Megan J. Huchko

Building capacity for cervical cancer screening in outpatient HIV clinics in the Nyanza province of western Kenya

To evaluate outcomes of cervical cancer screening within HIV care and treatment clinics in Kenya.

A systematic review of randomized trials assessing human papillomavirus testing in cervical cancer screening

Our objective was to assess the sensitivity and specificity of human papillomavirus (HPV) testing for cervical cancer screening in randomized trials. We conducted a systematic literature search of the following databases: MEDLINE, CINAHL, EMBASE, and Cochrane. Eligible studies were randomized trials comparing HPV-based to cytology-based screening strategies, with disease status determined by colposcopy/biopsy for participants with positive results. Disease rates (cervical intraepithelial neoplasia [CIN]2 or greater and CIN3 or greater), sensitivity, and positive predictive value were abstracted or calculated from the articles. Six studies met inclusion criteria. Relative sensitivities for detecting CIN3 or greater of HPV testing-based strategies vs cytology ranged from 0.8 to 2.1. The main limitation of our study was that testing methodologies and screening/management protocols were highly variable across studies. Screening strategies in which a single initial HPV-positive test led to colposcopy were more sensitive than cytology but resulted in higher colposcopy rates. These results have implications for cotesting with HPV and cytology as recommended in the United States.

Risk factors for cervical precancer detection among previously unscreened HIV-infected women in Western Kenya.

HIV and cervical cancer are intersecting epidemics in many low‐resource settings, yet there are few accurate estimates of the scope of this public health challenge. To understand disease prevalence and risk factors for cervical intraepithelial neoplasia 2 or greater (CIN2+), we conducted a cross‐sectional study of women undergoing cervical cancer screening as part of routine HIV care in Kisumu, Kenya. Women were offered screening with visual inspection with acetic acid, followed by confirmation with colposcopy and biopsy as needed. Univariable and multivariable analyses were carried out to determine clinical and demographic predictors of prevalent CIN2+. Among 3,241 women screened, 287 (9%) had an initial diagnosis of biopsy‐confirmed CIN2+. On multivariable analysis, combined oral contraceptives remained significantly associated with detection of CIN2+ among women on HAART (AOR 1.84, CI 1.20–2.82), and not on HAART (AOR 1.72, 95% CI 1.08–2.73), while use of a progesterone implant was associated with increased detection of CIN2+ (AOR 9.43, 95% CI 2.85–31.20) only among women not on HAART. CD4+ nadir over 500 cells/mm3 was associated with reduced detection of CIN2+ (AOR 0.61, CI 0.38, 0.97) in the overall group, but current CD4+ was only associated with reduced detection of CIN2+ among women not on HAART (AOR 0.42, CI 0.22, 0.80). In conclusion, a history of less severe immunosuppression appeared to reduce the risk of CIN2+ detection, but current CD4+ count was significant only in non‐HAART users. The association of CIN2+ with hormonal contraception should be explored more in prospective studies designed to better control for confounding factors.

A comparison of two visual inspection methods for cervical cancer screening among HIV-infected women in Kenya

OBJECTIVE To determine the optimal strategy for cervical cancer screening in women with human immunodeficiency virus (HIV) infection by comparing two strategies: visual inspection of the cervix with acetic acid (VIA) and VIA followed immediately by visual inspection with Lugols iodine (VIA/VILI) in women with a positive VIA result. METHODS Data from a cervical cancer screening programme embedded in two HIV clinic sites in western Kenya were evaluated. Women at a central site underwent VIA, while women at a peripheral site underwent VIA/VILI. All women positive for cervical intraepithelial neoplasia grade 2 or worse (CIN 2+) on VIA and/or VILI had a confirmatory colposcopy, with a biopsy if necessary. Overall test positivity, positive predictive value (PPV) and the CIN 2+ detection rate were calculated for the two screening methods, with biopsy being the gold standard. FINDINGS Between October 2007 and October 2010, 2338 women were screened with VIA and 1124 with VIA/VILI. In the VIA group, 26.4% of the women tested positive for CIN 2+; in the VIA/VILI group, 21.7% tested positive (P < 0.01). Histologically confirmed CIN 2+ was detected in 8.9% and 7.8% (P = 0.27) of women in the VIA and VIA/VILI groups, respectively. The PPV of VIA for biopsy-confirmed CIN 2+ in a single round of screening was 35.2%, compared with 38.2% for VIA/VILI (P = 0.41). CONCLUSION The absence of any differences between VIA and VIA/VILI in detection rates or PPV for CIN 2+ suggests that VIA, an easy testing procedure, can be used alone as a cervical cancer screening strategy in low-income settings.

The Association of HIV Counseling and Testing with HIV Risk Behaviors in a Random Population-based Survey in Kisumu, Kenya

HIV testing has been promoted as a key HIV prevention strategy in low-resource settings, despite studies showing variable impact on risk behavior. We sought to examine rates of HIV testing and the association between testing and sexual risk behaviors in Kisumu, Kenya. Participants were interviewed about HIV testing and sexual risk behaviors. They then underwent HIV serologic testing. We found that 47% of women and 36% of men reported prior testing. Two-thirds of participants who tested HIV-positive in this study reported no prior HIV test. Women who had undergone recent testing were less likely to report high-risk behaviors than women who had never been tested; this was not seen among men. Although rates of HIV testing were higher than seen in previous studies, the majority of HIV-infected people were unaware of their status. Efforts should be made to increase HIV testing among this population.

