Mulindi H. Mwanahamuntu

Prevalence and distribution of HPV genotypes among HIV-infected women in Zambia.

We screened 145 HIV-infected non-pregnant women at a tertiary care centre in Lusaka, Zambia. Liquid-based cytology and human papillomavirus (HPV) genotyping with PGMY09/11 biotinylated primers (Roche Linear Array® HPV genotyping test) maximised sensitivity of cytology and HPV assessments. Among high-risk (HR) types, HPV 52 (37.2%), 58 (24.1%) and 53 (20.7%) were more common overall than HPV 16 (17.2%) and 18 (13.1%) in women with high-grade squamous intraepithelial lesions or squamous cell carcinoma (SCC) on cytology. High-risk HPV types were more likely to be present in women with CD4+ cell counts <200 μ l−1 (odds ratios (OR): 4.9, 95% confidence intervals (CI): 1.4–16.7, P=0.01) and in women with high-grade or severe cervical cytological abnormalities (OR: 8.0, 95% CI: 1.7–37.4, P=0.008). Human papillomavirus diversity in high-grade lesions and SCC on cytology suggests that HPV 16- and 18-based vaccines may not be adequately polyvalent to induce protective immunity in this population.

Implementation of 'see-and-treat' cervical cancer prevention services linked to HIV care in Zambia.

Greater than 80% of the worlds new cases and deaths due to cervical cancer occur in the developing world [1]. No more than 5% of women in these settings are screened for cervical cancer even once in their lifetimes [2]. Earlier attempts to establish population-based cervical cancer prevention programs using cytology screening in resource-limited settings have inevitably fallen short or failed [3–5]. Although many of the reasons for failure can be attributed to lack of resources and trained manpower, the multiple visit requirements of cytology-based screening programs jeopardizes success and sustainability.

Advancing Cervical Cancer Prevention Initiatives in Resource-Constrained Settings: Insights from the Cervical Cancer Prevention Program in Zambia

Groesbeck Parham and colleagues describe their Cervical Cancer Prevention Program in Zambia, which has provided services to over 58,000 women over the past five years, and share lessons learned from the programs implementation and integration with existing HIV/AIDS programs.

Cervical Cancer Prevention in Low- and Middle-Income Countries: Feasible, Affordable, Essential

The annual worldwide burden of the preventable disease cervical cancer is more than 530,000 new cases and 275,000 deaths, with the majority occurring in low- and middle-income countries (LMIC), where cervical cancer screening and early treatment are uncommon. Widely used in high-income countries, Pap smear (cytology based) screening is expensive and challenging for implementation in LMICs, where lower-cost, effective alternatives such as visual inspection with acetic acid (VIA) and rapid human papillomavirus (HPV)-based screening tests offer promise for scaling up prevention services. Integrating HPV screening with VIA in “screen-and-treat-or-refer” programs offers the dual benefits of HPV screening to maximize detection and using VIA to triage for advanced lesions/cancer, as well as a pelvic exam to address other gynecologic issues. A major issue in LMICs is coinfection with human immunodeficiency virus (HIV) and HPV, which further increases the risk for cervical cancer and marks a population with perhaps the greatest need of cervical cancer prevention. Public–private partnerships to enhance the availability of cervical cancer prevention services within HIV/AIDS care delivery platforms through initiatives such as Pink Ribbon Red Ribbon present an historic opportunity to expand cervical cancer screening in LMICs. Cancer Prev Res; 5(1); 11–17. ©2011 AACR.

Utilization of cervical cancer screening services and trends in screening positivity rates in a 'screen-and-treat' program integrated with HIV/AIDS care in Zambia.

Background 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. Yet, evidence demonstrating the utilization of cervical cancer prevention services in such integrated programs by women of the general population is lacking. Methods We 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. Results Between 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. Conclusions This 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.

Myths and misconceptions about cervical cancer among Zambian women: rapid assessment by peer educators.

Objective. To make a rapid assessment of the common myths and misconceptions surrounding the causes of cervical cancer and lack of screening among unscreened low-income Zambian women. Methods. We initiated a door-to-door community-based initiative, led by peer educators, to inform unscreened women about the existence of a new see-and-treat cervical cancer prevention program. During home visits peer educators posed the following two questions to women: 1. What do you think causes cervical cancer? 2. Why haven’t you been screened for cervical cancer? The most frequent types of responses gathered in this exercise were analyzed thematically. Results. Peer educators contacted over 1100 unscreened women over a period of two months. Their median age was 33 years, a large majority (58%) were not educated beyond primary school, over two-thirds (71%) did not have monthly incomes over 500,000 Zambian Kwacha (US

Integrating cervical cancer prevention in HIV/AIDS treatment and care programmes

100) per month, and just over half (51%) were married and cohabiting with their spouses. Approximately 75% of the women engaged in discussions had heard of cervical cancer and had heard of the new cervical cancer prevention program in the local clinic. The responses of unscreened low-income Zambian women to questions posed by peer educators in urban Lusaka reflect the variety of prevalent ‘folk’ myths and misconceptions surrounding cervical cancer and its prevention methods. Conclusion. The information in our rapid assessment can serve as a basis for developing future educational and intervention campaigns for improving uptake of cervical cancer prevention services in Zambia. It also speaks to the necessity of ensuring that programs addressing women’s reproductive health take into account societal inputs at the time they are being developed and implemented. Taking a community-based participatory approach to program development and implementation will help ensure sustainability and impact. (Global Health Promotion, 2010; Supp (2): pp. 47—50)

Clinical Performance Validation of 4 Point-of-Care Cervical Cancer Screening Tests in HIV-Infected Women in Zambia.

