Edith Welty

Integrating prevention of mother-to-child HIV transmission into routine antenatal care: the key to program expansion in Cameroon.

With funds from Elizabeth Glaser Pediatric AIDS Foundation, the Cameroon Baptist Convention Health Board implemented a program to prevent mother-to-child transmission of HIV-1 (PMTCT) as part of its routine antenatal care, with single-dose maternal and infant peripartum nevirapine (NVP) prophylaxis of HIV-positive mothers and their babies. Nurses, midwives, nurse aides, and trained birth attendants counseled pregnant women, obtained risk factor data, and offered free HIV testing with same-day results. From February 2000 through December 2004, this program rapidly expanded to 115 facilities in 6 of Cameroons 10 provinces, not only to large hospitals but to remote health centers staffed by trained birth attendants. We trained 690 health workers in PMTCT and counseled 68,635 women, 91.9% of whom accepted HIV testing. Of 63,094 women tested, 8.7% were HIV-1-positive. Independent risk factors for HIV-1 infection included young age at first sexual intercourse, multiple sex partners, and positive syphilis serology (P < 0.001 for each). We counseled 98.7% of positive and negative mothers on a posttest basis. Of 5550 HIV-positive mothers, we counseled 5433 (97.9%) on single-dose NVP prophylaxis. Consistent training and programmatic support contributed to rapid upscaling and high uptake and counseling rates.

Knowledge and Awareness of HPV Vaccine and Acceptability to Vaccinate in Sub-Saharan Africa: A Systematic Review

Objectives We assessed the knowledge and awareness of cervical cancer, HPV and HPV vaccine, and willingness and acceptability to vaccinate in sub-Saharan African (SSA) countries. We further identified countries that fulfill the two GAVI Alliance eligibility criteria to support nationwide HPV vaccination. Methods We conducted a systematic review of peer-reviewed studies on the knowledge and awareness of cervical cancer, HPV and HPV vaccine, and willingness and acceptability to vaccinate. Trends in Diphtheria-tetanus-pertussis (DTP3) vaccine coverage in SSA countries from 1990–2011 were extracted from the World Health Organization database. Findings The review revealed high levels of willingness and acceptability of HPV vaccine but low levels of knowledge and awareness of cervical cancer, HPV or HPV vaccine. We identified only six countries to have met the two GAVI Alliance requirements for supporting introduction of HPV vaccine: 1) the ability to deliver multi-dose vaccines for no less than 50% of the target vaccination cohort in an average size district, and 2) achieving over 70% coverage of DTP3 vaccine nationally. From 2008 through 2011 all SSA countries, with the exception of Mauritania and Nigeria, have reached or maintained DTP3 coverage at 70% or above. Conclusion There is an urgent need for more education to inform the public about HPV, HPV vaccine, and cervical cancer, particularly to key demographics, (adolescents, parents and healthcare professionals), to leverage high levels of willingness and acceptability of HPV vaccine towards successful implementation of HPV vaccination programs. There is unpreparedness in most SSA countries to roll out national HPV vaccination as per the GAVI Alliance eligibility criteria for supporting introduction of the vaccine. In countries that have met 70% DTP3 coverage, pilot programs need to be rolled out to identify the best practice and strategies for delivering HPV vaccines to adolescents and also to qualify for GAVI Alliance support.

Evaluation of Rapid Prenatal Human Immunodeficiency Virus Testing in Rural Cameroon

ABSTRACT Pregnant women (n = 859) in rural Cameroonian prenatal clinics were screened by two rapid human immunodeficiency virus (HIV) antibody tests (rapid tests [RT]) (Determine and Hema-Strip) using either whole blood or plasma. One additional RT (Capillus, HIV-CHEK, or Sero-Card) was used to resolve discordant results. RT results were compared with HIV-1 enzyme immunoassay (EIA) and Western blot (WB) results of matched dried blood spots (DBS) to assess the accuracy of HIV RTs. DBS EIA/WB identified 83 HIV antibody-reactive, 763 HIV antibody-nonreactive, and 13 indeterminate specimens. RT results were evaluated in serial (two consecutive tests) or parallel (two simultaneous tests) testing algorithms. A serial algorithm using Determine and Hema-Strip yielded sensitivity and specificity results of 97.6% and 99.7%, respectively, whereas a parallel RT algorithm using Determine plus a second RT produced a sensitivity and specificity of 100% and 99.7%, respectively. HIV RTs provide excellent alternatives for identifying HIV infection, and their field performance could be monitored using DBS testing strategies.

