Cervical cancer screening and treatment, HIV infection, and age: Program implementation in seven regions of Namibia

Abstract

The aim of this study was to assess differences in cervical cancer screening and treatment outcomes by HIV status in a routine programmatic setting with a high generalized HIV prevalence. Women living with HIV (WLHIV) are at heightened risk of developing cervical cancer and the World Health Organization recommends all WLHIV who are sexually active be screened, regardless of age. In 2018, Namibia’s Ministry of Health and Social Services introduced a screen-and-treat approach using visual inspection with acetic acid (VIA) and ablative treatment with cryotherapy or thermocoagulation with a focus on screening HIV-positive women due to Namibia’s 11.5% prevalence of HIV in women aged 15–49. Using program data from October 2018 to March 2020 from seven of the country’s 14 regions, we calculated descriptive statistics and chi-square tests to test the statistical significance of differences in VIA-positivity, ineligibility for ablative treatment, treatment completion, and same day treatment completion by HIV status. Between October 2018 and March 2020, the program conducted 14,786 cervical cancer screenings. Among 8,150 women who received their first VIA screening, more WLHIV screened VIA-positive (17%) than HIV-negative women (15%). This difference was statistically significant (p = 0.02). Among 2,272 women who screened VIA-positive at any screening, 1,159 (82%) completed ablative treatment. This suggests ablative treatment is feasible and acceptable in resource-limited settings. WLHIV were also more likely to complete treatment than HIV-negative women (p<0.01). Differences in health seeking behavior of sub-populations as well as resource availability between service delivery points should be considered for further investigation. Going forward in order to strengthen program implementation and expand screening access and uptake further investigation is needed to determine cancer incidence by HIV status, age, and time since last screening to assess cases that are averted as well as potential rates of overtreatment.

Real-World Cervical Cancer Screening Uptake and Predictors of Visual Inspection With Acetic Acid Positivity Among Women Living With HIV in Care Programs in Western Kenya

“… 37 The variability in VIA positivity rates, given its subjective nature, has previously been documented. 38 Our finding that younger women were more likely to be VIA-positive has been demonstrated in a study in Zambia 37 and in a study in Namibia, 36 and is consistent with the epidemiology of HPV being more common in younger women. The association of lower VIA positivity among those on ART was previously demonstrated among WLWHIV in Malawi, 39 and also in a meta-analysis of 31 studies where WLWHIV on ART were less likely to have high-risk HPV or biopsy-confirmed cervical precancer.…”

Screen-and-Treat Approach in Secondary Prevention of Cervical Cancer among HIV-Infected Women in Faith Alive Hospital, Jos Nigeria

“…The peak prevalence of cervical precancerous lesions was observed at 36 -45 years and this is comparable to findings of other studies [18] [19]. A total of 63 (62.4%) clients with cervical precancerous lesions were married, 54 (53.5%) had a parity of ≥3, 47 (46.5%) reported coitarche at less than 18 years, and 78 (77.2%) had a history of multiple sexual The prevalence of suspected cervical cancer in this study was 1.6%, similar to 1.0% in Namibia [18], 0.9% in Malawi [21], and 2.1% in Harare City [23]; however, a lower prevalence of 0.56% was reported among HIV-negative women in rural South Indian women [25]. A bimodal age classification for suspected cancer was noted: 7 (38.9%) for ages 26 -35 years and 36 -45 years; this corresponds to the bimodal age distribution of cervical cancer, with a first peak at age 43 years and a relative rebound at age 61 years, taking into account a 5 -15 year shift from precancerous to full-blown cervical cancer [26].…”

“…Multiple sexual partners, age 36 -45 years, and sexually transmitted infections (STIs) were factors found to be associated with precancerous lesions, and these are at par with findings in other studies [18] [19] [21] [22]. After subjecting these factors to multiple logistic regression, STI was found to be a significant predictor of cervical precancerous lesion in this study (OR 1.634, 95% CI: 1.061 -2.518, p-value 0.026).…”

“…In this screen-and-treat approach, women are tested through visual inspection of the cervix with acetic acid (VIA) and Lugol's iodine (VILI) and receive immediate treatment for pre-cancerous lesions using thermal ablation if they screen positive. This approach is a simple and affordable alternative, allowing nurses, midwives, and other non-physician healthcare workers to become trained providers, potentially improving access to cervical cancer prevention services [18] [19] [20] [21].…”

Facilitators and Barriers to HPV Self-Sampling as a Cervical Cancer Screening Option among Women Living with HIV in Rural Uganda

“…Perceived benefits of the clinic-based HPV self-sampling were mainly considered to be the visualization of the cervix and free service. An example would be the findings in other studies, where HIV-infected women were motivated to screen for CC at the clinic [9], and all those who were suspected of having the disease completed treatment, compared to the HIV-negative women [28,32]. In Uganda, HIV-infected women are also motivated to be screened at the clinic and by the HW, as this increases the chances for the early diagnosis and treatment of the disease [28].…”