California, Irvine, California, USA
| | | | | | - Lisa Bazzett-Matabele
- Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana.,Princess Marina Hospital, Gaborone, Botswana.,Department of Obstetrics and Gynecology, Yale University, New Haven, Connecticut, USA
| | - Thabo Moloi
- Princess Marina Hospital, Gaborone, Botswana
| | | | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
| | - Sanghyuk S Shin
- Sue and Bill Gross School of Nursing, University of California, Irvine, California, USA
| | - Nicola M Zetola
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Botswana-UPenn Partnership, Gaborone, Botswana
| | - Surbhi Grover
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA .,Princess Marina Hospital, Gaborone, Botswana.,Botswana-UPenn Partnership, Gaborone, Botswana.,Department of Medicine, University of Botswana, Gaborone, Botswana
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36
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Sims T, Ramogola-Masire D, Ngoni K, Biegert G, Solley T, Ning M, El Alam M, Mezzari M, Ramondetta L, Schmeler K, Colbert L, Jhingran A, Grover S, Klopp A. An analysis of tumor microbial diversity and composition between women with cervical cancer in Botswana and the United States. Gynecol Oncol 2021. [DOI: 10.1016/s0090-8258(21)00806-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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37
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Grover S, Ning MS, Bale M, Lichter KE, Shah S, Bvochora-Nsingo M, Chiyapo S, Balang D, McGinnis GJ, Ralefala T, Moloi T, Luckett R, Ramogola-Masire D, Robertson ES, Zetola NM. Chemoradiation versus radiation alone in stage IIIB cervical cancer patients with or without human immunodeficiency virus. Int J Gynecol Cancer 2021; 31:1220-1227. [PMID: 34312220 DOI: 10.1136/ijgc-2021-002601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/08/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Cervical cancer remains the most common cancer among women in sub-Saharan Africa and is also a leading cause of cancer related deaths among these women. The benefit of chemoradiation in comparison with radiation alone for patients with stage IIIB disease has not been evaluated prospectively in women living with human immunodeficiency virus (HIV). We assessed the survival of chemoradiation versus radiation alone among stage IIIB cervical cancer patients based on HIV status. METHODS Between February 2013 and June 2018, patients with International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IIIB cervical cancer with or without HIV and treated with chemoradiation or radiation alone, were prospectively enrolled in an observational cohort study. Overall survival was evaluated using the Kaplan-Meier method. Cox proportional hazards modeling was used to analyze associations with survival. RESULTS Among 187 patients, 63% (n=118) of women had co-infection with HIV, and 48% (n=69) received chemoradiation. Regardless of HIV status, patients who received chemoradiation had improved 2 year overall survival compared with those receiving radiation alone (59% vs 41%, p<0.01), even among women living with HIV (60% vs 38%, p=0.02). On multivariable Cox regression analysis, including all patients regardless of HIV status, 2 year overall survival was associated with receipt of chemoradiation (hazard ratio (HR) 0.63, p=0.04) and total radiation dose ≥80 Gy (HR 0.57, p=0.02). Among patients who received an adequate radiation dose of ≥80 Gy, adjusted overall survival rates were similar between chemoradiation versus radiation alone groups (HR 1.07; p=0.90). However, patients who received an inadequate radiation dose of <80 Gy, adjusted survival was significantly higher in chemoradiation versus radiation alone group (HR 0.45, p=0.01). CONCLUSIONS Addition of chemotherapy to standard radiation improved overall survival, regardless of HIV status, and is even more essential in women who cannot receive full doses of radiation.
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Affiliation(s)
- Surbhi Grover
- Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA .,Oncology, University of Botswana, Gaborone, Botswana
| | - Matthew S Ning
- Radiation Oncology, University of Texas MD Anderson Cancer Center Division of Radiation Oncology, Houston, Texas, USA
| | - Michelle Bale
- Radiation Oncology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Katie E Lichter
- Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - Sidrah Shah
- The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Sebathu Chiyapo
- Life Gaborone Private Hospital, Gaborone, Gaborone, Botswana
| | - Dawn Balang
- Life Gaborone Private Hospital, Gaborone, Gaborone, Botswana
| | - Gwendolyn J McGinnis
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Thabo Moloi
- Princess Marina Hospital, Gaborone, Gaborone, Botswana
| | - Rebecca Luckett
- Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Doreen Ramogola-Masire
- Obstetrics & Gynaecology - Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Erle S Robertson
- Microbiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nicola M Zetola
- Botswana-University of Pennsylvania Partnership, Philadelphia, Pennsylvania, USA
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38
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Hansman E, Wynn A, Moshashane N, Ramontshonyana K, Mompe A, Mussa A, Ryan R, Ramogola-Masire D, Klausner JD, Morroni C. Experiences and preferences with sexually transmitted infection care and partner notification in Gaborone, Botswana. Int J STD AIDS 2021; 32:1250-1256. [PMID: 34304619 DOI: 10.1177/09564624211033231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Partner notification and treatment are essential to sexually transmitted infection (STI) management. However, in low- and middle-income countries, half of partners do not receive treatment. A mixed methods study was conducted to explore experiences and preferences around partner notification and treatment in patients seeking STI care in Gaborone, Botswana. Thirty participants were administered a quantitative survey, followed by a semi-structured interview on partner notification, treatment, and expedited partner therapy (EPT). Among the 30 participants, 77% were female with a median age of 28 years (IQR = 24-36), 87% notified their partner, and 45% of partners requiring treatment received treatment. Partners who received a contact slip were more likely to have been treated than those who did not (75% vs. 25%). Contact slips were identified as facilitators of notification and treatment, while asymptomatic partners and limited clinic resources were identified as barriers to treatment. Few participants expressed a preference for EPT and concerns included preference for medical supervision, a belief their partner would refuse, and an inability to explain the treatment. Despite successful notification, partner treatment was modest within this population. Information for partners, provider counseling, and improved access to services may increase partner treatment. Education on STIs and treatment options may improve EPT acceptability.
