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Background Cervical cancer is a leading cause of cancer deaths among women of reproductive age in Peru. Screening and early identification of pre-cancerous lesions are a cornerstone of the cervical cancer prevention strategy. Yet, there is limited literature on barriers to screening among Peruvian women. In this cross-sectional study, we aimed to examine Peruvian women’s knowledge, attitudes, and practices regarding cervical cancer screening and identify possible reasons for the gap between knowledge and screening. Methods The study was conducted in metropolitan Lima from June–August 2019. We purposefully recruited 12 women who had previously been screened, and 12 who had never been screened for cervical cancer. The women completed a 40-question knowledge and attitude survey and an in-depth interview about barriers to screening. Descriptive analysis was used to calculate a knowledge and attitude score and qualitative analysis was guided by the Health Belief Model constructs. Results Previously screened participants had greater knowledge of cervical cancer symptoms, risk factors, and prevention (mean score = 28.08, S.D. = 4.18) compared to participants who had never been screened (mean score = 21.25, S.D. = 6.35). Both groups described lack of priority and embarrassment as barriers to cervical cancer screening. For participants who had never been screened before, major barriers included the fear of a cancer diagnosis and lack of information about screening services. Pregnancy, unusual gynecological symptoms and encouragement from friends and family were cues to action for participants seeking screening. Most participants in both groups recognized the benefits of getting screened for cervical cancer. Being previously screened increased participants’ self-efficacy for engaging in screening behaviors again. Misconceptions regarding screening procedures and cervical cancer were also noted as barriers for participants accessing screening services. Conclusions Improving knowledge and awareness about cervical cancer and screening programs may improve screening behaviors among women. Targeting women who have never been screened before and addressing their fears and concerns around embarrassment may be other areas for intervention. Misconceptions that deter women from screening services are an important issue that should be addressed in order to increase the number of women who get timely screenings.

About nine out of 10 cervical cancer deaths occur in low-resource countries, with a particularly high burden in sub-Saharan Africa. The objectives of this study were to assess barriers and facilitators to cervical cancer screening in western Kenya from the perspectives of community members and healthcare providers. We conducted two focus groups with female community members (n = 24) and one with providers (n = 12) in Migori County, Kenya. Discussion guides queried about knowledge and awareness of cervical cancer prevention; structural, social, and personal barriers; and facilitators towards cervical cancer screening uptake. Group discussions were recorded, transcribed, and analyzed for emerging themes. Participants in both groups reported low awareness of HPV and cervical cancer screening in the community, and identified that as a main barrier to screening. Community members reported fear of pain and embarrassment as significant barriers to a screening pelvic exam. They also reported that providers' lack of knowledge and discomfort with a sensitive subject were significant barriers. A personal connection to cervical cancer and/or screening was associated with willingness to screen and awareness. Providers reported workload and lack of supplies and trained staff as significant barriers to offering services. Based on these findings, we identified three intervention components to address these facilitators and barriers to screening. They include utilizing existing social networks to expand awareness of cervical cancer risk and screening, training non-physician health workers to meet the demand for screening, and employing female-driven screening techniques such as self-collection of specimens for HPV testing. Cervical cancer prevention programs must take into account the local realities in which they occur. In low-resource areas in particular, identifying low-cost, effective, and culturally appropriate strategies for addressing poor screening uptake is important given limited funding. This study took a formative approach to identify facilitators and barriers to cervical cancer screening based on focus groups and interviews with community members and healthcare providers.

PURPOSE Cervical cancer screening is not well implemented in many low- and middle-income countries (LMICs). Mobile health (mHealth) refers to utilization of mobile technologies in health promotion and disease management. We aimed to qualitatively synthesize published articles reporting the impact of mHealth on cervical cancer screening–related health behaviors. METHODS Three reviewers independently reviewed articles with the following criteria: the exposure or intervention of interest was mHealth, including messages or educational information sent via mobile telephone or e-mail; the comparison was people not using mHealth technology to receive screening-related information, and studies comparing multiple different mHealth interventional strategies were also eligible; the primary outcome was cervical cancer screening uptake, and secondary outcomes included awareness, intention, and knowledge of screening; appropriate research designs included randomized controlled trials and quasi-experimental or observational research; and the study was conducted in an LMIC. RESULTS Of the 8 selected studies, 5 treated mobile telephone or message reminders as the exposure or intervention, and 3 compared the effects of different messages on screening uptake. The outcomes were diverse, including screening uptake (n = 4); health beliefs regarding the Papanicolaou (Pap) test (n = 1); knowledge of, attitude toward, and adherence to colpocytologic examination (n = 1); interest in receiving messages about Pap test results or appointment (n = 1); and return for Pap test reports (n = 1). CONCLUSION Overall, our systematic review suggests that mobile technologies, particularly telephone reminders or messages, lead to increased Pap test uptake; additional work is needed to unequivocally verify whether mhealth interventions can improve knowledge regarding cervical cancer. Our study will inform mHealth-based interventions for cervical cancer screening promotion in LMICs.

The World Health Organization (WHO) refers to cervical cancer as a public health problem, and sub‐Saharan Africa bears the world's highest incidence. In the realm of screening, simplified WHO recommendations for low‐resource countries now present an opportunity for a public health approach to this public health problem. We evaluated the feasibility of such a public health approach to cervical cancer screening that features community‐based self‐administered HPV testing and mobile treatment provision. In two rural districts of western‐central Uganda, Village Health Team members led community mobilization for cervical cancer screening fairs in their communities, which offered self‐collection of vaginal samples for high‐risk human papillomavirus (hrHPV) testing. High‐risk human papillomavirus‐positive women were re‐contacted and referred for treatment with cryotherapy by a mobile treatment unit in their community. We also determined penetrance of the mobilization campaign message by interviewing a probability sample of adult women in study communities about the fair and their attendance. In 16 communities, 2142 women attended the health fairs; 1902 were eligible for cervical cancer screening of which 1892 (99.5%) provided a self‐collected vaginal sample. Among the 393 (21%) women with detectable hrHPV, 89% were successfully contacted about their results, of which 86% returned for treatment by a mobile treatment team. Most of the women in the community (93%) reported hearing about the fair, and among those who had heard of the fair, 68% attended. This public health approach to cervical cancer screening was feasible, effectively penetrated the communities, and was readily accepted by community women. The findings support further optimization and evaluation of this approach as a means of scaling up cervical cancer control in low‐resource settings., A public health approach to cervical cancer screening was feasible, effectively penetrated the communities, and was readily accepted by community women. The findings support further optimization and evaluation of this approach as a means of scaling up cervical cancer control in low‐resource settings.

PURPOSE The WHO now recommends thermal ablation as an alternative to cryotherapy within “screen-and-treat” cervical cancer programs in low- and middle-income countries (LMICs). We conducted a safety and acceptability clinical trial of thermal ablation in a Kenyan Ministry of Health hospital among women living with HIV (WLWH; ClinicalTrials.gov identifier: NCT04191967 ). METHODS Between August 2019 and February 2020, WLWH age 25-65 years underwent human papillomavirus (HPV) self-collection in western Kenya. HPV-positive women underwent visual inspection with acetic acid, biopsy, and treatment with thermal ablation performed by a nonphysician clinician, if eligible by standard guidelines. A questionnaire was administered after treatment to assess for pain and treatment acceptability. Adverse events (AEs) were evaluated 4-6 weeks after treatment with a standardized grading tool. RESULTS A total of 293 HPV-positive WLWH underwent thermal ablation in the study period. The mean age was 40.4 years (standard deviation, 8.7 years). After treatment, 15 (5.1%), 231 (78.8%), 42 (14.3%), and 5 (1.8%) reported none, mild, moderate, and severe pain with treatment, respectively. At follow-up, spotting, vaginal discharge, and pelvic pain were reported by 99 (37.8%), 258 (98.5%), and 46 (17.6%), respectively, for a median of 3.3 (interquartile range [IQR], 2-3), 14 (IQR, 7-21), and 7 (IQR, 3-7) days, respectively. Most participants graded their AEs as mild (grade 1): 94 (95.0%) for bleeding, 125 (48.5%) for vaginal discharge, and 37 (80.4%) for pelvic pain. No grade 3 or 4 AEs were reported. The vast majority (99.2%) were satisfied with the treatment and would recommend it to a friend. CONCLUSION Thermal ablation performed by nonphysicians in the public health sector in Kenya proved safe and highly acceptable in treating HPV-positive WLWH.

It is unknown whether the HPV vaccine is effective in immunocompromised women during catch-up ages. We performed a case-control study of 4,357 women with incident CIN2+ (cases) and 5:1 age-matched, incidence-density selected controls (N=21,773) enrolled in an integrated health care system from 2006 to 2014. Vaccine effectiveness was estimated from multivariable conditional logistic regression models, with results stratified by immunosuppression history, defined as prior HIV infection, solid organ transplant history, or recently prescribed immunosuppressive medications. HPV vaccination resulted in a 19% reduction in CIN2+rates for women without an immunosuppression history but a nonsignificant 4% reduction for women with an immunosuppression history. Further research is needed to evaluate whether catch-up HPV vaccine effectiveness varies by immunosuppression status, especially given the recent approval of the HPV vaccine for adults up to 45years of age.

Objective To characterize the efficiency of screening through high-volume community health campaigns (CHCs) by comparing the costs and population reach and identify factors associated with gains in efficiency. Access to effective cervical cancer screening remains limited in low-resource settings, especially in rural areas. Periodic CHCs are a novel method of offering screening for HPV at lower costs and higher population coverage than health facilities. Methods A micro-costing study was conducted within a cervical cancer screening trial to measure efficiency (cost per woman screened) and population uptake of HPV-based screening offered through CHCs in Migori County, Kenya between January and September 2016. Regression analysis assessed relationships between population size and efficiency. Structured observations and qualitative interviews identified implementation factors that affected efficiency in individual campaigns. Results Communities screening through CHCs had costs per woman screened ranging from US $22.06 to $30.21. Efficiency was directly correlated to overall numbers of women screened, but not to proportion of population screened. Modifiable factors that acted as context-specific facilitators and barriers with a potential impact on efficiency were identified. Conclusion There was substantial variation in efficiency among CHCs. Cultural factors, health beliefs, and poor coordination among implementation partners as potential key barriers to screening uptake were identified.

