Cervical Cancer Screening for Women With Disabilities: Time for a New Approach?

Women with disabilities are underscreened for cervical cancer compared with the general population, likely because, in part, of both emotional and physical challenges associated with Pap testing. Women with certain disabilities often require an examination under anesthesia to undergo a speculum examination. However, anesthesia is not without risks and the perioperative experience can be burdensome to patients and caregivers. Either self-collected or provider-collected samples for human papillomavirus (HPV) testing might be better tolerated by patients, and recent evidence suggests that it is a suitable primary screening strategy. The Society of Gynecologic Oncology and the American Society for Colposcopy and Cervical Pathology published an Interim Guidance Report outlining using primary HPV testing as an option for women 25 years and older. More recently, the US Preventive Services Task Force released a recommendation statement that included the option to use oncogenic HPV testing alone for women aged 30 to 65 years. We encourage clinical researchers and professional organizations to evaluate primary HPV screening among women with disabilities to advise providers about how to best perform cervical cancer screening without the need for a speculum examination. We cannot ignore the screening disparity experienced by this population, and advocating for screening approaches that reduce patient and caregiver burden would be a step in the right direction.

Intravaginal practices are associated with greater odds of high-risk HPV infection in Haitian women.

OBJECTIVE: Haitian women have the highest incidence of cervical cancer within the Western hemisphere. Intravaginal hygiene practices have been linked with human papilloma virus (HPV) infection and cervical dysplasia. These practices, known as 'twalet deba' in Haitian Creole, are common among Haitian women and are performed with various natural and synthetic agents. As part of a community-based participatory research initiative aimed at reducing cervical cancer disparities in rural Haiti, we explored the use of intravaginal agents and their associations with high-risk HPV infection. DESIGN: Community Health Workers recruited 416 women for cervical self-sampling from two neighborhoods within Thomonde, Haiti. Participants were interviewed regarding intravaginal hygiene practices and completed a cervical self-sampling procedure. Cervical samples were analyzed for the presence of high-risk HPV infection. Associations between each intravaginal agent and high-risk HPV infection were examined via univariate logistic regression analyses, as well as via multivariate analyses controlling for sociodemographic factors and concurrent agent use. RESULTS: Nearly all women (97.1%) performed twalet deba, using a variety of herbal and commercially produced intravaginal agents. Approximately 11% of the participants tested positive for high-risk HPV. Pigeon pea and lime juice were the only agents found to be associated with high-risk HPV in the univariate analyses, with women who used these agents being approximately twice as likely to have high-risk HPV as those who did not. Only pigeon pea remained significantly associated with high-risk HPV after controlling for sociodemographic factors and concurrent agent use. CONCLUSION: Two agents, pigeon pea and lime juice, may contribute to risk for HPV infection in this population. Results suggest that in addition to cervical cancer screening interventions, future preventive initiatives should focus on minimizing risk by advocating for the use of less-toxic twalet deba alternatives.

Out-of-pocket expenses incurred by patients obtaining free breast cancer care in Haiti.

BACKGROUND: Women with breast cancer in low-income and middle-income countries (LMICs) account for 51% of cases globally and often present with advanced disease. Fear of costs contributes to delay in seeking care, as health expenditures are financially catastrophic for families worldwide. Despite efforts to improve affordability of health care in LMICs, the financial burden of indirect costs (eg, transportation and lost wages) is often overlooked. We aimed to identify and quantify the expenditures of patients seeking breast cancer care in a LMIC. METHODS: Patients receiving breast cancer care free of charge at Hôpital Universitaire de Mirebalais (HUM) in Haiti were interviewed to quantify their costs and assess the effect of these costs on patients and families. These costs included expenses for food, lodging, transportation, childcare, medical costs at other institutions, and lost wages. 61 patients were interviewed during diagnostic, chemotherapy, and surgical visits between March 1, and May 12, 2014. Institutional review board exemption was granted from Boston Children's Hospital and Partners in Health/Zanmi Lasante. FINDINGS: The median non-medical out-of-pockent expenses incurred by breast cancer patients at HUM were US$233 (95% CI 170-304) for diagnostic visits, US$259 (95% CI 200-533) for chemotherapy, and US$38 (95% CI 23-140) for surgery. The median total out-of-pockent expense (including medical costs) was US$717 (95% CI 619-1171). These costs forced 52% of participants into debt and 20% to sell possessions. The median percentage of potential individual income spent on out-of-pocket costs was 60%. The median sum of out-of-pocket costs and lost wages was US$2996 (95% CI 1676-5179). INTERPRETATION: In Haiti, 74% of people earn less than US$2 per day. Even when breast cancer treatment is provided for free, out-of-pocket expenses could account for more than 91% of annual earnings at this income level. This financial burden is an overwhelming obstacle for Haiti's poorest citizens, and probably for many patients in LMICs. High-powered, multisite studies are needed to further characterise this burden worldwide. Funders and health-care providers should reduce indirect costs to achieve equitable access to oncology care. FUNDING: Boston Children's Hospital and Partners in Health.