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Affiliation(s)
- Emily Hansman
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Adriane Wynn
- Division of Infectious Diseases and Global Health, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Neo Moshashane
- 292006Botswana-UPenn Partnership, Gaborone, Botswana.,Botswana Sexual & Reproductive Health Initiative, Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Kehumile Ramontshonyana
- 292006Botswana-UPenn Partnership, Gaborone, Botswana.,Botswana Sexual & Reproductive Health Initiative, Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Atlang Mompe
- 292006Botswana-UPenn Partnership, Gaborone, Botswana
| | - Aamirah Mussa
- Botswana Sexual & Reproductive Health Initiative, Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Rebecca Ryan
- Botswana Sexual & Reproductive Health Initiative, Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | - Jeffrey D Klausner
- Department of Preventive Medicine, University of Southern California, CA, USA
| | - Chelsea Morroni
- Botswana Sexual & Reproductive Health Initiative, Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,9655Liverpool School of Tropical Medicine, Liverpool, UK
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39
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Johnson KM, Zash R, Modest AM, Luckett R, Diseko M, Mmalane M, Makhema J, Ramogola-Masire D, Wylie BJ, Shapiro R. Anti-hypertensive use for non-severe gestational hypertension in Botswana: A case-control study. Int J Gynaecol Obstet 2021; 156:481-487. [PMID: 34196980 DOI: 10.1002/ijgo.13809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 06/07/2021] [Accepted: 06/30/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The fetal risks and benefits of antihypertensives to treat gestational hypertension in pregnancy are understudied, particularly in low- and middle-income countries. METHODS We performed a nested case-control study within a retrospective cohort of obstetrical patients in Botswana from 2014 to 2019. We included women carrying singletons who developed new onset non-severe hypertension (140-159 mm Hg systolic or 90-109 mm Hg diastolic blood pressure) after 20 weeks of pregnancy. Cases were defined as women with either small-for-gestational-age (SGA) infants or stillbirth, analyzed separately; controls were otherwise similar women without the adverse outcome in each analysis. RESULTS We identified 1932 cases of SGA (7925 controls) and 316 cases of stillbirth (9619 controls). Cases with SGA were more likely to have used an anti-hypertensive than controls (33% vs 29%, adjusted odds ratio [aOR] 1.28, 95% confidence interval [CI] 1.15-1.43). Cases with stillbirth were more likely to have used an anti-hypertensive than controls (42% versus 29%, aOR 1.45, 95% CI 1.14-1.83). CONCLUSION Anti-hypertensive use for new-onset gestational hypertension was associated with an increased risk of having an SGA infant or a stillbirth among women who never developed severe hypertension. These data support conduct of a randomized clinical trial to determine the appropriate use of anti-hypertensives in non-severe gestational hypertension.
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Affiliation(s)
- Katherine M Johnson
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, USA
| | - Rebecca Zash
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Botswana-Harvard Partnership, Gaborone, Botswana
| | - Anna M Modest
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, USA
| | - Rebecca Luckett
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, USA
| | | | | | | | - Doreen Ramogola-Masire
- Botswana-Harvard Partnership, Gaborone, Botswana.,Department of Obstetrics and Gynecology, Faculty of Medicine, University of Botswana
| | - Blair J Wylie
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, USA
| | - Roger Shapiro
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Botswana-Harvard Partnership, Gaborone, Botswana.,Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Luckett R, Painter H, Hacker MR, Simon B, Seiphetlheng A, Erlinger A, Eakin C, Moyo S, Kyokunda LT, Esselen K, Feldman S, Morroni C, Ramogola-Masire D. Persistence and clearance of high-risk human papillomavirus and cervical dysplasia at 1 year in women living with human immunodeficiency virus: a prospective cohort study. BJOG 2021; 128:1986-1996. [PMID: 34008294 DOI: 10.1111/1471-0528.16758] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Evaluate 1-year outcomes of cervical cancer screening and treatment using primary high-risk human papillomavirus (HPV) testing in women living with human immunodeficiency virus (HIV). DESIGN Prospective cohort study. SETTING HIV treatment centre in Botswana. POPULATION Women living with HIV. METHODS Participants underwent cervical cancer screening with high-risk HPV testing and triage evaluation at baseline and 1-year follow up. Excisional treatment was offered as indicated. Histopathology was the reference standard. MAIN OUTCOME MEASURES Persistence, clearance and incidence of high-risk HPV infection; and persistence, progression, regression, cure and incidence of cervical dysplasia. RESULTS Among 300 women screened at baseline, 237 attended follow up (79%). High-risk HPV positivity significantly decreased from 28% at baseline to 20% at 1 year (P = 0.02). High-risk HPV persistence was 46% and clearance was 54%; incidence was high at 9%. Prevalence of cervical intraepithelial neoplasia Grade 2 (CIN2) or higher was most common in participants with incident high-risk HPV (53%). CIN2 or higher was also common in those with persistent high-risk HPV (32%) and even in those who cleared high-risk HPV (30%). Of the high-risk HPV-positive participants at baseline with <CIN2, 40% progressed to CIN2 or higher at follow up. CONCLUSION The high incidence of high-risk HPV and high-grade cervical dysplasia in women living with HIV after one round of high-risk HPV-based screening and treatment raises concern about the rate of progression of high-risk HPV infection to dysplasia. Persistent disease is common. Caution in spacing cervical cancer screening intervals using high-risk HPV testing in women living with HIV is warranted. TWEETABLE ABSTRACT High incidence and persistence of HPV and CIN2+ in women living with HIV 1 year after screening and treatment.