A chord diagram is an innovative tool that can be used to visualize switching and quitting in contraceptive use between 2 discrete time points. It complements existing analysis of contraceptive failure rates and provides a richer understanding of contraceptive discontinuation and method switching that can lead to fresh insights to improve family planning programs., We applied a novel approach to visualizing contraceptive histories from the Demographic and Health Surveys (DHS) contraceptive calendar to elucidate patterns of contraceptive switching and discontinuation (e.g., “churn” in contraceptive use across 2 points in time). Taking the contraceptive calendar from the 2014 Kenya DHS, we used R, an open source statistical programming platform, and the chorddiag package to create interactive chord diagrams to visualize contraceptive use trajectories, including switching and discontinuation, for all contraceptive types queried in the DHS. We present screenshots from the interactive version. We also tested the usefulness of our chord diagram with potential users, including family planning researchers and advocates. Chord diagrams are visually appealing and provide users with the ability to investigate unique patterns in contraceptive discontinuation using publicly available data from the DHS. After receiving a brief orientation to a chord diagram, users found the chord diagram easy to understand and manipulate. The chord diagram is a potentially powerful way for family planning researchers, advocates, and program managers to visualize women’s contraceptive trajectories and provides insights into the churn in contraceptive use between 2 discrete time periods.

Purpose Human papillomavirus (HPV) testing is being more widely used in simplified cervical cancer screening protocols in low-resource settings. One challenge to successful implementation is the multiple visits necessary to provide results and follow-up. mHealth strategies may reduce visit burden by providing information through text message. Methods As part of a cluster-randomized trial to compare HPV testing in clinics and community health campaigns in western Kenya, we carried out a mixed-methods study to assess women’s preferences and experiences with different strategies to receive their results. Women could opt to receive their HPV results via text message, cell phone call, home visit, or return clinic visit. We examined overall receipt of results, follow-up rates, and acceptability by notification method. Results Among the 4,947 women who underwent HPV-based cervical cancer screening, 1,596 (32%) received results via text message, 1,181 (24%) via cell phone call, 1,563 (32%) via clinic visit, and 605 (12%) via home visit. Women opting for texts or calls were younger and had higher rates of prior cervical cancer screening, HIV testing, and modern contraceptive use ( P < .001 for all). Home visits were associated with a significantly higher rate of treatment acquisition (45%) than texts (38%), cell phone calls (38%), and clinic visits (23%; P < .001). In a model controlling for age, prior screening, HIV testing, and contraceptive use, clinic visits remained significantly associated with decreased odds of treatment (adjusted odds ratio, 0.45; 95% CI, 0.29 to 0.69) compared with texts. Among treated women, there was no difference in time to treatment by notification method. Conclusion Cell phone–based results notification strategies were preferred by women with greater health-seeking behavior; however, HPV-positive women who received results via home visit were more likely to pursue for treatment.

Background Nearly 90% of deaths due to cervical cancer occur in low- and middle-income countries (LMICs). In recent years, many digital health strategies have been implemented in LMICs to ameliorate patient-, provider-, and health system–level challenges in cervical cancer control. However, there are limited efforts to systematically review the effectiveness and current landscape of digital health strategies for cervical cancer control in LMICs. Objective We aim to conduct a systematic review of digital health strategies for cervical cancer control in LMICs to assess their effectiveness, describe the range of strategies used, and summarize challenges in their implementation. Methods A systematic search was conducted to identify publications describing digital health strategies for cervical cancer control in LMICs from 5 academic databases and Google Scholar. The review excluded digital strategies associated with improving vaccination coverage against human papillomavirus. Titles and abstracts were screened, and full texts were reviewed for eligibility. A structured data extraction template was used to summarize the information from the included studies. The risk of bias and data reporting guidelines for mobile health were assessed for each study. A meta-analysis of effectiveness was planned along with a narrative review of digital health strategies, implementation challenges, and opportunities for future research. Results In the 27 included studies, interventions for cervical cancer control focused on secondary prevention (ie, screening and treatment of precancerous lesions) and digital health strategies to facilitate patient education, digital cervicography, health worker training, and data quality. Most of the included studies were conducted in sub-Saharan Africa, with fewer studies in other LMIC settings in Asia or South America. A low risk of bias was found in 2 studies, and a moderate risk of bias was found in 4 studies, while the remaining 21 studies had a high risk of bias. A meta-analysis of effectiveness was not conducted because of insufficient studies with robust study designs and matched outcomes or interventions. Conclusions Current evidence on the effectiveness of digital health strategies for cervical cancer control is limited and, in most cases, is associated with a high risk of bias. Further studies are recommended to expand the investigation of digital health strategies for cervical cancer using robust study designs, explore other LMIC settings with a high burden of cervical cancer (eg, South America), and test a greater diversity of digital strategies.

Background Primary human papillomavirus (HPV) screening (PHS) utilizes oncogenic human papillomavirus (oncHPV) testing as the initial cervical cancer screening method and typically, if positive, additional reflex-triage (eg, HPV16/18-genotyping, Pap testing). While US guidelines support PHS usage in the general population, PHS has been little studied in women living with HIV (WLWH). Methods We enrolled n = 865 WLWH (323 from the Women’s Interagency HIV Study [WIHS] and 542 from WIHS-affiliated colposcopy clinics). All participants underwent Pap and oncHPV testing, including HPV16/18-genotyping. WIHS WLWH who tested oncHPV[+] or had cytologic atypical squamous cells of undetermined significance or worse (ASC-US+) underwent colposcopy, as did a random 21% of WLWH who were oncHPV[−]/Pap[−] (controls). Most participants additionally underwent p16/Ki-67 immunocytochemistry. Results Mean age was 46 years, median CD4 was 592 cells/µL, 95% used antiretroviral therapy. Seventy WLWH had histologically-determined cervical intraepithelial neoplasia grade 2 or greater (CIN-2+), of which 33 were defined as precancer (ie, [i] CIN-3+ or [ii] CIN-2 if concurrent with cytologic high grade squamous intraepithelial lesions [HSILs]). PHS had 87% sensitivity (Se) for precancer, 9% positive predictive value (PPV), and a 35% colposcopy referral rate (Colpo). “PHS with reflex HPV16/18-genotyping and Pap testing” had 84% Se, 16% PPV, 30% Colpo. PHS with only HPV16/18-genotyping had 24% Colpo. “Concurrent oncHPV and Pap Testing” (Co-Testing) had 91% Se, 12% PPV, 40% Colpo. p16/Ki-67 immunochemistry had the highest PPV, 20%, but 13% specimen inadequacy. Conclusions PHS with reflex HPV16/18-genotyping had fewer unnecessary colposcopies and (if confirmed) could be a potential alternative to Co-Testing in WLWH.

ObjectivesThis study aimed to report the proportion of women with a new diagnosis of cervical cancer recommended for curative hysterectomy as well as associated factors. We also report recommended treatments by stage and patterns of treatment initiation.DesignThis was an observational cohort study. Inperson surveys were followed by a phone call.SettingParticipants were recruited at the two public tertiary care referral hospitals in Kampala, Uganda.ParticipantsAdult women with a new diagnosis of cervical cancer were eligible: 332 were invited to participate, 268 met the criteria and enrolled, and 255 completed both surveys.Primary and secondary outcomes measuresThe primary outcome of interest was surgical candidacy; a secondary outcome was treatment initiation. Descriptive and multivariate statistical analyses examined the associations between predictors and outcomes. Sensitivity analyses were performed to examine outcomes in subgroups, including stage and availability of radiation.ResultsAmong 268 participants, 76% were diagnosed at an advanced stage (IIB–IVB). In total, 12% were recommended for hysterectomy. In adjusted analysis, living within 15 km of Kampala (OR 3.10, 95% CI 1.20 to 8.03) and prior screening (OR 2.89, 95% CI 1.22 to 6.83) were significantly associated with surgical candidacy. Radiotherapy availability was not significantly associated with treatment recommendations for early-stage disease (IA–IIA), but was associated with recommended treatment modality (chemoradiation vs primary chemotherapy) for locally advanced stage (IIB–IIIB). Most (67%) had started treatment. No demographic or health factor, treatment recommendation, or radiation availability was associated with treatment initiation. Among those recommended for hysterectomy, 55% underwent surgery. Among those who had initiated treatment, 82% started the modality that was recommended.ConclusionWomen presented to public referral centres in Kampala with mostly advanced-stage cervical cancer and few were recommended for surgery. Most were able to initiate treatment. Lack of access to radiation did not significantly increase the proportion of early-stage cancers recommended for hysterectomy.

ObjectivesTo estimate the cost of human papillomavirus (HPV)-based screening through community health campaigns (CHCs) and home-based testing.SettingCHCs and home-based testing in six communities in rural Western Kenya.ParticipantsCHCs and home-based screening reached 2297 and 1002 women aged 25–65 years, respectively.Outcome measuresOutcome measures were overall cost per woman screened achieved through the CHCs and home-based testing and the cost per woman for each activity comprising the screening intervention.ResultsThe mean cost per woman screened through CHCs and home-based testing were similar, at $37.7 (range $26.4–$52.0) and $37.1 (range $27.6–$54.0), respectively. For CHCs, personnel represented 49% of overall cost, supplies 25%, services 5% and capital goods 23%. For home-based testing, these were: personnel 73%, supplies 25%, services 1% and capital goods 2%. A greater number of participants was associated with a lower cost per participant.ConclusionsThe mean cost per woman screened is comparable for CHC and home-based testing, with differences in type of input. The CHCs generally reached more eligible women in the six communities, whereas home-based strategies more efficiently reached populations with low screening rates.Trial registration numberNCT02124252.

