Cervical cancer is entirely preventable through vaccination, screening, and early treatment. However, this disease remains a leading cause of death in sub-Saharan Africa, where HIV rates are also high.
Women living with HIV (WHIV) are a priority population for cervical cancer screening because human papillomavirus (HPV) infection will progress more often and quickly to cervical cancer in HIV-infected women. Despite this, most WHIV in countries like Uganda have never been screened and are unaware of their risk for cervical cancer.
The ASPIRE project
The Advances in Screening and Prevention in Reproductive Cancers (ASPIRE) research team continues to examine novel ways to better integrate cervical cancer and reproductive health screening with HIV care to protect the health of vulnerable women in Uganda.
The ASPIRE program is a collaboration between the University of British Columbia and Makerere University in Uganda. Since 2006, ASPIRE has coupled cervical cancer screening, using self-collected samples for HPV testing, with sexually transmitted infections (STI) testing to improve access to reproductive health in Uganda. With this approach, community health workers offer women a swab so they can self-collect a vaginal sample in the comfort of their own home.
This approach has been shown to significantly improve uptake of screening compared to clinic-based screening among women in Kisenyi, an impoverished district of Kampala.
HPV screening in WHIV
In 2013, the team initiated a project that focused on WHIV at the local HIV clinic in Kisenyi.
Women completed a questionnaire administered by a community health worker to determine:
- if they had ever heard about cervical cancer or HPV,
- if they had ever been screened for cervical cancer, and
- if they would be interested in self-collecting a sample for HPV testing.
This initial study was followed by contacting study participants to offer them self-collected HPV testing for cervical cancer screening and follow-up care. Of 87 WHIV who completed the survey, 96.4% had never heard of HPV and 98.9% did not think it was necessary to be screened for cervical cancer. Among women screened, 45% were positive for high risk strains of HPV. The positivity of HPV 16 or 18, the strains most likely to progress to cervical cancer, was 15% overall.
In settings like Kisenyi, HIV clinics are busy, crowded, understaffed and have limited resources, leaving little opportunity to expand or add services. In order for cervical cancer and reproductive health screening to be successful, strategies must be low-cost, with little added burden to overextended staff.
The integration of self-collection based screening with HIV care is promising for several reasons:
- Community health workers can offer screening to women while they wait for their HIV appointment.
- Samples can be tested for both HPV and other STIs.
- Sample testing is performed at laboratory facilities that are typically already in place at HIV service sites.
WHIV often lack the time and money to make multiple clinic visits for screening. This approach improves the health care interaction for women by tackling multiple reproductive health interventions in the same visit.
In the future, ASPIRE will use lessons learned from this project to a partnership in South Africa, Northern Uganda, and to vulnerable women in British Columbia.
- World Health Organization. Comprehensive Cervical Cancer Control: A guide to essential practice. 2nd ed. 2014. Available from: http://apps.who.int/iris/bitstream/10665/144785/1/9789241548953_eng.pdf?ua=1
- Moses E, Pedersen H, Mitchell S, Sekikubo M, Mwesigwa D, Singer J, Biryabarema C, Byamugisha J, Money D, Ogilvie G. Uptake of community-based, self-collected HPV testing vs. visual inspection with acetic acid for cervical cancer screening in Kampala, Uganda: preliminary results of a randomised controlled trial. Tropical Medicine & International Health. 2015;20(10):1355-67.
- Mitchell SM, Pedersen HN, Eng Stime E, Sekikubo M, Moses E, Mwesigwa D, Biryabarema C, Christilaw J, Byamugisha JK, Money DM, Ogilvie GS. Self-collection based HPV testing for cervical cancer screening among women living with HIV in Uganda: a descriptive analysis of knowledge, intentions to screen and factors associated with HPV positivity. BMC Womens Health. 2017;17(1):4. Available from: https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-016-0360-0