Objectives-HIV-infected women living in resource-constrained nations like Zambia are now accessing antiretroviral therapy and thus may live long enough for HPV-induced cervical cancer to manifest and progress. We evaluated the prevalence and predictors of cervical squamous intraepithelial lesions (SIL) among HIV-infected women in Zambia.Methods-We screened 150 consecutive, non-pregnant HIV-infected women accessing HIV/AIDS care services in Lusaka, Zambia. We collected cervical specimens for cytological analysis by liquidbased monolayer cytology (ThinPrep Pap Test®) and HPV typing using the Roche Linear Array® PCR assay.Results-The median age of study participants was 36 years (range 23-49 years) and their median CD4+ count was 165/μL (range 7-942). The prevalence of SIL on cytology was 76% (114/150), of which 23.3% (35/150) women had low-grade SIL, 32.6% (49/150) had high-grade SIL, and 20% (30/150) had lesions suspicious for squamous cell carcinoma (SCC). High-risk HPV types were present in 85.3% (128/150) women. On univariate analyses, age of the participant, CD4+ cell count, and presence of any high-risk HPV type were significantly associated with the presence of severely abnormal cytological lesions (i.e., high-grade SIL and lesions suspicious for SCC). Multivariable logistic regression modeling suggested the presence of any high-risk HPV type as an independent predictor of severely abnormal cytology (adjusted OR: 12.4, 95% CI 2.62-58.1, p=0.02).Conclusions-The high prevalence of abnormal squamous cytology in our study is one of the highest reported in any population worldwide. Screening of HIV-infected women in resourceconstrained settings like Zambia should be implemented to prevent development of HPV-induced SCC.
BackgroundVery few efforts have been undertaken to scale-up low-cost approaches to cervical cancer prevention in low-resource countries.MethodsIn a public sector cervical cancer prevention program in Zambia, nurses provided visual-inspection with acetic acid (VIA) and cryotherapy in clinics co-housed with HIV/AIDS programs, and referred women with complex lesions for histopathologic evaluation. Low-cost technological adaptations were deployed for improving VIA detection, facilitating expert physician opinion, and ensuring quality assurance. Key process and outcome indicators were derived by analyzing electronic medical records to evaluate program expansion efforts.FindingsBetween 2006-2013, screening services were expanded from 2 to 12 clinics in Lusaka, the most-populous province in Zambia, through which 102,942 women were screened. The majority (71.7%) were in the target age-range of 25–49 years; 28% were HIV-positive. Out of 101,867 with evaluable data, 20,419 (20%) were VIA positive, of whom 11,508 (56.4%) were treated with cryotherapy, and 8,911 (43.6%) were referred for histopathologic evaluation. Most women (87%, 86,301 of 98,961 evaluable) received same-day services (including 5% undergoing same-visit cryotherapy and 82% screening VIA-negative). The proportion of women with cervical intraepithelial neoplasia grade 2 and worse (CIN2+) among those referred for histopathologic evaluation was 44.1% (1,735/3,938 with histopathology results). Detection rates for CIN2+ and invasive cervical cancer were 17 and 7 per 1,000 women screened, respectively. Women with HIV were more likely to screen positive, to be referred for histopathologic evaluation, and to have cervical precancer and cancer than HIV-negative women.InterpretationWe creatively disrupted the 'no screening' status quo prevailing in Zambia and addressed the heavy burden of cervical disease among previously unscreened women by establishing and scaling-up public-sector screening and treatment services at a population level. Key determinants for successful expansion included leveraging HIV/AIDS program investments, and context-specific information technology applications for quality assurance and filling human resource gaps.
Groesbeck Parham and colleagues describe their Cervical Cancer Prevention Program in Zambia, which has provided services to over 58,000 women over the past five years, and share lessons learned from the program's implementation and integration with existing HIV/AIDS programs.