Fear of the speculum and feelings of vulnerability during the gynecologic exams are two of the biggest barriers to cervical cancer screening for women. To address these barriers, we have developed a novel, low-cost tool called the Callascope to reimagine the gynecological exam, enabling clinician and self-imaging of the cervix without the need for a speculum. The Callascope contains a 2 megapixel camera and contrast agent spray mechanism housed within a form factor designed to eliminate the need for a speculum during contrast agent administration and image capture. Preliminary bench testing for comparison of the Callascope camera to a $20,000 high-end colposcope demonstrated that the Callascope camera meets visual requirements for cervical imaging. Bench testing of the spray mechanism demonstrates that the contrast agent delivery enables satisfactory administration and cervix coverage. Clinical studies performed at Duke University Medical Center, Durham, USA and in Greater Accra Regional Hospital, Accra, Ghana assessed (1) the Callascope’s ability to visualize the cervix compared to the standard-of-care speculum exam, (2) the feasibility and willingness of women to use the Callascope for self-exams, and (3) the feasibility and willingness of clinicians and their patients to use the Callascope for clinician-based examinations. Cervix visualization was comparable between the Callascope and speculum (83% or 44/53 women vs. 100%) when performed by a clinician. Visualization was achieved in 95% (21/22) of women who used the Callascope for self-imaging. Post-exam surveys indicated that participants preferred the Callascope to a speculum-based exam. Our results indicate the Callascope is a viable option for clinician-based and self-exam speculum-free cervical imaging.Clinical study registration ClinicalTrials.gov https://clinicaltrials.gov/ct2/show/record/ NCT00900575, Pan African Clinical Trial Registry (PACTR) https://www.pactr.org/ PACTR201905806116817.

ObjectiveTo identify health systems-level barriers to treatment for women who screened positive for high-risk human papillomavirus (hrHPV) in a cervical cancer prevention program in Kenya.MethodsIn a trial of implementation strategies for hrHPV-based cervical cancer screening in western Kenya in 2018-2019, women underwent hrHPV testing offered through community health campaigns, and women who tested positive were referred to government health facilities for cryotherapy. The current analysis draws on treatment data from this trial, as well as two observational studies that were conducted: 1) periodic assessments of the treatment sites to ascertain availability of resources for treatment and 2) surveys with treatment providers to elicit their views on barriers to care. Bivariate analyses were performed for the site assessment data, and the provider survey data were analyzed descriptively.ResultsSeventeen site assessments were performed across three treatment sites. All three sites reported instances of supply stockouts, two sites reported treatment delays due to lack of supplies, and two sites reported treatment delays due to provider factors. Of the 16 providers surveyed, ten (67%) perceived lack of knowledge of HPV and cervical cancer as the main barrier in women's decision to get treated, and seven (47%) perceived financial barriers for transportation and childcare as the main barrier to accessing treatment. Eight (50%) endorsed that providing treatment free of cost was the greatest facilitator of treatment.ConclusionPatient education and financial support to reach treatment are potential areas for intervention to increase rates of hrHPV+ women presenting for treatment. It is also essential to eliminate barriers that prevent treatment of women who present, including ensuring adequate supplies and staff for treatment.

Background Cervical cancer is the most frequent neoplasm among Kenyan women, with 4800 diagnoses and 2400 deaths per year. One reason is an extremely low rate of screening through pap smears, at 13.8% in 2014. Knowing the costs of screening will help planners and policymakers design, implement, and scale programs. Methods We conducted HPV-based cervical cancer screening via self-collection in 12 communities in rural Migori County, Kenya. Six communities were randomized to community health campaigns (CHCs), and six to screening at government clinics. All HPV-positive women were referred for cryotherapy at Migori County Hospital. We prospectively estimated direct costs from the health system perspective, using micro-costing methods. Cost data were extracted from expenditure records, staff interviews, and time and motion logs. Total costs per woman screening included three activities: outreach, HPV-based screening, and notification. Types of inputs include personnel, recurrent goods, capital goods, and services. We costed potential changes to implementation for scaling. Results From January to September 2016, 2899 women were screened in CHCs and 2042 in clinics. Each CHC lasted for 30 working days, 10 days each for outreach, screening, and notification. The mean cost per woman screened was $25.00 for CHCs [median: $25.09; Range: $22.06-30.21] and $29.56 for clinics [$28.90; $25.27-37.08]. Clinics had higher costs than CHCs for personnel ($14.27 vs. $11.26) and capital ($5.55 vs. $2.80). Screening costs were higher for clinics at $21.84, compared to $17.48 for CHCs. In contrast, CHCs had higher outreach costs ($3.34 vs. $0.17). After modeling a reduction in staffing, clinic per-screening costs ($25.69) were approximately equivalent to CHCs. Conclusions HPV-based cervical cancer screening through community health campaigns achieved lower costs per woman screened, compared to screening at clinics. Periodic high-volume CHCs appear to be a viable low-cost strategy for implementing cervical cancer screening. Electronic supplementary material The online version of this article (10.1186/s12913-018-3195-6) contains supplementary material, which is available to authorized users.

OBJECTIVE: To determine the effectiveness of community health campaigns (CHCs) as a strategy for human papillomavirus (HPV)-based cervical cancer screening in rural western Kenya. METHODS: Between January and November 2016, a cluster-randomized trial was carried out in 12 communities in western Kenya to investigate high-risk HPV testing offered via self-collection to women aged 25–65 years in CHCs versus government health facilities. Outcome measures were the total number of women accessing cervical cancer screening and the proportion of HPV-positive women accessing treatment. RESULTS: In total, 4944 women underwent HPV-based cervical cancer screening in CHCs (n=2898) or health facilities (n=2046). Screening uptake as a proportion of total eligible women in the population was greater in communities assigned to CHCs (60.0% vs 37.0%, P

Objective To evaluate access to treatment after community-based HPV testing as testing within screen-and-treat programs has the potential to lower mortality from cervical cancer in low-resource settings. Methods A prospective cohort study was conducted in western Kenya in 2018. Women aged 25-65 years underwent HPV self-testing. HPV-positive women were referred for cryotherapy. Participant data were obtained from questionnaires during screening and treatment. The proportion successfully accessing treatment and variables associated with successful treatment was determined. Results Of the 750 women included, 140 (18.6%) tested positive for HPV. Of them, 135 were notified of their results, of whom 77 (59.2%) sought treatment and 73 (52.1%) received cryotherapy. Women who received treatment had a shorter time from screening to result notification (median 92 days, interquartile range [IQR] 84-104) compared to those who did not (97 days, IQR 89-106; P=0.061). In adjusted analyses, women with a history of cervical cancer screening (odds ratio [OR] 11, 95% confidence interval [CI] 1.42-85.20) and those electing result notification through a home visit (OR 4, 95% CI 1.23-14.17) were significantly more likely to acquire treatment at follow-up. Conclusion Linkage to treatment after community-based HPV screening in this population was low, highlighting the need for strategies aimed at strengthening treatment linkage in similar settings.

Background To be effective, population-based cervical cancer prevention programs must be tailored to meet the needs of the target population. One important factor in cervical cancer screening may include male involvement. To iteratively improve a screening program employing self-collected vaginal swabs for human-papillomavirus (HPV) testing in western Kenya, we examined the role of male partners and community leaders in decision-making and accessing screening services. Methods We carried out 604 semi-structured, in-depth interviews (IDIs) with women and community health volunteers who took part in a multiphase trial of implementation strategies for HPV-based cervical cancer screening. IDIs were coded and themes related to decision-making, screening and treatment barriers, and influence of male partners and community leaders were identified and analyzed. Results Women experienced both support and opposition from their male partners. Partner support took the form of financial support for transportation and emotional support and encouragement, while opposition ranged from anticipated negative reactions to lack of permission, isolation, and abandonment. Though most women described their own partners as supportive, many felt that other male partners would not be supportive. Most participants believed that increased HPV and cervical cancer knowledge would increase partner support. Women reported a general acceptance of involvement of community leaders in education and screening campaigns, in a setting where such leaders may hold influence over men in the community. Conclusion There was a clear interest in involving male partners in the cervical cancer prevention process, specifically in increasing knowledge and awareness. Future research should explore the feasibility and effectiveness of engaging male partners in cervical cancer screening and prevention programs. Electronic supplementary material The online version of this article (10.1186/s12905-019-0804-4) contains supplementary material, which is available to authorized users.

Background Despite cervical cancer being preventable with effective screening programs, it is the most common cancer and the leading cause of cancer-related death among women in many countries in Africa. Screening involving pelvic examination may not be feasible or acceptable in limited-resource settings. We sought to evaluate women’s perspectives on human papillomavirus (HPV) self-sampling as part of a larger trial on cervical cancer prevention implementation strategies in rural western Kenya. Methods We invited 120 women participating in a cluster randomized trial of cervical cancer screening implementation strategies in Migori County, Kenya for in-depth interviews. We explored reasons for testing, experience with and ability to complete HPV self-sampling, importance of clinician involvement during screening, factors and people contributing to screening decision-making, and ways to encourage other women to come for screening. We used validated theoretical frameworks to analyze the qualitative data. Results Women reported having positive experiences with the HPV self-sampling strategy. The factors facilitating uptake included knowledge and beliefs such as prior awareness of HPV, personal perception of cervical cancer risk, desire for improved health outcomes, and peer and partner encouragement. Logistical and screening facilitators included confidence in the ability to complete HPV self-sampling strategy, proximity to screening sites and feelings of privacy and comfort conducting the HPV self- sampling. The barriers to screening included fear of need for a pelvic exam, fear of disease and death associated with cervical cancer. We classified these findings as capabilities, opportunities and motivations for health behavior using the COM-B framework. Conclusions Overall, HPV self-sampling was an acceptable cervical cancer screening strategy that seemed to meet the needs of the women in this community. These findings will further inform aspects of implementation, including outreach messaging, health education, screening sites and emphasis on availability and effectiveness of preventative treatment for women who screen positive.