Peckham and Hann’s call for integrating cervical cancer prevention as part of broader sexual and reproductive health prevention services1 is especially relevant to sub-Saharan Africa where both cervical cancer and sexually transmitted infections, especially HIV/AIDS, are widely prevalent. Over the past decade, successful HIV/AIDS care and treatment programmes have been instituted in over a dozen hardest-hit sub-Saharan African countries, largely through bilateral and multilateral programmes like the United States President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria.2 HIV-infected women are at heightened risk for pre-invasive and invasive neoplasia of the cervix.3,4 HIV/AIDS care and treatment programmes thus provide an ideal platform to integrate cervical cancer prevention activities in countries which face a dual burden of both AIDS and cervical cancer, an AIDS-defining disease. With steady donor support over the past 5 years, these programmes are slowly but steadily contributing to the development of health-care service delivery capacity in emerging nations by establishing infrastructures, training the health-care work force, and tackling complex and challenging problems in implementation and scale-up.5 Limited access to cervical cancer prevention services, the usual circumstance for women in low-resource environments, serves as a counterforce to the life-prolonging potential of increased access to affordable antiretroviral therapy. Cervical cancer prevention strategies that use visual inspection with acetic acid (VIA) and same-visit cryotherapy (“see-and-treat”) are cost-effective alternatives to cytology-based screening programmes. These procedures can be performed by nurses and other non-physician health-care workers and allow screening and treatment to be linked to the same clinic visit. Our experience in Zambia has shown that VIA-based prevention services that are nested within the context of antiretroviral therapy programmes allow early detection of cervical cancer in high-risk HIV-infected women in a cost-effective way.6,7 It also allows opportunities for the provision of broader gynaecologic and other health care for women. Eventual integration of low-cost, rapid screening tests for detecting human papillomavirus within VIA-based screening services will additionally increase programmatic efficiency. When cervical cancer prevention services are offered to HIV-infected women in a venue attended by non-HIV-infected women, a scalable intervention is established that can reach out to all women regardless of HIV status. Horizontal and diagonal collaborations between agencies and individuals focusing on HIV/AIDS care and cancer prevention could open new vistas for expanding availability of care for women at risk of one or both of these conditions, thereby ensuring wider programme impact. The conjoint contributions of such collaborations may be larger than the sum of their parts. ■

Clinical performance of digital cervicography and cytology for cervical cancer screening in HIV-infected women in Lusaka Zambia.

Objectives We sought to determine the clinical performance of visual inspection with acetic acid (VIA), digital cervicography (DC), Xpert human papillomavirus (HPV), and OncoE6 for cervical cancer screening in an HIV-infected population. Materials and Methods HIV-infected women 18 years or older were included in this cross-sectional validation study conducted in Lusaka, Zambia. The screening tests were compared against a histological gold standard. We calculated sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios, and odds ratios using cervical intraepithelial neoplasia grade 2 or worse (CIN 2+) and grade 3 or worse (CIN 3+) thresholds. Results Between January and June 2015, a total of 200 women were enrolled. Fifteen percent were screen positive by VIA, 20% by DC, 47% by Xpert HPV, and 6% by OncoE6. Using a CIN 2+ threshold, the sensitivity and specificity of VIA were 48% (95% CI = 30%–67%) and 92% (95% CI = 86%–95%), respectively. Similarly, the sensitivity and specificity of DC were 59% (95% CI = 41%–76%) and 88% (95% CI = 82%–93%), respectively. The sensitivity and specificity of Xpert HPV were 88% (95% CI = 71%–97%) and 60% (95% CI = 52%–68%), respectively. Finally, the sensitivity and specificity of OncoE6 were 31% (95% CI = 16%–50%) and 99% (95% CI = 97%–100%), respectively. Conclusions VIA and DC displayed moderate sensitivity and high specificity. Xpert HPV performed equivalently to currently approved HPV DNA tests, with high sensitivity and moderate specificity. OncoE6 displayed excellent specificity but low sensitivity. These results confirm an important role for VIA, DC, and Xpert HPV in screen-and-treat cervical cancer prevention in low- and middle-income countries, such as Zambia.

Predictors and outcomes of low birth weight in Lusaka, Zambia.

Abstract:Although there is a growing literature on the clinical performance of visual inspection with acetic acid in HIV-infected women, to the best of our knowledge, none have studied visual inspection with acetic acid enhanced by digital cervicography. We estimated clinical performance of cervicography and cytology to detect cervical intraepithelial neoplasia grade 2 or worse. Sensitivity and specificity of cervicography were 84% [95% confidence interval (CI): 72 to 91) and 58% (95% CI: 52 to 64). At the high-grade squamous intraepithelial lesion or worse cutoff for cytology, sensitivity and specificity were 61% (95% CI: 48 to 72) and 58% (95% CI: 52 to 64). In our study, cervicography seems to be as good as cytology in HIV-infected women.