Abstract
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.
Highlights
Invasive cervical cancer (ICC) is a leading cause of cancerrelated mortality and morbidity among women in the developing world [1,2]
Simplified ‘‘screen and treat’’ approaches [such as visual inspection with acetic acid (VIA) and immediate cryotherapy] for secondary prevention of cervical cancer have been developed for field adoption in resource-constrained settings where implementation and expansion of cytology (Pap smear)-based screening programs have proven unsustainable and human papillomavirus (HPV) testing is not yet available [3,4,5,6,7,8]
HIV serostatus confirmation is by selfreport, most HIV-seropositive women are ‘linked’ to the HIV/ AIDS care and treatment clinics co-located and operational in the same premises
Summary
Invasive cervical cancer (ICC) is a leading cause of cancerrelated mortality and morbidity among women in the developing world [1,2]. Several international efforts are currently underway in sub-Saharan Africa to dovetail cervical cancer screening with ongoing vertical health initiatives, prominently with HIV/AIDS care and treatment programs [8,9,10]. Access to affordable combination antiretroviral therapy (cART) over the past decade has led to longer lifespans among HIV-seropositive women They continue to be at higher risk for cervical cancer given lack of access to cervical cancer screening [11,12]. Evidence demonstrating the utilization and uptake of cervical cancer services offered in this format by women of the general population, beyond those who are HIV-seropositive, is lacking. In 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. Evidence demonstrating the utilization of cervical cancer prevention services in such integrated programs by women of the general population is lacking
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