Importance Many cervical cancer screening strategies are now recommended in the United States, but the benefits, harms, and costs of each option are unclear. Objective To estimate the cost-effectiveness of 12 cervical cancer screening strategies. Design, Setting, and Participants The cross-sectional portion of this study enrolled a convenience sample of 451 English-speaking or Spanish-speaking women aged 21 to 65 years from September 22, 2014, to June 16, 2016, identified at women's health clinics in San Francisco. In this group, utilities (preferences) were measured for 23 cervical cancer screening–associated health states and were applied to a decision model of type-specific high-risk human papillomavirus (hrHPV)–induced cervical carcinogenesis. Test accuracy estimates were abstracted from systematic reviews. The evaluated strategies were cytologic testing every 3 years for women aged 21 to 65 years with either repeat cytologic testing in 1 year or immediate hrHPV triage for atypical squamous cells of undetermined significance (ASC-US), cytologic testing every 3 years for women age 21 to 29 years followed by cytologic testing plus hrHPV testing (cotesting), or primary hrHPV testing alone for women aged 30 to 65 years. Screening frequency, abnormal test result management, and the age to switch from cytologic testing to hrHPV testing (25 or 30 years) were varied. Analyses were conducted from both the societal and health care sector perspectives. Main Outcomes and Measures Utilities for 23 cervical cancer screening–associated health states (cross-sectional study) and quality-adjusted life-years (QALYs) and total costs for each strategy. Results Utilities were measured in a sociodemographically diverse group of 451 women (mean [SD] age, 38.2 [10.7] years; 258 nonwhite [57.2%]). Cytologic testing every 3 years with repeat cytologic testing for ASC-US yielded the most lifetime QALYs and conferred more QALYs at higher costs ($2166 per QALY) than the lowest-cost strategy (cytologic testing every 3 years with hrHPV triage of ASC-US). All cytologic testing plus hrHPV testing (cotesting) and primary hrHPV testing strategies provided fewer QALYs at higher costs. Adding indirect costs did not change the conclusions. In sensitivity analyses, hrHPV testing every 5 years with genotyping triage beginning at age 30 years was the lowest-cost strategy when hrHPV test sensitivity was markedly higher than cytologic test sensitivity or when hrHPV test cost was equated to the lowest reported cytologic test cost ($14). Conclusions and Relevance Cytologic testing every 3 years for women aged 21 to 29 years with either continued cytologic testing every 3 years or switching to a low-cost hrHPV test every 5 years confers a reasonable balance of benefits, harms, and costs. Comparative modeling is needed to confirm the association of these novel utilities with cost-effectiveness.

In the United States, the historical condemnation and punitive legal consequences of substance use during pregnancy—ranging from incarceration to termination of parental custody of a newborn—render pregnant women in state of biosocial precarity. Yet pregnant women who use illicit substances who desire to parent must generate a legible narrative for bureaucratic groups, such as Child Protective Services, through engagement with biomedical care in order to demonstrate parental capacity. Based on longitudinal interviews with pregnant women who were actively using illicit substances and attempting to parent after delivery, we posit that the relationship between biosocial precarity and biomedical care is a procedural interaction that is rooted in the potential to parent, described as the ability to have a “take-home baby.” In order to achieve this goal, the need for engagement in biomedical care and the creation of a biomedical narrative, described as a “resume for the baby” is required. The relationship between care and biosocial precarity is a unique, underdeveloped concept within medical anthropology and has important consequences not only for the ethical turn within anthropology, but also how applied researchers consider engagement with this highly marginalized, vulnerable population.

The risk of cervical cancer (CC) among women immunosuppressed for a variety of reasons is well documented in the literature. Although there is improved organ function, quality of life and life expectancy gained through use of immunosuppressant therapy, there may be increased long-term risk of cervical neoplasia and cancer and the need for more intense screening, surveillance, and management. Although guidance for CC screening among HIV-infected women (see Table 1) has been supported by evidence from retrospective and prospective studies, recommendations for CC screening among non-HIV immunosuppressed women remains limited because quality evidence is lacking. Moreover, CC screening guidelines for HIV-infected women have changed because better treatments evolved and resulted in longer life expectancy.The objective of this report was to summarize current knowledge of CC, squamous intraepithelial lesions, and human papillomavirus (HPV) infection in non-HIV immunocompromised women to determine best practices for CC surveillance in this population and provide recommendations for screening. We evaluated those with solid organ transplant, hematopoietic stem cell transplant, and a number of autoimmune diseases.A panel of health care professionals involved in CC research and care was assembled to review and discuss existing literature on the subject and come to conclusions about screening based on available evidence and expert opinion. Literature searches were performed using key words such as CC, cervical dysplasia/squamous intraepithelial lesion, HPV, and type of immunosuppression resulting in an initial group of 346 articles. Additional publications were identified from review of citations in these articles. All generated abstracts were reviewed to identify relevant articles. Articles published within 10 years were considered priority for review. Reviews of the literature were summarized with relevant statistical comparisons. Recommendations for screening generated from each group were largely based on expert opinion. Adherence to screening, health benefits and risks, and available clinical expertise were all considered in formulating the recommendations to the degree that information was available.Solid Organ Transplant: Evidence specific for renal, heart/lung, liver, and pancreas transplants show a consistent increase in risk of cervical neoplasia and invasive CC, demonstrating the importance of long-term surveillance and treatment. Reports demonstrate continued risk long after transplantation, emphasizing the need for screening throughout a woman's lifetime.Hematopoietic Stem Cell Transplant: Although there is some evidence for an increase in CC in large cohort studies of these patients, conflicting results may reflect that many patients did not survive long enough to evaluate the incidence of slow-growing or delayed-onset cancers. Furthermore, history of cervical screening or previous hysterectomy was not included in registry study analysis, possibly leading to underestimation of CC incidence rates.Genital or chronic graft versus host disease is associated with an increase in high-grade cervical neoplasia and posttransplant HPV positivity.Inflammatory Bowel Disease: There is no strong evidence to support that inflammatory bowel disease alone increases cervical neoplasia or cancer risk. In contrast, immunosuppressant therapy does seem to increase the risk, although results of observational studies are conflicting regarding which type of immunosuppressant medication increases risk. Moreover, misclassification of cases may underestimate CC risk in this population. Recently published preventive care guidelines for women with inflammatory bowel disease taking immunosuppressive therapy recommend a need for continued long-term CC screening.Systemic Lupus Erythematosus and Rheumatoid Arthritis: The risk of cervical high-grade neoplasia and cancer was higher among women with systemic lupus erythematosus than those with rheumatoid arthritis (RA), although studies were limited by size, inclusion of women with low-grade neoplasia in main outcomes, and variability of disease severity or exposure to immunosuppressants. In studies designed to look specifically at immunosuppressant use, however, there did seem to be an increase in risk, identified mostly in women with RA. Although the strength of the evidence is limited, the increase in risk is consistent across studies.Type 1 DM: There is a paucity of evidence-based reports associating type 1 DM with an increased risk of cervical neoplasia and cancer.The panel proposed that CC screening guidelines for non-HIV immunocompromised women follow either the (1) guidelines for the general population or (2) current center for disease control guidelines for HIV-infected women. The following are the summaries for each group reviewed, and more details are noted in accompanying table:Solid Organ Transplant: The transplant population reflects a greater risk of CC than the general population and guidelines for HIV-infected women are a reasonable approach for screening and surveillance.Hematopoietic Stem Cell Transplant: These women have a greater risk of CC than the general population and guidelines for HIV-infected women are a reasonable approach for screening. A new diagnosis of genital or chronic graft versus host disease in a woman post-stem cell transplant results in a greater risk of CC than in the general population and should result in more intensive screening and surveillance.Inflammatory Bowel Disease: Women with inflammatory bowel disease being treated with immunosuppressive drugs are at greater risk of cervical neoplasia and cancer than the general population and guidelines for HIV-infected women are a reasonable approach for screening and surveillance. Those women with inflammatory bowel disease not on immunosuppressive therapy are not at an increased risk and should follow screening guidelines for the general population.Systemic Lupus Erythematosus and Rheumatoid Arthritis: All women with systemic lupus erythematosus, whether on immunosuppressant therapy or not and those women with RA on immunosuppressant therapy have a greater risk of cervical neoplasia and cancer than the general population and should follow CC screening guidelines for HIV-infected women. Women with RA not on immunosuppressant therapy should follow CC screening guidelines for the general population.Type 1 Diabetes Mellitus: Because of a lack of evidence of increased risk of cervical neoplasia and cancer among women with type 1 DM, these women should follow the screening guidelines for the general population.

The World Health Organization (WHO) is leading a call to action to eliminate cervical cancer by the end of the century through global implementation of two effective evidence-based preventive interventions: HPV vaccination and cervical screening and management (CSM). Models estimate that without intervention, over the next 50 years 12.2 million new cases of cervical cancer will occur, nearly 60% of which are preventable only through CSM. Given that more than 80% of the cervical cancer occurs in low- and middle-income countries (LMICs), scaling up sustainable CSM programs in these countries is a top priority for achieving the global elimination goals. Multiple technologies have been developed and validated to meet this need. Now it is critical to identify strategies to implement these technologies into complex, adaptive health care delivery systems. As part of the coordinated cervical cancer elimination effort, we applied a systems thinking lens to reflect on our experiences with implementation of HPV-based CSM programs using the WHO health systems framework. While many common health system barriers were identified, the effectiveness of implementation strategies to address them was context dependent; often reflecting differences in stakeholder's belief in the quality of the evidence supporting a CSM algorithm, the appropriateness of the evidence and algorithm to context, and the ‘implementability’ of the algorithm under realistic assessments of resource availability and constraints. A structured planning process, with early and broad stakeholder engagement, will ensure that shared-decisions in CSM implementation are appropriately aligned with the culture, values, and resource realities of the setting.

ObjectivePrevious studies identified several factors associated with cervical cancer screening. However, many of them used samples from the general population and limited studies focused on women with high-risk health behaviours. We aimed to disentangle the association of cervical cancer screening with healthcare access and HIV testing among women at a high risk of HIV infection.DesignNationwide cross-sectional survey in the USA.Setting2016 Behavioral Risk Factor Surveillance System.Participants3448 women with a history of high-risk behaviours associated with HIV infectionExposure and outcomeClinical check-up, having personal healthcare provider, health coverage and HIV testing history were treated as exposures. Appropriate cervical cancer screening, which was defined according to 2016 US Preventive Services Task Force guideline, was treated as the outcome of interest.Data analysisMultivariable logistic regression model was performed to evaluate associations of healthcare access and HIV testing with the uptake of cervical cancer screening; adjusted odds ratio (aOR) and 95% CI were reported. We further investigated if educational attainment modified associations identified in the primary multivariable model.ResultsA total of 2911 (84.4%) high-risk women in our sample underwent cervical cancer screening. In the multivariable model, delayed clinical check-up (≥5 years ago vs within the past year: aOR: 0.19, 95% CI: 0.14 to 0.26), having no health insurance (aOR: 0.60, 95% CI: 0.46 to 0.79) and no history of HIV testing (no testing vs testing within the past year: aOR: 0.46, 95% CI: 0.35 to 0.61) were inversely associated with cervical cancer screening utilisation.ConclusionFactors reflecting healthcare access, specifically clinical check-up and health coverage, as well as history of HIV testing were associated with cervical cancer screening in this population-based study of high-risk women. Targeted interventions are warranted to further increase cervical cancer screening among women at high risk of HIV infection.