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Affiliation(s)
- R Luckett
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - H Painter
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - M R Hacker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - B Simon
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - A Seiphetlheng
- Department of Obstetrics and Gynaecology, Princess Marina Hospital, Gaborone, Botswana
| | - A Erlinger
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - C Eakin
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Department of Obstetrics and Gynecology, Creighton University School of Medicine-Phoenix, Phoenix, AZ, USA
| | - S Moyo
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - L T Kyokunda
- Department of Pathology, University of Botswana, Gaborone, Botswana
| | - K Esselen
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - S Feldman
- Harvard Medical School, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
| | - C Morroni
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - D Ramogola-Masire
- Department of Obstetrics and Gynaecology, University of Botswana, Gaborone, Botswana
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Davey S, Bazzett-Matabele L, Monare B, Seiphetleng A, Ramontshonyana G, Vuylsteke P, Chiyapo S, Luckett R, Ramogola-Masire D, Grover S. Gynecologic Cancer: New and Follow-Up Patient Appointments in Botswana During the COVID-19 Pandemic. JCO Glob Oncol 2021; 7:453-454. [PMID: 33822642 PMCID: PMC8081498 DOI: 10.1200/go.20.00590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Sonya Davey
- Sonya Davey, MD, MPhil, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Lisa Bazzett-Matabele, MD, Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana; Barati Monare, RN, MPH, Botswana-UPenn Partnership, Gaborone, Botswana; Alexander Seiphetleng, RN, BPH and GaobakweRamontshonyana, RN, Princess Marina Hospital, Gaborone, Botswana; Peter Vuylsteke, MD, Department of Internal Medicine, University of Botswana, Gaborone, Botswana; Sebathu Chiyapo, MD, Gaborone Private Hospital, Gaborone, Botswana; Rebecca Luckett, MD, MPH, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA; Doreen Ramogola-Masire, MD, Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana; and Surbhi Grover, MD, MPH, Botswana-UPenn Partnership, Gaborone, Botswana; Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Lisa Bazzett-Matabele
- Sonya Davey, MD, MPhil, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Lisa Bazzett-Matabele, MD, Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana; Barati Monare, RN, MPH, Botswana-UPenn Partnership, Gaborone, Botswana; Alexander Seiphetleng, RN, BPH and GaobakweRamontshonyana, RN, Princess Marina Hospital, Gaborone, Botswana; Peter Vuylsteke, MD, Department of Internal Medicine, University of Botswana, Gaborone, Botswana; Sebathu Chiyapo, MD, Gaborone Private Hospital, Gaborone, Botswana; Rebecca Luckett, MD, MPH, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA; Doreen Ramogola-Masire, MD, Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana; and Surbhi Grover, MD, MPH, Botswana-UPenn Partnership, Gaborone, Botswana; Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Barati Monare
- Sonya Davey, MD, MPhil, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Lisa Bazzett-Matabele, MD, Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana; Barati Monare, RN, MPH, Botswana-UPenn Partnership, Gaborone, Botswana; Alexander Seiphetleng, RN, BPH and GaobakweRamontshonyana, RN, Princess Marina Hospital, Gaborone, Botswana; Peter Vuylsteke, MD, Department of Internal Medicine, University of Botswana, Gaborone, Botswana; Sebathu Chiyapo, MD, Gaborone Private Hospital, Gaborone, Botswana; Rebecca Luckett, MD, MPH, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA; Doreen Ramogola-Masire, MD, Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana; and Surbhi Grover, MD, MPH, Botswana-UPenn Partnership, Gaborone, Botswana; Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Alexander Seiphetleng
- Sonya Davey, MD, MPhil, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Lisa Bazzett-Matabele, MD, Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana; Barati Monare, RN, MPH, Botswana-UPenn Partnership, Gaborone, Botswana; Alexander Seiphetleng, RN, BPH and GaobakweRamontshonyana, RN, Princess Marina Hospital, Gaborone, Botswana; Peter Vuylsteke, MD, Department of Internal Medicine, University of Botswana, Gaborone, Botswana; Sebathu Chiyapo, MD, Gaborone Private Hospital, Gaborone, Botswana; Rebecca Luckett, MD, MPH, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA; Doreen Ramogola-Masire, MD, Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana; and Surbhi Grover, MD, MPH, Botswana-UPenn Partnership, Gaborone, Botswana; Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Gaobakwe Ramontshonyana
- Sonya Davey, MD, MPhil, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Lisa Bazzett-Matabele, MD, Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana; Barati Monare, RN, MPH, Botswana-UPenn Partnership, Gaborone, Botswana; Alexander Seiphetleng, RN, BPH and GaobakweRamontshonyana, RN, Princess Marina Hospital, Gaborone, Botswana; Peter Vuylsteke, MD, Department of Internal Medicine, University of Botswana, Gaborone, Botswana; Sebathu Chiyapo, MD, Gaborone Private Hospital, Gaborone, Botswana; Rebecca Luckett, MD, MPH, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA; Doreen Ramogola-Masire, MD, Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana; and Surbhi Grover, MD, MPH, Botswana-UPenn Partnership, Gaborone, Botswana; Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Peter Vuylsteke
- Sonya Davey, MD, MPhil, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Lisa Bazzett-Matabele, MD, Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana; Barati Monare, RN, MPH, Botswana-UPenn Partnership, Gaborone, Botswana; Alexander Seiphetleng, RN, BPH and GaobakweRamontshonyana, RN, Princess Marina Hospital, Gaborone, Botswana; Peter Vuylsteke, MD, Department of Internal Medicine, University of Botswana, Gaborone, Botswana; Sebathu Chiyapo, MD, Gaborone Private Hospital, Gaborone, Botswana; Rebecca Luckett, MD, MPH, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA; Doreen Ramogola-Masire, MD, Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana; and Surbhi Grover, MD, MPH, Botswana-UPenn Partnership, Gaborone, Botswana; Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Sebathu Chiyapo