A time-driven activity-based costing model to improve health-care resource use in Mirebalais, Haiti.

BACKGROUND: In resource-limited settings, efficiency is crucial to maximise resources available for patient care. Time driven activity-based costing (TDABC) estimates costs directly from clinical and administrative processes used in patient care, thereby providing valuable information for process improvements. TDABC is more accurate and simpler than traditional activity-based costing because it assigns resource costs to patients based on the amount of time clinical and staff resources are used in patient encounters. Other costing approaches use somewhat arbitrary allocations that provide little transparency into the actual clinical processes used to treat medical conditions. TDABC has been successfully applied in European and US health-care settings to facilitate process improvements and new reimbursement approaches, but it has not been used in resource-limited settings. We aimed to optimise TDABC for use in a resource-limited setting to provide accurate procedure and service costs, reliably predict financing needs, inform quality improvement initiatives, and maximise efficiency. METHODS: A multidisciplinary team used TDABC to map clinical processes for obstetric care (vaginal and caesarean deliveries, from triage to post-partum discharge) and breast cancer care (diagnosis, chemotherapy, surgery, and support services, such as pharmacy, radiology, laboratory, and counselling) at Hôpital Universitaire de Mirebalais (HUM) in Haiti. The team estimated the direct costs of personnel, equipment, and facilities used in patient care based on the amount of time each of these resources was used. We calculated inpatient personnel costs by allocating provider costs per staffed bed, and assigned indirect costs (administration, facility maintenance and operations, education, procurement and warehouse, bloodbank, and morgue) to various subgroups of the patient population. This study was approved by the Partners in Health/Zanmi Lasante Research Committee. FINDINGS: The direct cost of an uncomplicated vaginal delivery at HUM was US$62 and the direct cost of a caesarean delivery was US$249. The direct costs of breast cancer care (including diagnostics, chemotherapy, and mastectomy) totalled US$1393. A mastectomy, including post-anaesthesia recovery and inpatient stay, totalled US$282 in direct costs. Indirect costs comprised 26-38% of total costs, and salaries were the largest percentage of total costs (51-72%). INTERPRETATION: Accurate costing of health services is vital for financial officers and funders. TDABC showed opportunities at HUM to optimise use of resources and reduce costs-for instance, by streamlining sterilisation procedures and redistributing certain tasks to improve teamwork. TDABC has also improved budget forecasting and informed financing decisions. HUM leadership recognised its value to improve health-care delivery and expand access in low-resource settings. FUNDING: Boston Children's Hospital, Harvard Business School, and Partners in Health.

Systematic review of laparoscopic surgery in low- and middle-income countries: benefits, challenges, and strategies.