Detection and treatment of human papillomavirus (HPV) and cervical precancer through screening programs is an effective way to reduce cervical cancer deaths. However, high cervical cancer mortality persists in low- and middle-income countries. As screening programs become more widely available, it is essential to understand how knowledge about cervical cancer and perceived disease risk impacts screening uptake and acceptability. We evaluated women's experiences with a cervical cancer education strategy led by community health volunteers (CHVs) in Migori County, Kenya, as part of a cluster randomized controlled trial of cervical cancer screening implementation strategies. The educational modules employed simple language and images and sought to increase understanding of the relationship between HPV and cervical cancer, the mechanisms of self-collected HPV testing, and the importance of cervical cancer screening. Modules took place in three different contexts throughout the study: (1) during community mobilization; (2) prior to screening in either community health campaigns or health facilities; and (3) prior to treatment. Between January and September 2016, we conducted in-depth interviews with 525 participants to assess their experience with various aspects of the screening program. After the context-specific educational modules, women reported increased awareness of cervical cancer screening and willingness to screen, described HPV- and cervical cancer-related stigma and emphasized the use of educational modules to reduce stigma. Some misconceptions about cervical cancer were evident. With effective and context-specific training, lay health workers, such as CHVs, can help bridge the gap between cervical cancer screening uptake and acceptability.

Background The incidence of cervical cancer in Kenya is among the highest in the world. Few Kenyan women are able to access screening, thus fueling the high cervical cancer burden. Self-collected human papilloma Virus (HPV) tests, administered during community-health campaigns in rural areas may be a way to expand access to screening. Methods In December 2015, we carried out a four-day community health campaign (CHC) to educate participants about cervical cancer prevention and offer self-administered HPV screening. Community enumeration, outreach and mobilization preceded the CHC. Samples were sent to Migori County Hospital for HPV DNA testing using careHPV Test Kits. Women were notified of results through their choice of short message service (SMS), phone call, home visit or clinic visit. HPV positive women were referred for cryotherapy following a screen-and-treat strategy. Results Door-to-door enumeration identified approximately 870 eligible women in Ngodhe Community in Migori County. Among the 267 women attending the campaign, 255 women enrolled and collected samples: 243 tests were successfully resulted and 12 were indeterminate. Of the 243 resulted tests, 47 (19%) were positive for HPV, with young age being the only significant predictor of positivity. In multivariate analysis, each additional year of age conferred about a 4% decrease in the odds of testing positive (95% CI 0.1 to 7%, p = 0.046). Just over three-quarters of all women (195/255), were notified of their results. Those who were unable to be reached were more likely to prefer receiving results from clinic (54/60, 90%) and were less likely to have mobile phones (24/60, 73%). Although 76% of HPV positive women were notified of their results, just half (51%) of those testing positive presented for treatment. HPV positive women who successfully accessed the treatment facility did not differ from their non-presenting counterparts by demographics, health history, desired route of notification or access to a mobile phone. Conclusion Nearly a third of eligible women in Ngodhe Community attended the CHC and were screened for cervical cancer. Nearly all women who attended the CHC underwent cervical cancer screening by self-collected HPV tests. Three-quarters of all participants received results, but just half of HPV positive participants presented for treatment in a timely fashion, suggesting that linkage to treatment remains a major challenge. Trial registration NCT02124252, Registered 25 April 2014.

Summary Background The population effectiveness of human papillomavirus (HPV) catch-up vaccination, defined in the USA as first vaccination at ages 13–26 years, has not been studied extensively. We aimed to assess the risk of cervical intraepithelial neoplasia (CIN) 2, CIN3, adenocarcinoma in situ, or cancer (CIN2+ and CIN3+) by prior HPV vaccination status, age at first dose, and number of doses in women participating in a screening programme within a large integrated health-care system. Methods We performed a nested case-control study of women enrolled in Kaiser Permanente Northern California (an integrated health-care delivery system in California, USA). Cases were women with CIN2+ or CIN3+ confirmed by histology between Jan 1, 1995, and June 30, 2014, and incidence density-selected controls were age-matched women without CIN2+ or CIN3+ at the time each case occurred. For each case, we randomly selected five controls. Cases and controls were aged 26 years or younger when the HPV quadrivalent vaccine became available in 2006. Rate ratios (RRs) from conditional logistic regression were estimated by age at time of first HPV quadrivalent vaccine dose (14–17 years, 18–20 years, and ≥21 years), and number of doses (one, two, and three or more doses) compared with no prior vaccination, with adjustment for smoking, hormonal contraceptive prescription, race or ethnicity, sexually transmitted infections, immunosuppression, parity, and number of outpatient visits. Findings 4357 incident CIN2+ cases and 21 773 matched controls were included in the study. Of these, 1849 were incident CIN3+ cases with 9242 matched controls. The youngest age at time of first vaccination was 14 years. One or more HPV vaccine doses conferred protection against CIN2+ (RR 0·82, 95% CI 0·73–0·93) and CIN3+ (0·77, 0·64–0·94). We found the strongest protection against CIN2+ in women who had received at least three vaccine doses and had received their first dose aged 14–17 years (0·52, 0·36–0·74) or aged 18–20 years (0·65, 0·49–0·88). No significant protection was found in women aged 21 years or older at time of first dose (0·94, 0·81–1·09). Inferences were similar for CIN3+, but with stronger effects for women who received at least three vaccine doses and had received their first dose aged 14–17 years (0·27, 0·13–0·56) or aged 18–20 years (0·59, 0·36–0·97). Interpretation Catch-up quadrivalent HPV vaccination with three doses was effective against CIN2+ and CIN3+ in girls and women aged 14–20 years at time of first vaccine dose but not for women aged 21 years and older at first dose. Funding US National Cancer Institute.

Author(s): Silverberg, Michael J; Leyden, Wendy A; Chi, Aileen; Gregorich, Steven; Huchko, Megan J; Kulasingam, Shalini; Kuppermann, Miriam; Seto, Anna; Smith-McCune, Karen K; Sawaya, George F | Abstract: OBJECTIVE:To estimate the risk of cervical intraepithelial neoplasia grade 2, 2-3, 3, adenocarcinoma in situ, or cancer (CIN 2 or worse) among women with human immunodeficiency virus (HIV)- and non-HIV-associated immunosuppression. METHODS:We performed a case-control study of 20,146 women with incident CIN 2 or worse and 5:1 age-matched, incidence-density selected women in a control group (n=100,144) enrolled in an integrated health care system from 1996 to 2014. Adjusted rate ratios (RRs) from conditional logistic regression were obtained for HIV status (stratified by CD4 T-cells), solid organ transplant history, and immunosuppressive medication use. RESULTS:Risk of CIN 2 or worse was increased among women with HIV (n=36 women in the case group and 79 women in the control group; adjusted RR 2.0, 95% CI 1.3-3.0) compared with those without HIV and in solid organ transplant recipients (n=51 women in the case group and 68 women in the control group; RR 3.3, 95% CI 2.3-4.8) compared with women without a prior transplant. The highest risks were among women with HIV and less than 200 CD4 T-cells/microliter (n=9 women in the case group and eight women in the control group; RR 5.6, 95% CI 2.1-14.7) compared with those without HIV and in solid organ transplant recipients prescribed three or greater immunosuppressive medication classes (n=32 women in the case group and 33 women in the control group; RR 4.1, 95% CI 2.5-6.8) compared with women without a prior transplant and zero medication classes. No increased risks were observed for women with HIV and 500 or greater CD4 T-cells/microliter (n=9 women in the case group and 43 women in the control group; RR 0.8, 95% CI 0.4-1.7) compared with those without HIV or women without prior solid organ transplantation prescribed two or fewer immunosuppressive medication classes (n=1,262 women in the case group and 6,100 women in the control group; RR 0.95, 95% CI 0.89-1.01) compared with women without and a prior transplant and zero medication classes. CONCLUSION:Risk of CIN 2 or worse is increased in women with a prior solid organ transplant or who have HIV and CD4 cells/microliter less than 500 but not in women with HIV and higher CD4 levels or in women without a prior solid organ transplant but who are prescribed only one or two immunosuppressive medication classes.

Prenatal care providers are frequently asked to provide employment notes for their patients requesting medical leave or changes to work duties. Writing employment notes correctly can help patients negotiate for and obtain medically indicated workplace accommodations, allowing them to continue to work and earn an income. However, a poorly written or poorly timed note can jeopardize a patient's employment and salary. This commentary provides an overview of pregnancy-related employment laws and guidance in writing work accommodations letters that allow pregnant women to keep their jobs while maintaining a healthy pregnancy.

Objective Cervical cancer screening uptake may be influenced by inadequate knowledge in resource-limited settings. This randomized trial evaluated a health talk's 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 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.

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.

Cervical cancer is a highly preventable disease that disproportionately affects women in developing countries and women with HIV. As integrated HIV and cervical cancer screening programs in Sub-Saharan Africa mature, we have an opportunity to measure the impact of outreach and education efforts and identify areas for future improvement. We conducted a cross-sectional survey of 106 women enrolled in care at an integrated HIV clinic in the Nyanza Province of Kenya 5 years after the start of a cervical cancer screening program. Female clinic attendees who met clinic criteria for cervical cancer screening were asked to complete an oral questionnaire assessing their cervical cancer knowledge, attitudes, and screening history. Ninety-nine percent of women had heard of screening, 70 % felt at risk, and 84 % had been screened. Increased duration of HIV diagnosis was associated with feeling at risk and with a screening history. Nearly half (48 %) of women said they would not get screened if they had to pay for it.