- Sonya Davey, MD, MPhil, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Lisa Bazzett-Matabele, MD, Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana; Barati Monare, RN, MPH, Botswana-UPenn Partnership, Gaborone, Botswana; Alexander Seiphetleng, RN, BPH and GaobakweRamontshonyana, RN, Princess Marina Hospital, Gaborone, Botswana; Peter Vuylsteke, MD, Department of Internal Medicine, University of Botswana, Gaborone, Botswana; Sebathu Chiyapo, MD, Gaborone Private Hospital, Gaborone, Botswana; Rebecca Luckett, MD, MPH, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA; Doreen Ramogola-Masire, MD, Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana; and Surbhi Grover, MD, MPH, Botswana-UPenn Partnership, Gaborone, Botswana; Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Rebecca Luckett
- Sonya Davey, MD, MPhil, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Lisa Bazzett-Matabele, MD, Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana; Barati Monare, RN, MPH, Botswana-UPenn Partnership, Gaborone, Botswana; Alexander Seiphetleng, RN, BPH and GaobakweRamontshonyana, RN, Princess Marina Hospital, Gaborone, Botswana; Peter Vuylsteke, MD, Department of Internal Medicine, University of Botswana, Gaborone, Botswana; Sebathu Chiyapo, MD, Gaborone Private Hospital, Gaborone, Botswana; Rebecca Luckett, MD, MPH, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA; Doreen Ramogola-Masire, MD, Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana; and Surbhi Grover, MD, MPH, Botswana-UPenn Partnership, Gaborone, Botswana; Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Doreen Ramogola-Masire
- Sonya Davey, MD, MPhil, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Lisa Bazzett-Matabele, MD, Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana; Barati Monare, RN, MPH, Botswana-UPenn Partnership, Gaborone, Botswana; Alexander Seiphetleng, RN, BPH and GaobakweRamontshonyana, RN, Princess Marina Hospital, Gaborone, Botswana; Peter Vuylsteke, MD, Department of Internal Medicine, University of Botswana, Gaborone, Botswana; Sebathu Chiyapo, MD, Gaborone Private Hospital, Gaborone, Botswana; Rebecca Luckett, MD, MPH, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA; Doreen Ramogola-Masire, MD, Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana; and Surbhi Grover, MD, MPH, Botswana-UPenn Partnership, Gaborone, Botswana; Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Surbhi Grover
- Sonya Davey, MD, MPhil, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Lisa Bazzett-Matabele, MD, Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana; Barati Monare, RN, MPH, Botswana-UPenn Partnership, Gaborone, Botswana; Alexander Seiphetleng, RN, BPH and GaobakweRamontshonyana, RN, Princess Marina Hospital, Gaborone, Botswana; Peter Vuylsteke, MD, Department of Internal Medicine, University of Botswana, Gaborone, Botswana; Sebathu Chiyapo, MD, Gaborone Private Hospital, Gaborone, Botswana; Rebecca Luckett, MD, MPH, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA; Doreen Ramogola-Masire, MD, Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana; and Surbhi Grover, MD, MPH, Botswana-UPenn Partnership, Gaborone, Botswana; Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
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Gutin SA, Harper GW, Moshashane N, Bitsang C, Harries J, Ramogola-Masire D, Morroni C. "What if they are pre-conception? What should we do?": Knowledge, practices, and preferences for safer conception among women living with HIV and healthcare providers in Gaborone, Botswana. Front Glob Womens Health 2021; 1. [PMID: 33693437 PMCID: PMC7943178 DOI: 10.3389/fgwh.2020.582463] [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] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Safer conception interventions that address HIV care, treatment, and prevention for HIV-affected couples are increasingly available in sub-Saharan Africa. Botswana, an HIV endemic country, is yet to offer formal safer conception services although universal test-and-treat approaches mean that increasing numbers of young, sexually active people living with HIV will start treatment and likely desire childbearing. In order to advance the safer conception discussion in Botswana, it is necessary to understand the current safer conception knowledge, practices, and preferences of healthcare providers and women living with HIV (WLHIV). We conducted qualitative in-depth interviews with 10 HIV healthcare providers and 10 WLHIV in Gaborone. Interviews were analyzed using a phenomenological approach. Safer conception knowledge was limited and safer conception discussions were rare. Healthcare provider and WLHIV preferences were at odds, with providers preferring WLHIV to initiate safer conception discussions, and WLHIV desiring providers to initiate safer conception discussions. Quotes from women and providers highlight deeper issues about power dynamics, concerns about stigma among women, and provider fears about promoting pregnancy. Providers emphasized the need for guidelines and training in order to improve the provision of safer conception counseling. These findings point to areas where safer conception in Botswana can be improved. Both WLHIV and providers would benefit from having information about a range of safer conception methods and approaches. In addition, since WLHIV felt hesitant about initiating safer conception conversations and feared stigma, and because putting the onus for starting safer conception discussions on women is a reversal of normal roles and power structures, providers must take the lead and routinely initiate fertility desire and safer conception discussions. Assisting healthcare providers with clear safer conception guidelines and training would improve the provision of accurate safer conception counseling and facilitate reproductive choice.