BACKGROUND: Laparoscopy may prove feasible to address surgical needs in limited-resource settings. However, no aggregate data exist regarding the role of laparoscopy in low- and middle-income countries (LMICs). This study was designed to describe the issues facing laparoscopy in LMICs and to aggregate reported solutions. METHODS: A search was conducted using Medline, African Index Medicus, the Directory of Open Access Journals, and the LILACS/BIREME/SCIELO database. Included studies were in English, published after 1992, and reported safety, cost, or outcomes of laparoscopy in LMICs. Studies pertaining to arthroscopy, ENT, flexible endoscopy, hysteroscopy, cystoscopy, computer-assisted surgery, pediatrics, transplantation, and bariatrics were excluded. Qualitative synthesis was performed by extracting results that fell into three categories: advantages of, challenges to, and adaptations made to implement laparoscopy in LMICs. PRISMA guidelines for systematic reviews were followed. RESULTS: A total of 1101 abstracts were reviewed, and 58 articles were included describing laparoscopy in 25 LMICs. Laparoscopy is particularly advantageous in LMICs, where there is often poor sanitation, limited diagnostic imaging, fewer hospital beds, higher rates of hemorrhage, rising rates of trauma, and single income households. Lack of trained personnel and equipment were frequently cited challenges. Adaptive strategies included mechanical insufflation with room air, syringe suction, homemade endoloops, hand-assisted techniques, extracorporeal knot tying, innovative use of cheaper instruments, and reuse of disposable instruments. Inexpensive laboratory-based trainers and telemedicine are effective for training. CONCLUSIONS: LMICs face many surgical challenges that require innovation. Laparoscopic surgery may be safe, effective, feasible, and cost-effective in LMICs, although it often remains limited in its accessibility, acceptability, and quality. This study may not capture articles written in languages other than English or in journals not indexed by the included databases. Surgeons, policymakers, and manufacturers should focus on plans for sustainability, training and retention of providers, and regulation of efforts to develop laparoscopy in LMICs.

Phylogenomics of unusual histone H2A Variants in Bdelloid rotifers.

Rotifers of Class Bdelloidea are remarkable in having evolved for millions of years, apparently without males and meiosis. In addition, they are unusually resistant to desiccation and ionizing radiation and are able to repair hundreds of radiation-induced DNA double-strand breaks per genome with little effect on viability or reproduction. Because specific histone H2A variants are involved in DSB repair and certain meiotic processes in other eukaryotes, we investigated the histone H2A genes and proteins of two bdelloid species. Genomic libraries were built and probed to identify histone H2A genes in Adineta vaga and Philodina roseola, species representing two different bdelloid families. The expressed H2A proteins were visualized on SDS-PAGE gels and identified by tandem mass spectrometry. We find that neither the core histone H2A, present in nearly all other eukaryotes, nor the H2AX variant, a ubiquitous component of the eukaryotic DSB repair machinery, are present in bdelloid rotifers. Instead, they are replaced by unusual histone H2A variants of higher mass. In contrast, a species of rotifer belonging to the facultatively sexual, desiccation- and radiation-intolerant sister class of bdelloid rotifers, the monogononts, contains a canonical core histone H2A and appears to lack the bdelloid H2A variant genes. Applying phylogenetic tools, we demonstrate that the bdelloid-specific H2A variants arose as distinct lineages from canonical H2A separate from those leading to the H2AX and H2AZ variants. The replacement of core H2A and H2AX in bdelloid rotifers by previously uncharacterized H2A variants with extended carboxy-terminal tails is further evidence for evolutionary diversity within this class of histone H2A genes and may represent adaptation to unusual features specific to bdelloid rotifers.

Degenerate tetraploidy was established before bdelloid rotifer families diverged.

Rotifers of Class Bdelloidea are abundant freshwater invertebrates known for their remarkable ability to survive desiccation and their lack of males and meiosis. Sequencing and annotation of approximately 50-kb regions containing the four hsp82 heat shock genes of the bdelloid Philodina roseola, each located on a separate chromosome, have suggested that its genome is that of a degenerate tetraploid. In order to determine whether a similar structure exists in a bdelloid distantly related to P. roseola and if degenerate tetraploidy was established before the two species separated, we sequenced regions containing the hsp82 genes of a bdelloid belonging to a different family, Adineta vaga, and the histone gene clusters of P. roseola and A. vaga. Our findings are entirely consistent with degenerate tetraploidy and show that it was established before the two bdelloid families diverged and therefore probably before the bdelloid radiation.

Vaginal Infections in Haitian Immigrant Women Living in Miami, Florida.