Cervical cancer screening in the United States has accompanied profound decreases in cancer incidence and mortality over the last half century. Two screening strategies are currently endorsed by US-based guideline groups: (1) triennial cytology for women aged 21 to 65 years, and (2) triennial cytology for women aged 21 to 29 years followed by cytology plus testing for high-risk human papillomavirus types every 5 years for women aged 30 years and older. Providing women with affordable, easily accessible screening, follow-up of abnormal tests, and timely treatment will result in the greatest impact of screening on cervical cancer incidence and mortality.

Background Despite guidelines for cervical cancer prevention in low-resource countries, a very small proportion of women in these settings undergo screening, and even fewer women are successfully treated. Using pilot data from western Kenya and World Health Organization recommendations, we developed a protocol to implement evidence-based cervical cancer screening and linkage to treatment strategies to the rural communities. We describe the protocol for a cluster-randomized trial to compare two implementation strategies for human-papillomavirus (HPV)-based cervical cancer screening program using metrics described in the RE-AIM (reach, efficacy, adaption, implementation and maintenance) framework. Methods The study is a three-year, two-phase cluster-randomized trial in 18 communities in western Kenya. During Phase 1, six control communities were offered screening in health facilities; and six intervention communities were offered screening in community health campaigns. Screening was done with human-papillomavirus testing through self-collected specimens. Phase 1 ended and we are working in partnership with communities to further contextualize the implementation strategy for screening, and develop an enhanced linkage to treatment plan. This plan will be tested in an additional six communities in Phase 2 (enhanced intervention). We will compare the reach, efficacy, cost-effectiveness and adaptability of the implementation strategies. Discussion Effective low-cost cervical cancer prevention technologies are becoming more widely available in low- and middle-income countries. Despite increasing government support for cervical cancer prevention, there remains a sizeable gap in service availability. We will use implementation science to identify the most effective strategies to fill this gap through development of context-specific evidence-based solutions. This protocol design and results can help guide implementation of cervical cancer screening in similar settings, where women are most underserved and at highest risk for disease. Trial registration This trial is registered at ClinicalTrials.gov, NCT02124252. Electronic supplementary material The online version of this article (10.1186/s12885-017-3818-z) contains supplementary material, which is available to authorized users.

SummaryThis paper reviews the literature examining the relationship between women’s empowerment and contraceptive use, unmet need for contraception and related family planning topics in developing countries. Searches were conducted using PubMed, Popline and Web of Science search engines in May 2013 to examine literature published between January 1990 and December 2012. Among the 46 articles included in the review, the majority were conducted in South Asia (n=24). Household decision-making (n=21) and mobility (n=17) were the most commonly examined domains of women’s empowerment. Findings show that the relationship between empowerment and family planning is complex, with mixed positive and null associations. Consistently positive associations between empowerment and family planning outcomes were found for most family planning outcomes but those investigations represented fewer than two-fifths of the analyses. Current use of contraception was the most commonly studied family planning outcome, examined in more than half the analyses, but reviewed articles showed inconsistent findings. This review provides the first critical synthesis of the literature and assesses existing evidence between women’s empowerment and family planning use.

Opportunistic infections (OIs) are the main cause of morbidity and mortality in patients with HIV-1 infection throughout the world, particularly among patients who have not had access to anti-retroviral therapy (ART) and other HIV care services. 1, 2, 3 Among patients taking ART, OIs can present when the immune system starts to recover aka immune reconstitution inflammatory syndrome (IRIS). 4, 5 Also, some patients do not have a sustained response to ART due to lack of adherence to medications, development of drug resistance, or suboptimal therapeutic regimens. 1 Therefore, OIs continue to cause substantial morbidity and mortality even after initiation of ART. The World Health Organization (WHO) developed HIV clinical staging criteria based on OIs to standardize disease severity classification in the absence of virologic or immunologic measurements. 6, 7 Diagnosis of WHO stage 4 conditions remains important in the ART era in order to: 1) help determine timing of ART initiation, and 2) treat OIs to reduce morbidity and mortality. There are no published data from Kenya that quantify the burden of WHO stage 4 conditions that persist in the ART era and continue to negatively impact patient survival. We therefore set out to determine the prevalence and gender distribution of WHO stage 4 conditions among patients enrolled in a large peri-urban HIV clinic in western Kenya.

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 Lugol's iodine (VIA/VILI) in women with a positive VIA result.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.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).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.Déterminer la stratégie optimale pour dépister le cancer du col de l'utérus chez les femmes infectées par le virus de l'immunodéficience humaine (VIH) en comparant deux stratégies: l'inspection visuelle du col de l'utérus en utilisant de l'acide acétique (IVA) et l'IVA suivie immédiatement par une inspection visuelle en utilisant du soluté de Lugol (IVA/IVL) chez les femmes ayant obtenu un résultat positif pour l'IVA.Les données provenant d'un programme de dépistage du cancer du col de l'utérus mis en œuvre dans deux sites cliniques pour le VIH dans l'ouest du Kenya ont été évaluées. Les femmes qui consultaient dans un site central ont été examinées par IVA alors que les femmes qui consultaient dans un site périphérique ont été examinées par IVA/IVL. Toutes les femmes présentant un résultat positif pour une néoplasie intraépithéliale du col de l'utérus de grade 2 ou supérieur (CIN 2+) après examen par IVA et/ou IVL ont ensuite eu une colposcopie de confirmation, avec une biopsie si nécessaire. La positivité globale du test, la valeur prédictive positive (VPP) et le taux de détection des lésions CIN 2+ ont été calculés pour les deux méthodes de dépistage, avec la biopsie comme référence absolue.Entre octobre 2007 et octobre 2010, 2338 femmes ont été examinées par IVA et 1124 par IVA/IVL. Dans le groupe IVA, 26,4% des femmes ont obtenu un résultat positif pour des lésions CIN 2+; dans le groupe IVA/IVL, 21,7% des femmes ont obtenu un résultat positif (L'absence de différence entre l'IVA et l'IVA/IVL pour les taux de détection ou la VPP des lésions CIN 2+ suggère que l'IVA est une procédure de test simple, qui peut être utilisée seule comme stratégie de dépistage du cancer du col de l'utérus dans les pays à faible revenu.Determinar la mejor estrategia para detectar el cáncer de cuello uterino en las mujeres con el virus de inmunodeficiencia humana (VIH) mediante la comparación de dos estrategias: la inspección visual del cuello uterino con ácido acético (IVAA) y la IVAA seguida inmediatamente de la inspección visual con yodo de Lugol (IVAA/IVYL) en mujeres con un resultado positivo en la IVAA.Se evaluaron los datos de un programa de detección de cáncer de cuello uterino integrado en dos centros clínicos de VIH en el oeste de Kenya. Las mujeres de una zona central se sometieron a la IVAA, mientras que las mujeres de una zona periférica se sometieron a la IVAA/IVYL. Se realizó una colposcopia de confirmación, además de una biopsia cuando era necesario, a todas las mujeres con un diagnóstico positivo de neoplasia intraepitelial cervical de grado 2 o peor (CIN 2+) en la IVAA y/o IVYL. Se calculó la positividad de la prueba general, el valor predictivo positivo (VPP) y la tasa de detección de CIN 2+ de ambos métodos de detección, con la biopsia como la regla de oro.Entre octubre de 2007 y octubre de 2010, se examinó a 2338 mujeres con la IVAA y a 1124 con la IVAA/IVYL. En el grupo IVAA, el 26,4 % de las mujeres dio positivo en CIN 2+, mientras que en el grupo IVAA/IVYL, el 21,7 % dio positivo (La ausencia de diferencias entre la IVAA y la IVAA/IVYL en las tasas de detección o el VPP para detectar CIN 2+ indica que la IVAA, un procedimiento de prueba sencillo, puede utilizarse por separado como estrategia de detección de cáncer cervical en comunidades de bajos ingresos.تحديد الاستراتيجية المثلى لتحري سرطان عنق الرحم لدى النساء المصابات بعدوى فيروس العوز المناعي البشري عن طريق مقارنة بين استراتيجيتين: الفحص البصري لعنق الرحم باستخدام حمض الخليك والفحص البصري لعنق الرحم باستخدام حمض الخليك المتبوع على الفور بالفحص البصري باستخدام يود لوغول مع النساء اللاتي كانت نتيجة الفحص البصري لعنق الرحم باستخدام حمض الخليك لديهن إيجابية.تم تقييم البيانات المستمدة من برنامج لتحري سرطان عنق الرحم المدمج في موقعين سريريين لفيروس العوز المناعي البشري في مناطق غرب كينيا. وخضعت النساء في موقع مركزي لفحص بصري لعنق الرحم باستخدام حمض الخليك، في حين خضعت النساء في موقع طرفي لفحص بصري لعنق الرحم باستخدام حمض الخليك المتبوع على الفور بفحص بصري باستخدام يود لوغول. وخضعت جميع النساء الإيجابيات للورم العنقي داخل الظهارة من الدرجة الثانية أو الأسوأ (CIN 2+)، اللاتي خضعن للفحص البصري لعنق الرحم باستخدام حمض الخليك و/أو الفحص البصري باستخدام يود لوغول، لتنظير المهبل التوكيدي مع أخذ خزعة عند الاقتضاء. وبشكل عام، تم حساب إيجابية الاختبار والقيمة التنبؤية الإيجابية (PPV) ومعدل كشف CIN 2+ في طريقتي التحري، وكانت الخزعة هي المعيار الذهبي.في الفترة من تشرين الأول/ أكتوبر 2007 إلى تشرين الأول/ أكتوبر 2010، تم تحري 2338 سيدة بالفحص البصري لعنق الرحم باستخدام حمض الخليك و1124 سيدة بالفحص البصري لعنق الرحم باستخدام حمض الخليك/الفحص البصري باستخدام يود لوغول. وفي مجموعة الفحص البصري لعنق الرحم باستخدام حمض الخليك، كانت نسبة 26.4 % من النساء اللاتي اختبرن إيجابيات للورم العنقي داخل الظهارة من الدرجة الثانية أو الأسوأ؛ وفي مجموعة الفحص البصري لعنق الرحم باستخدام حمض الخليك المتبوع على الفور بالفحص البصري باستخدام يود لوغول، كانت نسبة 21.7 % من النساء اللاتي اختبرن إيجابيات (الاحتمال0.01). وتم التأكيد من حيث الأنسجة على كشف CIN 2+ في 8.9 % و7.8 % (الاحتمال = 0.27) من النساء في مجموعتي الفحص البصري لعنق الرحم باستخدام حمض الخليك والفحص البصري لعنق الرحم باستخدام حمض الخليك المتبوع على الفور بالفحص البصري باستخدام يود لوغول، على التوالي. وكانت القيمة التنبؤية الإيجابية للورم العنقي داخل الظهارة من الدرجة الثانية أو الأسوأ في الفحص البصري لعنق الرحم باستخدام حمض الخليك الذي تم توكيده بالخزعة في جولة واحدة من التحري 35.2 %، مقارنة بنسبة 38.2 % في الفحص البصري لعنق الرحم باستخدام حمض الخليك/ الفحص البصري باستخدام يود لوغول (يشير عدم وجود أي اختلافات بين الفحص البصري لعنق الرحم باستخدام حمض الخليك والفحص البصري لعنق الرحم باستخدام حمض الخليك المتبوع على الفور بالفحص البصري باستخدام يود لوغول في معدلات الكشف أو القيمة التنبؤية الإيجابية للورم العنقي داخل الظهارة من الدرجة الثانية أو الأسوأ إلى إمكانية استخدام الفحص البصري لعنق الرحم باستخدام حمض الخليك، أحد إجراءات الاختبار السهلة، منفرداً كاستراتيجية تحري لسرطان عنق الرحم في البيئات المنخفضة الدخل.通过比较两种策略确定艾滋病毒感染（HIV）妇女宫颈癌筛查最佳策略：一种是使用醋酸（VIA）的宫颈癌肉眼观察，另一种是使用VIA检查之后立即对VIA结果为阳性的女性使用吕戈尔碘染色肉眼观察（VIA/VILI）。对来自肯尼亚西部的两个艾滋病诊所的宫颈癌筛查计划的数据进行评价。对在中心诊疗点的女性执行VIA检查，对在外围诊疗点的女性执行VIA/VILI检查。对VIA和/或VILI检查结果中宫颈上皮内瘤变2级或以上（CIN 2+）呈阳性的所有女性进行阴道镜确诊检查，必要时使用活组织检查。对两种筛查方法计算整体检测阳性、阳性预测值（PPV）和CIN 2+检出率，以活检为黄金标准。在2007年10月和2010年10月之间，对2338名妇女进行了VIA检查，对1124名妇女进行了VIA/VILI检查。在VIA组中，26.4%的妇女检测为CIN 2+阳性，在VIA/VILI组中，21.7%的妇女检测为阳性（VIA和VIA/VILI在检出率或CIN 2+的PPV上没任何差别，这表明在低收入地区可以单纯使用VIA这种简易的检查程序作为宫颈癌筛查策略。Определить оптимальную стратегию скрининга рака шейки матки у женщин с вирусом иммунодефицита человека (ВИЧ) посредством сравнения двух стратегий: визуального осмотра и теста с уксусной кислотой (VIA) и теста с уксусной кислотой (VIA) с немедленным последующим визуальным осмотром и тестом с йодным раствором Люголя (VIA/VILI) у женщин с положительным результатом по итогам VIA.Была проведена оценка данных программы скрининга рака шейки матки, которая была реализована в двух ВИЧ‑клиниках в западной части Кении. Женщины в центральной клинике прошли процедуру VIA, а женщины в периферийной клинике прошли процедуру VIA/VILI. В отношении всех женщин, у которых скрининг VIA или VILI выявил внутриэпителиальную неоплазию шейки матки второй степени или более тяжелое состояние (CIN 2+), была проведена кольпоскопия, а также, при необходимости, биопсия. Общий показатель положительных тестов, прогностичность положительного результата (PPV) и коэффициент обнаружения CIN 2+ были рассчитаны для обоих методов скрининга, причем результаты биопсии рассматривались в качестве эталонных.В период с октября 2007 года по октябрь 2010 года 2338 женщин были обследованы с использованием VIA и 1124 женщины — с использованием VIA/VILI. В группе, обследованной при помощи VIA, тесты 26,4% женщин оказались позитивными на CIN 2+, а в группе VIA/VILI 21,7% тестов дали положительный результат (Отсутствие каких-либо различий между VIA и VIA/VILI в части уровня обнаружения или PPV для CIN 2+ дает основания предположить, что более легкая процедура тестирования VIA может быть использована самостоятельно в качестве стратегии скрининга рака шейки матки в странах с низким уровнем доходов.

