Objective: To map the cervical cancer screening cascade among women living with HIV attending a public-sector cytology screening program in Johannesburg, South Africa. Methods: We conducted a retrospective cohort study of routinely collected clinical data captured in an electronic medical record system. Women (≥18 years) living with HIV with an abnormal Pap result between January 2013 and May 2018 were included. The proportion of women who received follow-up consistent with extant clinical guidelines, stratified by their initial Pap smear result, was examined. Results: The study included 2072 women: 1384 (66.8%) with a low-risk Pap result, 681 (32.9%) with a high-risk Pap result, and 7 (0.3%) with suspected cancer. Only 174 (25.6%) women with a high-risk Pap result underwent guideline-indicated management within 18 months. Among women with a low-risk Pap result, 375 (27.1%) received follow-up within 1 year; the cumulative incidence of follow-up increased to 63.1% at 3 years. All women with suspected cancer either received a colposcopic biopsy or were referred for further treatment. Conclusion: Attrition among South African women living with HIV who attended cervical screening in an urban public-sector program was high. Developing tailored interventions to address bottlenecks in the care cascade and improve cervical screening outcomes will be central to eliminating cervical cancer.
Objective To determine preferences for HPV‐based cervical cancer screening among South African women. Methods A discrete choice experiment survey was conducted among 298 women who attended two public‐sector clinics in South Africa from February 1 to May 31, 2018. Participants chose between hypothetical screening scenarios: method of swab collection (self or provider); timing of treatment (same day or return visit); type of clinic (static or mobile); cost of services (US $0 or US $4); and time spent at the clinic (30, 60, or 120 minutes). A logistic regression model was generated to evaluate the importance of each attribute. A market simulation analysis was performed to determine potential uptake of the various screening strategies. Results The participants expressed strong preferences for free services (β=0.50; P<0.001) and same‐day HPV testing and treatment (β=0.40; P<0.001). The market simulation indicated that 83.8% of women would be willing to undergo screening if services were free; the swab was collected by the provider; and treatment was offered at a return visit. Including same‐day testing and treatment in the model increased uptake to 96.4%. Conclusion Offering same‐day HPV testing and treatment could substantially improve uptake of cervical cancer screening in the South African public healthcare sector.
INTRODUCTION: Despite universal access to antiretroviral therapy (ART) in South Africa, the burden of cervical cancer and its precursors among HIV-infected women remains substantial. METHODS: Using electronic medical record data from our cervical cancer prevention program in Johannesburg, we conducted a retrospective analysis (IRB approval obtained) of HIV-infected women undergoing screening, colposcopy, and loop electrosurgical excision procedures (LEEP) for cervical intra-epithelia neoplasia (CIN). We report baseline characteristics of this high-risk cohort. RESULTS: Between January 2011 and June 2018, 2,801 HIV-infected women were included in the cohort. The median age was 42 years (interquartile range [IQR] 35-49). 2,649 (95%) women were receiving ART and the median CD4 count was 520 cells/uL (IQR 359-700). Our analysis database included 3,613 Pap smears, 556 diagnostic biopsies, and 153 LEEPs. More than half of the cytology results (54%) were abnormal, requiring follow-up. The risk of biopsy-confirmed disease was also high: 243/556 (44%) cases of CIN1 and 198/556 (36%) of CIN2/3. Among 153 LEEPs, there were 35 (23%) cases of CIN1 and 106 (69%) of CIN2/3. Of these, residual disease was reported in 65/91 (71%) cases, with one margin positive in 32/91 (35%) and both margins positive in 33/91 (36%). LEEP margin status was not associated with grade of CIN (P=.07). CONCLUSION: In this cohort of HIV-infected women living in urban South Africa, attrition between screening, diagnosis, and treatment was considerable. Additionally, the LEEP margins were positive in more than two-thirds of women, raising concern for treatment failure and subsequent progression to invasive cervical cancer.
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