Greater than 80% of the world's new cases and deaths due to cervical cancer occur in the developing world [1]. No more than 5% of women in these settings are screened for cervical cancer even once in their lifetimes [2]. Earlier attempts to establish population-based cervical cancer prevention programs using cytology screening in resource-limited settings have inevitably fallen short or failed [3][4][5]. Although many of the reasons for failure can be attributed to lack of resources and trained manpower, the multiple visit requirements of cytology-based screening programs jeopardizes success and sustainability.HIV infection is associated with higher incidence, more rapid progression, and increased recurrence rates of human papillomavirus (HPV)-associated cervical intraepithelial neoplasia (CIN) and invasive cervical cancer, an AIDS-defining disease [6][7][8][9][10][11][12][13][14]. The last decade has seen a global push for increasing access to affordable antiretroviral therapy (ART) for HIV-infected individuals in the developing world. Programs such as the US President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria, have substantially upgraded healthcare infrastructures in many parts of sub-Saharan Africa and elsewhere at a scale never experienced in history [15,16]. Zambia has one of the world's highest cervical cancer incidence rates (53.7/100 000 women/year) and also a national adult HIV seroprevalence rate of 16% (23% in Lusaka, the capital city) [1,17]. Through PEPFARsupported programs, greater than 100 000 people (50% women) are now (September 2008) accessing ART in Zambia [18]. This care is largely delivered through partnerships between the public sector, nonprofit organizations, development agencies, and academic institutions. [19,20]. To our knowledge, this is the first effort within PEPFAR-supported programs to undertake cervical cancer prevention as a component of HIV care. We describe some of the major lessons learned through our experiences in the field operationalization of this program:1. Integration of the program within preexisting healthcare infrastructures ensures access to the target population and sustainability.Government-operated clinics provide healthcare for a majority of Lusaka's residents who cannot afford private sector care. We integrated cervical cancer prevention services into these public sector health clinics as a routine healthcare service for women. Significant advantages of integration include access to physical space, preexisting utilities, maintenance and toxic waste disposal services, and other medical/pharmacy services for patients and ease of referral to and from other departments within the health center. Improvements to the infrastructure from our program's funds benefited the general healthcare infrastructure, and vice-versa. Such circumstances facilitated the initiation and roll-out of our program, and soon changed the 'on the ground' view of our activities from 'special project' to 'routine service.'2. Piggy...
BackgroundIn the absence of stand-alone infrastructures for delivering cervical cancer screening services, efforts are underway in sub-Saharan Africa to dovetail screening with ongoing vertical health initiatives like HIV/AIDS care programs. Yet, evidence demonstrating the utilization of cervical cancer prevention services in such integrated programs by women of the general population is lacking.MethodsWe analyzed program operations data from the Cervical Cancer Prevention Program in Zambia (CCPPZ), the largest public sector programs of its kind in sub-Saharan Africa. We evaluated patterns of utilization of screening services by HIV serostatus, examined contemporaneous trends in screening outcomes, and used multivariable modeling to identify factors associated with screening test positivity.ResultsBetween January 2006 and April 2011, CCPPZ services were utilized by 56,247 women who underwent cervical cancer screening with visual inspection with acetic acid (VIA), aided by digital cervicography. The proportion of women accessing these services who were HIV-seropositive declined from 54% to 23% between 2006–2010, which coincided with increasing proportions of HIV-seronegative women (from 22% to 38%) and women whose HIV serostatus was unknown (from 24% to 39%) (all p-for trend<0.001). The rates of VIA screening positivity declined from 47% to 17% during the same period (p-for trend <0.001), and this decline was consistent across all HIV serostatus categories. After adjusting for demographic and sexual/reproductive factors, HIV-seropositive women were more than twice as likely (Odds ratio 2.62, 95% CI 2.49, 2.76) to screen VIA-positive than HIV-seronegative women.ConclusionsThis is the first ‘real world’ demonstration in a public sector implementation program in a sub-Saharan African setting that with successful program scale-up efforts, nurse-led cervical cancer screening programs targeting women with HIV can expand and serve all women, regardless of HIV serostatus. Screening program performance can improve with adequate emphasis on training, quality control, and telemedicine-support for nurse-providers in clinical decision making.
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