ObjectiveTo identify patient factors associated with whether women who screened positive for high-risk human papillomavirus (hrHPV) successfully accessed treatment in a cervical cancer prevention program in Kenya.MethodsA prospective cohort study was conducted as part of a trial of implementation strategies for hrHPV-based cervical cancer screening in western Kenya from January 2018 to February 2019. In this larger trial, women underwent hrHPV testing during community health campaigns (CHCs), and hrHPV+ women were referred to government facilities for cryotherapy. For this analysis, we looked at rates of and predictors of presenting for treatment and presenting within 30 days of receiving positive hrHPV results ("timely" presentation). Data came from questionnaires completed at the time of screening and treatment. Multivariable logistic regression was used to identify factors associated with each outcome.ResultsOf the 505 hrHPV+ women, 266 (53%) presented for treatment. Cryotherapy was performed in 236 (89%) of the women who presented, while 30 (11%) were not treated: 15 (6%) due to gas outage, six (2%) due to pregnancy, five (2%) due to concern for cervical cancer, and four (2%) due to an unknown or other reason. After adjusting for other factors in the multivariable analysis, higher education level and missing work to come to the CHC were associated with presenting for treatment. Variables that were associated with increased likelihood of timely presentation were missing work to come to the CHC, absence of depressive symptoms, told by someone important to come to the CHC, and shorter distance to the treatment site.ConclusionThe majority of hrHPV+ women who did not get treated were lost at the stage of decision-making or accessing treatment, with a small number encountering barriers at the treatment sites. Patient education and financial support are potential areas for intervention to increase rates of hrHPV+ women seeking treatment.

BackgroundWe sought to understand the beliefs, social norms and logistical factors that affect human papillomavirus (HPV)-positive women’s uptake of cryotherapy treatment as part of a two-part cervical cancer screening strategy in rural Kenya.MethodsIn-depth interviews within a parent cluster-randomised trial.SettingGovernment-run county hospital in western Kenya.Participants273 of 372 (73.4%) HPV-positive women who underwent cryotherapyResultsMany women feared that an HPV infection meant they would develop cancer. Almost all women reported initial fear of the treatment procedure, followed by a more positive experience than anticipated. Lacking funds for transportation to the treatment site was the most common barrier. Women felt that decentralised treatment would be the most important facilitator of greater access. Spousal encouragement and financial support were key facilitators of treatment access, however many women felt that other husbands in the community would not be supportive. Women described successfully acquiring treatment as empowering, and almost all would recommend seeking cryotherapy to other women who test HPV-positive. Most felt eager to share their own experiences with others to encourage treatment.ConclusionsThe main facilitators of treatment access were understanding of the health risks and sense of empowerment. A decentralised treatment model or transportation support may facilitate access, along with improved health messaging about HPV infection, cancer and the treatment process. Focusing on women’s personal feelings of empowerment may further improve uptake and satisfaction. These data will be used to design a strategy to improve linkage to treatment.Trial RegistrationNCT02124252.

ObjectiveGiven the high prevalence of cervical intraepithelial neoplasia (CIN) grade 2/3 among HIV-infected women, we sought to examine the relationship between CIN 2/3 and HIV-1 genital shedding among women on highly active antiretroviral therapy (HAART).Materials and methodsPaired plasma and cervical wick specimens for HIV-1 RNA measurements were obtained from 44 HIV-infected women with biopsy-confirmed CIN 2/3 (cases) and 44 age-matched HIV-infected women with normal cervical findings on colposcopy (controls). All subjects tested negative for sexually transmitted infections and had been stable on HAART for at least 3 months. HIV-1 viral load was measured in both blood and cervical specimens using commercial real-time polymerase chain reaction assays.ResultsCervical intraepithelial neoplasia 2/3 was not significantly associated with the detection or magnitude of plasma or cervical HIV-1 RNA shedding. HIV was detected in the plasma in 10 cases (23%) and 10 controls (25%) (odds ratio = 1.0; 95% confidence interval = 0.33-3.1). Cervical HIV-1 was detected in 6 cases (13.6%) and 9 controls (20.4%) (odds ratio = 0.61; 95% confidence interval = 0.20-1.90). Mean HIV-1 concentration in cervical secretions among women with CIN 2/3 who shed was 2.93 log10 copies versus 2.72 among controls (p = .65).ConclusionsAmong women on HAART, we found no relationship between CIN 2/3 and HIV-1 genital shedding.

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.