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Affiliation(s)
- Sarah A Gutin
- Dept. of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA.,Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Center for AIDS Prevention Studies, Division of Prevention Science, University of California San Francisco, San Francisco, CA, USA
| | - Gary W Harper
- Dept. of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | | | - Christina Bitsang
- Career and Counseling Services, University of Botswana, Gaborone, Botswana
| | - Jane Harries
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Chelsea Morroni
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Botswana U-Penn Partnership, Gaborone, Botswana.,Liverpool School of Tropical Medicine, Liverpool, United Kingdom.,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
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43
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Maan I, Lawrence DS, Tlhako N, Ramontshonyana K, Mussa A, Wynn A, Marks M, Ramogola-Masire D, Morroni C. Using a dual antibody point-of-care test with visual and digital reads to diagnose syphilis among people living with HIV in Botswana. Int J STD AIDS 2021; 32:453-461. [PMID: 33570464 PMCID: PMC8008391 DOI: 10.1177/0956462420975639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Syphilis data from low- and middle-income countries are lacking due to limited testing. Point-of-care tests (POCTs) have been promoted to expand testing but previously only included treponemal tests, which cannot distinguish active from past infection. We aimed to assess the feasibility of using a combined treponemal and non-treponemal POCT in HIV clinic patients in Gaborone, Botswana, and estimate syphilis prevalence in our clinic sample using this approach. We recruited 390 non-pregnant patients. Participants underwent a combined treponemal and non-treponemal POCT (Dual Path Platform (DPP®) Syphilis Screen and Confirm Assay (Chembio Diagnostic Systems)) on finger-prick blood sample and a questionnaire. Median age 45 years, 30% men, median CD4 count 565 cells/μL, and 91% had an HIV viral load <400 copies/mL. Five participants had active syphilis (1.3%, 95% CI 0.5–3.0%) and 64 had previous syphilis (16.4%, 95% CI 13.0–20.4%) using the DPP POCT. There was a reasonable level of agreement between digital and visual reading of the POCT (kappa statistic of 0.81); however, visual reading missed three active infections (60%). The level of active syphilis was similar to local antenatal data. The DPP POCT led to five participants with active syphilis being diagnosed and starting same-day treatment. The digital reader should be used.
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Affiliation(s)
- Irfaan Maan
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, 218289London School of Hygiene and Tropical Medicine, London, UK
| | - David S Lawrence
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, 218289London School of Hygiene and Tropical Medicine, London, UK.,292006Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Nametso Tlhako
- 292006Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | - Aamirah Mussa
- 292006Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Adriane Wynn
- Division of Infectious Diseases & Global Public Health, 8784University of California, San Diego, USA
| | - Michael Marks
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, 218289London School of Hygiene and Tropical Medicine, London, UK.,Hospital for Tropical Diseases, London, UK
| | | | - Chelsea Morroni
- 292006Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Botswana University of Pennsylvania Partnership, Gaborone, Botswana.,Department of International Public Health, 9655Liverpool School of Tropical Medicine, Liverpool, UK
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Luckett R, Nassali M, Melese T, Moreri-Ntshabele B, Moloi T, Hofmeyr GJ, Chobanga K, Masunge J, Makhema J, Pollard M, Ricciotti HA, Ramogola-Masire D, Bazzett-Matabele L. Development and launch of the first obstetrics and gynaecology master of medicine residency training programme in Botswana. BMC Med Educ 2021; 21:19. [PMID: 33407415 PMCID: PMC7789389 DOI: 10.1186/s12909-020-02446-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 12/10/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Sub-Saharan Africa (SSA) faces a severe shortage of Obstetrician Gynaecologists (OBGYNs). While the Lancet Commission for Global Surgery recommends 20 OBGYNs per 100,000 population, Botswana has only 40 OBGYNs for a population of 2.3 million. We describe the development of the first OBGYN Master of Medicine (MMed) training programme in Botswana to address this human resource shortage. METHODS We developed a 4-year OBGYN MMed programme at the University of Botswana (UB) using the Kern's approach. In-line with UB MMed standards, the programme includes clinical apprenticeship training complemented by didactic and research requirements. We benchmarked curriculum content, learning outcomes, competencies, assessment strategies and research requirements with regional and international programmes. We engaged relevant local stakeholders and developed international collaborations to support in-country subspecialty training. RESULTS The OBGYN MMed curriculum was completed and approved by all relevant UB bodies within ten months during which time additional staff were recruited and programme financing was assured. The programme was advertised immediately; 26 candidates applied for four positions, and all selected candidates accepted. The programme was launched in January 2020 with government salary support of all residents. The clinical rotations and curricular development have been rolled out successfully. The first round of continuous assessment of residents was performed and internal programme evaluation was conducted. The national accreditation process was initiated. CONCLUSION Training OBGYNs in-country has many benefits to health systems in SSA. Curricula can be adjusted to local resource context yet achieve international standards through thoughtful design and purposeful collaborations.