Achieving high uptake of human papillomavirus vaccine in Cameroon: Lessons learned in overcoming challenges

BACKGROUND Cameroon has the highest age-standardized incidence rate of cervical cancer (30/100,000 women) in Central Africa. In 2010-2011, the Cameroon Baptist Convention Health Services (CBCHS) received donated human papillomavirus (HPV) vaccine, Gardasil, from Merck & Co. Inc. through Axios Healthcare Development to immunize 6400 girls aged 9-13 years. The aim was to inform the Cameroon Ministry of Health (MOH) of the acceptability, feasibility, and optimal delivery strategies for HPV vaccine. METHODS AND FINDINGS Following approval by the MOH, CBCHS nurses educated girls, parents, and communities about HPV, cervical cancer, and HPV vaccine through multimedia coverage, brochures, posters, and presentations. Because educators were initially reluctant to allow immunization in schools, due to fear of adverse events, the nurses performed 40.7% of vaccinations in the clinics, 34.5% in community venues, and only 24.7% in schools. When no adverse events were reported, more schools and communities permitted HPV vaccine immunization on their premises. To recover administrative costs, CBCHS charged a fee of US

Prevalence, Predictors, and Same Day Treatment of Positive VIA Enhanced by Digital Cervicography and Histopathology Results in a Cervical Cancer Prevention Program in Cameroon.

8 per 3-dose series only to those who were able to pay. Despite the fee, 84.6% of the 6,851 girls who received the first dose received all three doses. CONCLUSIONS AND LESSONS LEARNED With adequate education of all stakeholders, HPV vaccination is acceptable and feasible in Cameroon. Following this demonstration project, in 2014 the Global Access to Vaccines and Immunization (GAVI) Alliance awarded the Cameroon MOH HPV vaccine at a price of US

Cervical Cancer Screening in Cameroon: Interobserver Agreement on the Interpretation of Digital Cervicography Results.

4.50 per dose to immunize sixth grade girls and girls aged 10 years who are not in school in two districts of Cameroon.

Evaluation of See-and-Treat Cervical Cancer Screening in Human Immunodeficiency Virus–Positive and Human Immunodeficiency Virus–Negative Women in Cameroon [332]

Background In 2007, the Cameroon Baptist Convention Health Services (CBCHS) implemented a screen-and-treat cervical cancer prevention program using visual inspection with acetic acid enhanced by digital cervicography (VIA-DC). Methods We retrospectively analyzed 46,048 medical records of women who received care through the CBCHS Women’s Health Program from 2007 through 2014 to determine the prevalence and predictors of positive VIA-DC, rates of same day treatment, and cohort prevalence of invasive cervical cancer (ICC). Results Of the 44,979 women who were screened for cervical cancer, 9.0% were VIA-DC-positive, 66.8% were VIA-DC-negative, 22.0% were VIA-DC-inadequate (normal ectocervix, but portions of the transformation zone were obscured), and 2.2% were VIA-DC-uncertain (cervical abnormalities confounding VIA-DC interpretation). Risk factors significantly associated with VIA-DC-positive screen were HIV-positivity, young age at sexual debut, higher lifetime number of sexual partners, low education status and higher gravidity. In 2014, 31.1% of women eligible for cryotherapy underwent same day treatment. Among the 32,788 women screened from 2007 through 2013, 201 cases of ICC were identified corresponding to a cohort prevalence of 613 per 100,000. Conclusions High rate of VIA-DC-positive screens suggests a significant burden of potential cervical cancer cases and highlights the need for expansion of cervical cancer screening and prevention throughout the 10 regions of Cameroon. VIA-DC-inadequate rates were also high, especially in older women, and additional screening methods are needed to confirm whether these results are truly negative. In comparison to similar screening programs in sub-Saharan Africa there was low utilization of same day cryotherapy treatment. Further studies are required to characterize possible program specific barriers to treatment, for example cultural demands, health system challenges and cost of procedure. The prevalence of ICC among women who presented for screening was high and requires further investigation.