Objective A biomarker with increased specificity for cervical dysplasia compared with human papillomavirus (HPV) testing would be an attractive option for cervical cancer screening among HIV-infected women in resource-limited settings. p16INK4a has been explored as a biomarker for screening in general populations. Design A 2-year cross-sectional study. Setting 2 large HIV primary care clinics in western Kenya. Participants 1054 HIV-infected women in western Kenya undergoing cervical cancer screening as part of routine HIV care from October 2010 to November 2012. Interventions Participants underwent p16INK4a specimen collection and colposcopy. Lesions with unsatisfactory colposcopy or suspicious for cervical intraepithelial neoplasia 2+ (CIN2+; including CIN2/3 or invasive cervical cancer) were biopsied. Following biopsy, disease status was determined by histopathological diagnosis. Primary and secondary outcome measures We measured the sensitivity, specificity and predictive values of p16INK4a ELISA for CIN2+ detection among HIV-infected women and compared them to the test characteristics of current screening methods used in general as well as HIV-infected populations. Results Average p16INK4a concentration in cervical samples was 37.4 U/mL. After colposcopically directed biopsy, 127 (12%) women were determined to have CIN2+. Receiver operating characteristic analysis showed an area under the curve of 0.664 for p16INK4a to detect biopsy-proven CIN2+. At a p16INK4a cut-off level of 9 U/mL, sensitivity, specificity, positive and negative predictive values were 89.0%, 22.9%, 13.6% and 93.8%, respectively. The overall p16INK4a positivity at a cut-off level of 9 U/mL was 828 (78.6%) women. There were 325 (30.8%) cases of correct p16INK4a prediction to detect or rule out CIN2+, and 729 (69.2%) cases of incorrect p16INK4a prediction. Conclusions p16INK4a ELISA did not perform well as a screening test for CIN2+ detection among HIV-infected women due to low specificity. Our study contributes to the ongoing search for a more specific alternative to HPV testing for CIN2+ detection.

Cervical cancer is a leading cause of cancer-related death amongst women in sub-Saharan Africa, largely due to the lack of early screening and treatment. In addition to poor access to screening services, inadequate uptake of available services is a barrier to early identification of precancerous lesions. Given that cervical cancer is caused by a sexually transmitted virus and is associated with HIV positivity, stigma is one of the potential barriers to the utilization of cervical cancer programs in sub-Saharan Africa. We conducted a cross-sectional survey of 419 women attending health facilities in rural western Kenya to measure levels of cervical cancer and HIV stigma and to measure the associations between cervical cancer stigma, HIV stigma, and HIV status. Women who qualified for cervical cancer screening were asked to complete an oral questionnaire using a modified 9-point HIV stigma scale. Low cervical cancer stigma was reported in this study, with only 85/419 (20.3 %) of respondents answering yes to at least one cervical cancer stigma question. However, cervical cancer stigma was highly correlated with HIV stigma (correlation coefficient 0.72) and was significantly lower in HIV-positive women (p

To evaluate outcomes of cervical cancer screening within HIV care and treatment clinics in Kenya.Beginning in October 2007, visual inspection with acetic acid (VIA), colposcopy, and loop electrosurgical excision procedure (LEEP) were added to the clinical services offered at Family AIDS Care and Education Services (FACES) clinics in Kisumu, Kenya, after a systematic campaign to build capacity and community awareness.From October 2007 to October 2010, 3642 women underwent VIA as part of routine HIV care. Cervical intraepithelial neoplasia 2/3 was identified in 259 (7.1%) women, who were offered excisional treatment by LEEP in the clinic. Among those women offered screening, uptake was 87%. Clinical staff reported a high level of satisfaction with training for and implementation of cervical cancer screening strategies.Cervical cancer screening and prevention are feasible, acceptable, and effective within HIV care and treatment clinics. Screening test performance characteristics need to be defined for an HIV-positive population to determine the cost/benefit ratio of lower cost strategies that will ultimately be necessary to provide universal access to cervical cancer screening in low-resource settings.

INTRODUCTION HIV-infected women may have higher rates of recurrent cervical precancer after treatment. Knowledge about rates and predictors of recurrence could impact guidelines and program planning, especially in low-resource settings. METHODS In this prospective cohort study in Western Kenya, we followed HIV-infected women at 6 and 12 months after treatment for cervical intraepithelial neoplasia 2 or greater (CIN2+) after treatment with loop electrosurgical excision procedure (LEEP). All women underwent follow-up colposcopy with biopsy as indicated for the diagnosis of CIN2+. We calculated the incidence and predictors of primary disease recurrence after treatment. RESULTS Among the 284 women who underwent LEEP and had at least 1 follow-up visit, there were 37 (13%) cases of CIN2+ detected by 12-month follow-up. Four (10.8%) of the recurrences were invasive cancer, all stage IA1. The 6- and 12-month rates of recurrence were 13.7 and 12.8 cases per 100 person-years of follow-up, respectively. Antiretroviral therapy use did not significantly impact the rate of recurrence (hazard ratio: 1.24, 95% confidence interval: 0.59 to 2.79). The only significant predictor of recurrence in the multivariate analysis was CD4(+) nadir

Background HIV increases women’s risk for high-risk human papillomavirus (hrHPV) infection and invasive cervical cancer. South Africa has a high HIV prevalence but low cervical cancer screening coverage. Self-collection of cervical specimens and hrHPV testing, including hrHPV messenger-RNA (mRNA) testing, are methods aimed at increasing screening rates. However, data are limited on the acceptability and accuracy of tampon-based self-collection for hrHPV mRNA testing in HIV-infected women. Methods We recruited 325 HIV-infected women seeking care at a government HIV clinic in Pretoria, South Africa. A clinician performed a pelvic examination and obtained an endocervical specimen. Study participants performed self-collection using a tampon. Both clinician- and self-collected specimens were tested for hrHPV mRNA. Acceptability of both collection methods was assessed, the prevalence of hrHPV mRNA in our study population was estimated, test positivity of the two collection methods were compared, and test agreement was assessed by calculating the κ-statistic, sensitivity, and specificity. Results Over 90% of women reported no difficulties self-collecting specimens and 82% were willing to perform the tampon-collection at home. Based on clinician-collection specimens, the prevalence of hrHPV mRNA in our study population was 36.7% (95% CI: 31.4%– 42.0%). There was no difference in test positivity between clinician-collection, 36.7%, and tampon-collection, 43.5% (p-value = 0.08). Using clinician-collection as the reference test, the sensitivity and specificity for hrHPV mRNA of tampon-collection were 77.4% (95% CI: 69.8–85.0%) and 77.8% (95% CI: 71.9–83.6%), respectively. Conclusions Tampon-based self-collection is acceptable to women and has similar hrHPV mRNA positivity rates as clinician-collection, but has reduced sensitivity and specificity compared to clinician-collection. The hrHPV mRNA prevalence in our study population is high, but similar to other high-risk populations, and highlights the need for improved cervical cancer screening. Further research into the optimal use of tampon-based collection as a cervical cancer screening tool is warranted.

Visual inspection with Acetic Acid (VIA) and Visual Inspection with Lugol’s Iodine (VILI) are increasingly recommended in various cervical cancer screening protocols in low-resource settings. Although VIA is more widely used, VILI has been advocated as an easier and more specific screening test. VILI has not been well-validated as a stand-alone screening test, compared to VIA or validated for use in HIV-infected women. We carried out a randomized clinical trial to compare the diagnostic accuracy of VIA and VILI among HIV-infected women. Women attending the Family AIDS Care and Education Services (FACES) clinic in western Kenya were enrolled and randomized to undergo either VIA or VILI with colposcopy. Lesions suspicious for cervical intraepithelial neoplasia 2 or greater (CIN2+) were biopsied. Between October 2011 and June 2012, 654 were randomized to undergo VIA or VILI. The test positivity rates were 26.2% for VIA and 30.6% for VILI (p = 0.22). The rate of detection of CIN2+ was 7.7% in the VIA arm and 11.5% in the VILI arm (p = 0.10). There was no significant difference in the diagnostic performance of VIA and VILI for the detection of CIN2+. Sensitivity and specificity were 84.0% and 78.6%, respectively, for VIA and 84.2% and 76.4% for VILI. The positive and negative predictive values were 24.7% and 98.3% for VIA, and 31.7% and 97.4% for VILI. Among women with CD4+ count < 350, VILI had a significantly decreased specificity (66.2%) compared to VIA in the same group (83.9%, p = 0.02) and compared to VILI performed among women with CD4+ count ≥ 350 (79.7%, p = 0.02). VIA and VILI had similar diagnostic accuracy and rates of CIN2+ detection among HIV-infected women. Trial Registration ClinicalTrials.gov NCT02237326

Introduction : 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. Discussion : Despite the biologic, behavioural and demographic overlap between HIV and cervical cancer, cervical cancer prevention has for the most part been left out of sexual and reproductive health (SRH) services for HIV-positive women. Lower cost primary and secondary prevention strategies for cervical cancer are becoming more widely available in LMICs, with increasing evidence for their efficacy and cost-effectiveness. Going forward, cervical cancer prevention must be considered a part of the essential package of SRH services for HIV-positive women. Effective cervical cancer prevention programmes will require a coordinated response from international policymakers and funders, national governments and community leaders. Leveraging the improvements in healthcare infrastructure created by the response to the global HIV epidemic through integration of services may be an effective way to make an impact to prevent cervical cancer among HIV-positive women, but more work remains to determine optimal approaches. Conclusions : Cervical cancer prevention is an essential part of comprehensive HIV care. In order to ensure maximal impact and cost-effectiveness, implementation strategies for screening programmes must be adapted and rigorously evaluated through a framework that includes equal participation with policymakers, programme planners and key stakeholders in the target communities. Keywords: cervical cancer prevention; HIV; integration; low- and middle-income countries. (Published: 1 December 2015) Citation: Huchko MJ et al. Journal of the International AIDS Society 2015, 18(Suppl 5) :20282 http://www.jiasociety.org/index.php/jias/article/view/20282 | http://dx.doi.org/10.7448/IAS.18.6.20282

Background A number of studies have identified male involvement as an important factor affecting reproductive health outcomes, particularly in the areas of family planning, antenatal care, and HIV care. As access to cervical cancer screening programs improves in resource-poor settings, particularly through the integration of HIV and cervical cancer services, it is important to understand the role of male partner support in women’s utilization of screening and treatment. Methods We administered an oral survey to 110 men in Western Kenya about their knowledge and attitudes regarding cervical cancer and cervical cancer screening. Men who had female partners eligible for cervical cancer screening were recruited from government health facilities where screening was offered free of charge. Results Specific knowledge about cervical cancer risk factors, prevention, and treatment was low. Only half of the men perceived their partners to be at risk for cervical cancer, and many reported that a positive screen would be emotionally upsetting. Nevertheless, all participants said they would encourage their partners to get screened. Conclusions Future interventions should tailor cervical cancer educational opportunities towards men. Further research is needed among both men and couples to better understand barriers to male support for screening and treatment and to determine how to best involve men in cervical cancer prevention efforts.