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Affiliation(s)
- R Luckett
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana.
- Department of Obstetrics and Gynaecology, Princess Marina Hospital, Gaborone, Botswana.
- The Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, USA.
- Harvard Medical School, Boston, USA.
| | - M Nassali
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
- Department of Obstetrics and Gynaecology, Princess Marina Hospital, Gaborone, Botswana
| | - T Melese
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
- Department of Obstetrics and Gynaecology, Princess Marina Hospital, Gaborone, Botswana
| | - B Moreri-Ntshabele
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
- Department of Obstetrics and Gynaecology, Princess Marina Hospital, Gaborone, Botswana
| | - T Moloi
- Department of Obstetrics and Gynaecology, Princess Marina Hospital, Gaborone, Botswana
| | - G J Hofmeyr
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
- Department of Obstetrics and Gynaecology, Princess Marina Hospital, Gaborone, Botswana
| | - K Chobanga
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
- Department of Obstetrics and Gynaecology, Princess Marina Hospital, Gaborone, Botswana
| | - J Masunge
- Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - J Makhema
- The Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - M Pollard
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, USA
| | - H A Ricciotti
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, USA
- Harvard Medical School, Boston, USA
| | - D Ramogola-Masire
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
- Department of Obstetrics and Gynaecology, Princess Marina Hospital, Gaborone, Botswana
| | - L Bazzett-Matabele
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
- Department of Obstetrics and Gynaecology, Princess Marina Hospital, Gaborone, Botswana
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Grant JS, Chico RM, Lee ACC, Low N, Medina-Marino A, Molina RL, Morroni C, Ramogola-Masire D, Stafylis C, Tang W, Vallely AJ, Wynn A, Yeganeh N, Klausner JD. Sexually Transmitted Infections in Pregnancy: A Narrative Review of the Global Research Gaps, Challenges, and Opportunities. Sex Transm Dis 2020; 47:779-789. [PMID: 32773611 PMCID: PMC7668326 DOI: 10.1097/olq.0000000000001258] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [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: 03/08/2020] [Accepted: 07/21/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sexually transmitted infections (STI), such as chlamydial, gonorrheal, and trichomonal infections, are prevalent in pregnant women in many countries and are widely reported to be associated with increased risk of poor maternal and neonatal outcomes. Syndromic STI management is frequently used in pregnant women in low- and middle-income countries, yet its low specificity and sensitivity lead to both overtreatment and undertreatment. Etiologic screening for chlamydial, gonorrheal, and/or trichomonal infection in all pregnant women combined with targeted treatment might be an effective intervention. However, the evidence base is insufficient to support the development of global recommendations. We aimed to describe key considerations and knowledge gaps regarding chlamydial, gonorrheal, and trichomonal screening during pregnancy to inform future research needed for developing guidelines for low- and middle-income countries. METHODS We conducted a narrative review based on PubMed and clinical trials registry searches through January 20, 2020, guidelines review, and expert opinion. We summarized our findings using the frameworks adopted by the World Health Organization for guideline development. RESULTS Adverse maternal-child health outcomes of potential interest are wide-ranging and variably defined. No completed randomized controlled trials on etiologic screening and targeted treatment were identified. Evidence from observational studies was limited, and trials of presumptive STI treatment have shown mixed results. Subgroups that might benefit from specific recommendations were identified. Evidence on harms was limited. Cost-effectiveness was influenced by STI prevalence and availability of testing infrastructure and high-accuracy/low-cost tests. Preliminary data suggested high patient acceptability. DISCUSSION Preliminary data on harms, acceptability, and feasibility and the availability of emerging test technologies suggest that etiologic STI screening deserves further evaluation as a potential tool to improve maternal and neonatal health outcomes worldwide.