Improving American Indian Health

Objective The World Health Organization recommends visual inspection with acetic acid (VIA) for cervical cancer screening in resource-limited settings. In Cameroon, we use digital cervicography (DC) to capture images of the cervix after VIA. This study evaluated interobserver agreement of DC results, compared DC with histopathologic results, and examined interobserver agreement among screening methods. Method Three observers, blinded to each others interpretations, evaluated 540 DC photographs as follows: (1) negative/positive for acetowhite lesions or cancer and (2) assigned a presumptive diagnosis of histopathologic lesion grade in the 91 cases that had a histopathologic diagnosis. Observer A was the actual screening nurse; B, a reproductive health nurse; C, a gynecologic oncologist; and D, the histopathologic diagnosis. We compared inter-rater agreement of DC impressions among observers A, B, and C, and with D, with Cohen kappas. Results For interpretations of DC, (negative/positive) strengths of agreement of paired observers were the following: A/B, moderate [K, 0.54; 95% confidence interval (CI), 0.47–0.61], A/C, fair (K, 0.37; 95% CI, 0.29–0.44), and B/C, moderate (K, 0.45; 95% CI, 0.37–0.53). For presumptive pathologic grading, strengths of agreement for weighted Ks were as follows: A/B, moderate (K, 0.42; 95% CI, 0.28–0.56); A/C, fair (K, 0.33; 95% CI, 0.20–0.46); B/C, fair (K, 0.54; 95% CI, 0.40–0.67); A/D, moderate (K, 0.59; 95% CI, 0.45–0.74); B/D, moderate (K, 0.58; 95% CI, 0.46–0.70); and C/D, moderate (K, 0.50; 95% CI, 0.37-0.63). Conclusions Interobserver agreement of DC interpretations was mostly moderate among the 3 observers, between them and histopathology, and comparable to that of other visual-based screening methods, i.e., VIA, cytology, or colposcopy.

Assessing the Effectiveness of a Community-Based Sensitization Strategy in Creating Awareness About HPV, Cervical Cancer and HPV Vaccine Among Parents in North West Cameroon

BACKGROUND: Invasive cervical cancer is the second leading cause of cancer mortality among women in Cameroon. To decrease the burden of invasive cervical cancer, the Cameroon Baptist Convention Health Services implemented the World Health Organization-endorsed “see-and-treat” cervical cancer screening program using visual inspection with acetic acid enhanced by digital cervicography. Our aim was determine the prevalence and predictors of a positive screen, rates of same-day treatment, and prevalence of cervical intraepithelial neoplasia (CIN) and invasive cervical cancer. METHODS: We completed a retrospective analysis of 33,730 Cameroon Baptist Convention Health Services patients screened between 2007 and 2013. RESULTS: Of the 33,660 cases with valid visual inspection with acetic acid data, 9.5% of women screened visual inspection with acetic acid-positive, 62.7% were visual inspection with acetic acid-negative, and 27.8% were considered “uncertain” as a result of poor visualization of the cervix or concurrent cervicitis. After covariate adjustment in a multivariable logistic regression model, human immunodeficiency virus (HIV)–positive women were 1.33 times more likely to screen visual inspection with acetic acid-positive than HIV-negative women (95% confidence interval 1.16–1.54, P<.001). Other factors associated with visual inspection with acetic acid-positive screens were rural screening location, gravidity, age at sexual debut, and number of lifetime sexual partners. Among women eligible for same-day cryotherapy, only 43% accepted the treatment. Pathology specimens (n=750) collected from women with visual inspection with acetic acid-positive lesions ineligible for cryotherapy identified 30% of cases as invasive cervical cancer and 70% as CIN. CONCLUSION: Risk factors for a positive screen included HIV positivity, rural location, and sexual behavior. Less than half of eligible patients opted for same-day treatment. Further studies are required to better identify barriers to implementing same-day treatment protocols.

Awareness, knowledge and beliefs about HPV, cervical cancer and HPV vaccines among nurses in Cameroon: An exploratory study

In this autobiographical chapter, we have focused on the parts of our lives most likely to provide a unique perspective for health care professionals. By describing certain types of personal and professional experiences, we aim to encourage and inform medical students and physicians interested in social change. For those in the medical profession, we hope that our stories will stimulate some of you to seek innovative ways to identify and prioritize health problems and to improve medical care. In the hopes that readers may benefit, we have included not only successes but mistakes. We have never perceived our work as requiring major sacrifices. On the contrary, we have enjoyed the cross-cultural relationships with American Indians, the challenge and gratification of helping to improve medical care on a community-wide basis, and the outdoor life-style afforded by the rural locations where we have lived. We have chosen to write in the third person to enable us to express ourselves as individuals rather than as a unit.