Changing knowledge, attitudes, and behaviors regarding cervical cancer screening: The effects of an educational intervention in rural Kenya

OBJECTIVE Cervical cancer screening uptake may be influenced by inadequate knowledge in resource-limited settings. This randomized trial evaluated a health talks impact on cervical cancer knowledge, attitudes, and screening rates in rural Kenya. METHODS 419 women attending government clinics were randomized to an intervention (N=207) or control (N=212) group. The intervention was a brief health talk on cervical cancer. Participants completed surveys at enrollment (all), immediately after the talk (intervention arm), and at three-months follow-up (all). The primary outcomes were the change in knowledge scores and the final screening rates at three-months follow-up. Secondary outcomes were changes in awareness about cervical cancer screening, perception of personal cervical cancer risk, cervical cancer and HIV stigma, and screening acceptability. RESULTS Mean Knowledge Scores increased by 26.4% (8.7 points increased to 11.0 points) in the intervention arm compared to only 17.6% (8.5 points increased to 10.0 points) in the control arm (p<0.01). Screening uptake was moderate in both the intervention (58.9%; N=122) and control (60.9%; N=129) arms, with no difference between the groups (p=0.60). CONCLUSION A brief health talk increased cervical cancer knowledge, although it did not increase screening over simply informing women about free screening. PRACTICAL IMPLICATIONS Screening programs can increase patient understanding with just a brief educational intervention.

Loop Electrosurgical Excision Procedure: Safety and Tolerability Among Human Immunodeficiency Virus-Positive Kenyan Women

OBJECTIVES: To estimate the safety, tolerability, and acceptability of loop electrosurgical excision procedure (LEEP) for cervical intraepithelial neoplasia (CIN 2 or 3) in human immunodeficiency virus (HIV)–positive women performed by nonphysician health care providers in an HIV care and treatment clinic. METHODS: We performed a prospective cohort study among women undergoing LEEP for biopsy-confirmed CIN 2 or 3 at the Family Acquired Immunodeficiency Syndrome Care and Education Services Clinic in Kisumu, Kenya. Women were followed-up 4 weeks after the procedure and questioned for abstinence as well as presence and severity of side effects after the procedure. The results were analyzed using descriptive statistics and univariable and multivariable analysis. RESULTS: Among the 180 (91%) women who returned for a 4-week follow up after LEEP, 52% reported at least one postprocedure symptom, including bleeding, discharge, or pain. Using a Likert scale for severity of symptoms, 179 (99%) reported very mild to mild symptoms, whereas one (1%) participant described the symptoms as moderate. No participants reported severe symptoms. Mean CD4+ count was significantly higher among women who reported any symptoms compared with women who reported no symptoms after LEEP (419 cells/mm3 compared with 349 cells/mm,3 P<.05), an association that remained significant after adjustment for antiretroviral treatment. The presence or severity of postprocedure symptoms did not differ among women who reported sexual activity (16%) less than 4 weeks after the procedure. CONCLUSION: LEEP performed by clinical officers was well-accepted by HIV-positive women and appears safe, resulting in minimal side effects, even among women with early resumption of intercourse. LEVEL OF EVIDENCE: II

Prevalence, characteristics, and outcomes of HIV-positive women diagnosed with invasive cancer of the cervix in Kenya

To determine the prevalence of invasive cervical cancer (ICC) and assess access to, and outcomes of, treatment for ICC among HIV‐infected women in Kisumu, Kenya.

The time has come to make cervical cancer prevention an essential part of comprehensive sexual and reproductive health services for HIV-positive women in low-income countries

HIV and cervical cancer are intersecting epidemics that disproportionately affect one of the most vulnerable populations in the world: women in low‐ and middle‐income countries (LMICs). Historically, the disparity in cervical cancer risk for women in LMICs has been due to the lack of organized screening and prevention programmes. In recent years, this risk has been augmented by the severity of the HIV epidemic in LMICs. HIV‐positive women are at increased risk for developing cervical precancer and cancer, and while the introduction of antiretroviral therapy has dramatically improved life expectancies among HIV‐positive women it has not been shown to improve cancer‐related outcomes. Therefore, an increasing number of HIV‐positive women are living in LMICs with limited or no access to cervical cancer screening programmes. In this commentary, we describe the gaps in cervical cancer prevention, the state of evidence for integrating cervical cancer prevention into HIV programmes and future directions for programme implementation and research.

Barriers to Cervical Cancer Screening in Rural Kenya: Perspectives from a Provider Survey

Although cervical cancer is highly preventable through screening, it remains the number one cause of cancer-related death in Kenyan women due to lack of funding and infrastructure for prevention programs. In 2012, Family AIDS Care and Education Services in partnership with the Kenya Ministry of Health began offering free screening at eleven rural health facilities. We sought to explore why screening coverage remains low at some sites. We examined the barriers to screening through a survey of 106 healthcare staff. The most frequently cited barriers to service delivery included staffing shortages, lack of trained staff, insufficient space, and supply issues. The patient barriers commonly perceived by the staff included inadequate knowledge, wait time, discomfort with male providers, and fear of pain with the speculum exam. Despite multilateral efforts to implement cervical cancer screening, staff face significant challenges to service provision and increased education is needed for both providers and patients.