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Affiliation(s)
| | - R. Matthew Chico
- Department of Disease Control, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Topical Medicine, London, United Kingdom
| | - Anne CC. Lee
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Nicola Low
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Andrew Medina-Marino
- Research Unit, Foundation for Professional Development, East London, South Africa; The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Rose L. Molina
- Obstetrics, Gynecology, and Reproductive Biology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Chelsea Morroni
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom; Botswana Harvard AIDS Institute, Gaborone, Botswana; Botswana UPenn Partnership, Gaborone, Botswana; Women’s Health Research University, School of Public Health and Family Medicine, University of Cape Town, South Africa
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Botswana, Gabarone, Botswana
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, Perlman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Chrysovalantis Stafylis
- Division of Infectious Diseases, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Weiming Tang
- University of North Carolina Project-China
- Dermatology Hospital of Southern Medical University, Guangzhou, China
| | - Andrew J. Vallely
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Adriane Wynn
- Pediatric Infectious Disease, David Geffen School of Medicine
| | - Nava Yeganeh
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, San Diego
| | - Jeffrey D. Klausner
- Division of Infectious Diseases and Department of Epidemiology, University of California, Los Angeles David Geffen School of Medicine and Fielding School of Public Health, Los Angeles, CA
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Painter H, Erlinger A, Simon B, Morroni C, Ramogola-Masire D, Luckett R. Impact of cervicitis on performance of cervical cancer screening using HRHPV testing and visual evaluation in women living with HIV in Botswana. Int J Gynaecol Obstet 2020; 151:144-146. [PMID: 32449207 DOI: 10.1002/ijgo.13235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 04/28/2020] [Accepted: 05/19/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Helena Painter
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Botswana UPenn Partnership, Gaborone, Botswana
| | - Adrienne Erlinger
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Chelsea Morroni
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.,Botswana UPenn Partnership, Gaborone, Botswana
| | | | - Rebecca Luckett
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Obstetrics and Gynaecology, University of Botswana, Gaborone, Botswana.,Harvard Medical School, Boston, MA, USA
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47
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Gutin SA, Harper GW, Bitsang C, Moshashane N, Ramogola-Masire D, Harries J, Morroni C. Perspectives about childbearing and pregnancy planning amongst people living with HIV in Gaborone, Botswana. Cult Health Sex 2020; 22:1063-1079. [PMID: 31478784 PMCID: PMC7182082 DOI: 10.1080/13691058.2019.1650202] [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] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 07/26/2019] [Indexed: 06/10/2023]
Abstract
Despite advances in clinical care, safer conception services are not utilised in many high HIV prevalence countries, including Botswana. We conducted in-depth interviews with 10 HIV healthcare providers and 10 women living with HIV to develop a deeper understanding of attitudes surrounding childbearing and pregnancy planning. Interviews were analysed using a phenomenological approach. Providers felt it was a human right and normative for women living with HIV to have children but also expressed concern about women living with HIV having children. Women themselves anticipated stigma from providers regarding childbearing, although most described supportive care and had not experienced stigmatising treatment. Although providers believed pregnancies amongst women living with HIV were unplanned, women described discussing pregnancy desires with sexual partners. Despite providers voicing a rights-based approach to childbearing amongst women living with HIV, hesitancy towards pregnancy remains. This is felt by women living with HIV and perceived as stigma, which may make them less likely to seek fertility and safer conception advice. Safer conception interventions are unlikely to be successful if women do not feel comfortable discussing childbearing with health-care providers.
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Affiliation(s)
- Sarah A. Gutin
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
- Women’s Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Gary W. Harper
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Christina Bitsang
- Career and Counselling Services, University of Botswana, Gaborone, Botswana
| | - Neo Moshashane
- Botswana - University of Pennsylvania Partnership, University of Botswana Main Campus, Gaborone, Botswana
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynaecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Jane Harries
- Women’s Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Chelsea Morroni
- Women’s Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Botswana - University of Pennsylvania Partnership, University of Botswana Main Campus, Gaborone, Botswana
- Liverpool School of Tropical Medicine, Liverpool, UK
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48
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Sims TT, Biegert GWG, Ramogola-Masire D, Ngoni K, Solley T, Ning MS, El Alam MB, Mezzari M, Petrosino J, Zetola NM, Schmeler KM, Colbert LE, Klopp AH, Grover S. Tumor microbial diversity and compositional differences among women in Botswana with high-grade cervical dysplasia and cervical cancer. Int J Gynecol Cancer 2020; 30:1151-1156. [PMID: 32675252 DOI: 10.1136/ijgc-2020-001547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/17/2020] [Accepted: 06/22/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION We characterized the cervical 16S rDNA microbiome of patients in Botswana with high-grade cervical dysplasia and locally advanced cervical cancer. METHODS This prospective study included 31 patients: 21 with dysplasia and 10 with cancer. The Shannon diversity index was used to evaluate alpha (intra-sample) diversity, while the UniFrac (weighted and unweighted) and Bray-Curtis distances were employed to evaluate beta (inter-sample) diversity. The relative abundance of microbial taxa was compared among samples using linear discriminant analysis effect size. RESULTS Alpha diversity was significantly higher in patients with cervical cancer than in patients with cervical dysplasia (P<0.05). Beta diversity also differed significantly (weighted UniFrac Bray-Curtis, P<0.01). Neither alpha diversity (P=0.8) nor beta diversity (P=0.19) varied by HIV status. The results of linear discriminant analysis effect size demonstrated that multiple taxa differed significantly between patients with cervical dysplasia vs cancer. Lachnospira bacteria (in the Clostridia class) were particularly enriched among cervical dysplasia patients, while Proteobacteria (members of the Firmicutes phyla and the Comamonadaceae family) were enriched in patients with cervical cancer. DISCUSSION The results of our study suggest that differences exist in the diversity and composition of the cervical microbiota between patients with cervical dysplasia and patients with cervical cancer in Botswana. Additional studies are warranted to validate these findings and elucidate their clinical significance among women living in sub-Saharan Africa, as well as other regions of the world.
