In Botswana, where human immunodeficiency virus (HIV) prevalence remains high, cervical cancer is the leading cause of cancer deaths in women. Multiple organizations recommend high-risk human papillomavirus (hr-HPV) testing as a screening tool; however, high coverage may not be feasible with provider-collected samples. We conducted the first assessment of self- versus provider-collected samples for hr-HPV testing in HIV-positive women in Botswana and report prevalence of hr-HPV and histological outcomes. We recruited HIV-positive women ≥25 years attending an HIV clinic in Gaborone. Self- and provider-collected samples from participants were tested for hr-HPV using Cepheid GeneXpert. Women testing positive for any hr-HPV returned for colposcopy. We used unweighted κ statistics to determine hr-HPV agreement. We report that 31 (30%) of 103 women tested positive for any hr-HPV. The most common genotypes were HPV 31/33/35/52/58. Overall agreement between self- and provider-collected samples for any hr-HPV was 92% with a κ of 0.80. Ten of the 30 hr-HPV-positive women attending colposcopy had CIN2+ (33%). In conclusion, in this HIV-positive population, there was excellent agreement between self and provider samples, and self-sampling may play an important role in screening programs in high HIV burden settings with limited resources like Botswana.

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.

Background Intravaginal practices (IVPs) are behaviours undertaken by women in diverse global settings for the promotion of hygiene and sexual health. Although evidence is inconclusive, it has been suggested that they may be harmful and associated with adverse gynaecological outcomes. The objective of this study was to investigate whether there is an association between IVPs, human papillomavirus (HPV) infection and the development of cervical cancer. As human immunodeficiency virus (HIV) infection may be a factor accelerating progression, recent evidence on the association between IVPs and HIV was also considered. Methods A systematic review of primary observational studies was carried out according to PRISMA (Preferred Reporting Items for Systematic Reviews) guidelines. A detailed search strategy was developed and modified for use in six databases and grey literature sources, searching from 01 January 1990 to 03 June 2019. Due to marked heterogeneity, narrative synthesis was used to combine findings. Results Twenty studies met the review criteria. The majority of studies were cross-sectional, and of moderate to low quality. A total of 14,493 participants were included, from 15 countries. IVP prevalence ranged from below 10% to over 90% across study populations. Six of eleven studies found an increased risk of HPV infection with IVPs; five of seven studies found an increased risk of cervical disease with IVPs. Two studies examining association of IVPs with risk of HIV infection were identified: both found associations with intravaginal cleansing, one found an association with intravaginal insertion. Potential moderator variables including the types of substances used, the frequency, timing and duration of IVP use were assessed: evidence was conflicting and inconsistent. Conclusions Current evidence is largely suggestive of a harmful association between IVPs and the development of cervical cancer. However, significant methodological limitations were recognised; there is a need for well-designed studies using consistent definitions and classifications. Intravaginal practices (IVPs) are behaviours undertaken by women for the promotion of hygiene and sexual health in sub-Saharan Africa, SouthEast Asia, and North and South America. A classification of different IVPs has been proposed by the World Health Organization (WHO) Gender, Sexuality and Vaginal Practices (GSVP) Study Group 1,2 (Box 1). Use of IVPs can alter the vaginal micro-environment, and are postulated to lead to several adverse gynaecological outcomes. 3-5 This has been hypothesised to be due to micro-trauma, inflammation and changes to the vaginal pH and vaginal flora thereby interfering with protective immunological mechanisms. 6-8 However, evidence to support this association has been conflicting. Most recently, the association of IVPs with human immunodeficiency virus (HIV) was investigated in two systematic reviews 4,9 and was found to be inconclusive but potentially related to harm. No previous systematic review has assessed the general association ...

No abstract