Thomas Welty

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.

Scale-up and case-finding effectiveness of an HIV partner services program in Cameroon: an innovative HIV prevention intervention for developing countries.

Background Partner services (PSs) are a long-standing component of HIV control programs in the United States and some parts of Europe. Small randomized trials suggest that HIV PS can be effective in identifying persons with undiagnosed HIV infection. However, the scalability and effectiveness of HIV PS in low-income countries are unknown. Methods We used data collected from 2009 to 2010 through a large HIV PS program in Cameroon to evaluate HIV PS in a developing country. HIV-positive index cases diagnosed in antenatal care, voluntary counseling and testing, and inpatient facilities were interviewed to collect information on their sexual partners. Partners were contacted via telephone or home visit to notify, test, and enroll those found to be HIV positive in medical care. Results Health advisors interviewed 1462 persons with HIV infection during the evaluation period; these persons provided information about 1607 sexual partners. Health advisors notified 1347 (83.8%) of these partners, of whom 900 (66.8%) were HIV tested. Of partners tested, 451 (50.1%) were HIV positive, of whom 386 (85.6%) enrolled into HIV medical care. An average 3.2 index cases needed to be interviewed to identify 1 HIV case. Conclusions HIV PS can be successfully implemented in a developing country and is highly effective in identifying persons with HIV infection and linking them to care.

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

Time trends and regional differences in the prevalence of HIV infection among women attending antenatal clinics in 2 provinces 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.

Improving American Indian Health

Background:HIV prevalence time trends vary in sub-Saharan African countries. In the present study, we studied time trends and regional differences in the prevalence of HIV infection among women attending antenatal care clinics (ANC) in 7 sites located in 2 provinces in Cameroon. Methodology:As part of ANC, 16,626 women consented to HIV testing from 2000 to 2006. Sociodemographic and risk factor information was collected during the initial 3 years of the study. This information was aggregated within sites and used as site-level covariate in multilevel logistic regression analysis. Results:HIV prevalence decreased significantly in women younger than 20 years from 13% in 2000 to 5% in 2006. Age-specific prevalence varied among the sites, with a peak prevalence occurring more often at a higher age in 2004-2006 versus 2000-2003, suggesting a reduction of HIV incidence over time. There was a substantial heterogeneity across sites in HIV prevalence, which was lower in sites where women had earlier sexual debut and were less well educated. Conclusions:ANC surveillance indicates a decreasing trend in HIV prevalence in the studied sites in Cameroon. Cultural differences might have accounted for the heterogeneity of HIV infection observed across sites, which call for tailored interventions.

Coverage of Nevirapine-Based Services to Prevent Mother-to-Child HIV Transmission in 4 African Countries

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.

Health facility characteristics and their relationship to coverage of PMTCT of HIV services across four African countries: the PEARL 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.