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Affiliation(s)
- Travis T Sims
- Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Greyson W G Biegert
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Doreen Ramogola-Masire
- Obstetrics and Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Kebatshabile Ngoni
- Department of Biological Sciences, University of Botswana, Gaborone, Botswana
| | - Travis Solley
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Matthew S Ning
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Molly B El Alam
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Melissa Mezzari
- Molecular Virology and Microbiology, Baylor College of Medicine Alkek Center for Molecular Discovery, Houston, Texas, USA
| | - Joseph Petrosino
- Molecular Virology and Microbiology, Baylor College of Medicine Alkek Center for Molecular Discovery, Houston, Texas, USA
| | - Nicola M Zetola
- Radiation Oncology, Botswana-University of Pennsylvania Partnership, Philadelphia, Pennsylvania, USA
| | - Kathleen M Schmeler
- Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Lauren E Colbert
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ann H Klopp
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Surbhi Grover
- Radiation Oncology, Botswana-University of Pennsylvania Partnership, Philadelphia, Pennsylvania, USA
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Ramogola-Masire D, Poku O, Mazhani L, Ndwapi N, Misra S, Arscott-Mills T, Blank L, Ho-Foster A, Becker TD, Yang L. Botswana's HIV response: Policies, context, and future directions. J Community Psychol 2020; 48:1066-1070. [PMID: 31951283 PMCID: PMC7103557 DOI: 10.1002/jcop.22316] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 12/20/2019] [Indexed: 06/10/2023]
Abstract
This brief report describes key periods in the history of the national public health response to the human immunodeficiency virus (HIV) epidemic in Botswana. It reveals the context leading to the development of HIV policies presently in place and current challenges that remain. The report concludes with opportunities for future directions, initiatives, and policy changes to reduce the high rates of HIV.
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Affiliation(s)
- Doreen Ramogola-Masire
- Research and Graduate Studies, University of Botswana Faculty of Medicine, Gaborone, Botswana
| | - Ohemaa Poku
- Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Loeto Mazhani
- Research and Graduate Studies, University of Botswana Faculty of Medicine, Gaborone, Botswana
| | - Ndwapi Ndwapi
- Center for International Health, Education, and Biosecurity (CIHEB), University of Maryland School of Medicine, Baltimore, Maryland
| | - Supriya Misra
- Social and Behavioral Sciences, New York University College of Global Public Health, New York, New York
| | - Tonya Arscott-Mills
- Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Lilo Blank
- Psychology, University of Rochester School of Arts and Sciences, Rochester, New York
| | - Ari Ho-Foster
- Research and Graduate Studies, University of Botswana Faculty of Medicine, Gaborone, Botswana
- Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Timothy D Becker
- Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lawrence Yang
- Social and Behavioral Sciences, New York University College of Global Public Health, New York, New York
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50
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Gutin SA, Harper GW, Amico KR, Bitsang C, Moshashane N, Harries J, Ramogola-Masire D, Morroni C. 'I'm waiting for that': Interest in the use of PrEP for safer conception in Botswana. Glob Public Health 2020; 15:1200-1211. [PMID: 32175819 DOI: 10.1080/17441692.2020.1741663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Safe and effective low-cost safer conception (SC) methods are increasingly available and being integrated into national guidelines in sub-Saharan African contexts. Sero-different couples of childbearing age can benefit from such services and the routine provision of SC counselling. Pre-exposure prophylaxis (PrEP) to prevent HIV acquisition to uninfected partners can reduce the chances of HIV transmission when trying to achieve pregnancy. Botswana has a strong commitment to reducing new HIV infections but PrEP is not yet widely available and little guidance has been offered on counselling sero-different couples. We conducted qualitative in-depth interviews in Gaborone, Botswana with 10 HIV healthcare providers and 10 women living with HIV of childbearing age because they act as a key conduit for reaching sero-different partners with information about PrEP. We examined knowledge and attitudes towards PrEP to assess the viability and develop a deeper understanding of this SC option. Interviews were analysed using an interpretive phenomenological approach. Three themes emerged: (1) awareness of PrEP is limited, (2) providers and women overwhelmingly showed interest in PrEP and (3) women living with HIV and providers have concerns about PrEP use. With the correct support, PrEP could be a useful SC option for sero-different couples in Botswana and other sub-Saharan contexts.
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Affiliation(s)
- Sarah A Gutin
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA.,Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Center for AIDS Prevention Studies, Division of Prevention Science, University of California, San Francisco, San Francisco, CA, USA
| | - Gary W Harper
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - K Rivet Amico
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Christina Bitsang
- Career and Counseling Services, University of Botswana, Gaborone, Botswana
| | | | - Jane Harries
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Obstetrics and Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Chelsea Morroni
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Botswana U-Penn Partnership, Gaborone, Botswana.,Liverpool School of Tropical Medicine, Liverpool, UK
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