OBJECTIVE: To characterize vulvovaginal candidiasis (VC), trichomonas vaginalis (TV), and bacterial vaginosis (BV) among Haitian women living in Miami to identify contributing factors to cervical cancer disparity in this population. METHODS: Using a CBPR framework, 246 Haitian women (ages 21-65) were recruited. Self-collected cervical cytology specimens were analyzed for VC, TV, and BV. RESULTS: The proportion of participants with VC, TV, and BV, were 7.3%, 9.3%, and 19.9%, respectively. CONCLUSION: Haitian women may have a higher prevalence of TV than the general U.S. population, which may increase susceptibility to HPV, the primary cause of cervical cancer.

Pairing community health workers with HPV self-sampling for cervical cancer prevention in rural Haiti.

OBJECTIVE: To assess a program in which community health workers (CHWs) provided women with self-sampling devices to detect high-risk human papillomavirus (HPV). METHODS: In a cross-sectional study, 13 CHWs visited homes in a rural area in Haiti's Central Plateau to recruit premenopausal women aged 30-50 years between July 2009 and April 2010. Eligible women had not undergone a cervical smear in the previous 3 years. Participants learned about cervical cancer and self-sampling for HPV testing before using a self-sampler in private. They then completed a questionnaire. CHWs later returned to provide results and advice about follow-up care. RESULTS: CHWs enrolled 493 women. Among the 485 women for whom questionnaires were received, 468 (96.5%) were comfortable using the self-sampler and 484 (99.8%) stated they would recommend it to others. Among 426 analyzed samples, 54 (12.7%) were positive for high-risk HPV, of whom 46 (85.2%) received follow-up care and 17 (31.5%) had precursor lesions and were treated. CONCLUSION: Using a CHW-led intervention, women at high risk for developing cervical cancer were identified and navigated to preventive care. Therefore, pairing CHWs with HPV self-sampling is a promising strategy to combat cervical cancer in rural Haiti and similar settings.

Out-of-pocket expenses incurred by patients obtaining free breast cancer care in Haiti: A pilot study.

BACKGROUND: Women in low- and middle-income countries account for 51% of breast cancer cases globally. These patients often delay seeking care and, therefore, present with advanced disease, partly because of fear of catastrophic health care expenses. Although there have been efforts to make health care affordable in low- and middle-income countries, the financial burden of out-of-pocket (OOP) expenses for nonmedical costs, such as transportation and lost wages, often is overlooked. METHODS: An institutional review board exemption was granted from Boston Children's Hospital and Partners in Health/Zanmi Lasante for this cross-sectional study. In total, 61 patients receiving breast cancer care free of charge at Hôpital Universitaire de Mirebalais (HUM) in Haiti were selected via convenience sampling. They were interviewed between March and May 2014 to quantify the expenses they incurred during the course of diagnosis and treatment. These expenses included medical costs at outside facilities, as well as nonmedical costs (eg, transportation, meals, etc). RESULTS: The median, nonmedical OOP expenses incurred by breast cancer patients at HUM were $233 (95% confidence interval [95% CI] $170-304) for diagnostic visits, $259 (95% CI $200-533) for chemotherapy visits, and $38 (95% CI $23-140) for surgery visits. The median total OOP expense (including medical costs) was $717 (95% CI $619-1,171). To pay for these expenses, 52% of participants stated that they went into debt; however, the amount of debt was not quantified. The median income of these patients was $1,333 (95% CI $778-2,640), and the median sum of OOP expenses and lost wages was $2,996 (95% CI $1,676-5,179). CONCLUSION: Despite receiving free care: at HUM, more than two-thirds of participants met conservative criteria for catastrophic medical expenses (defined as spending more than 40% of their potential household income on OOP payments). Further studies are needed to understand the magnitude of OOP health care expenses for the poor worldwide, how to aid them during their treatment program, and its impact on their health outcomes.

Cost-effectiveness of surgery and its policy implications for global health: a systematic review and analysis.

BACKGROUND: The perception of surgery as expensive and complex might be a barrier to its widespread acceptance in global health efforts. We did a systematic review and analysis of cost-effectiveness studies that assess surgical interventions in low-income and middle-income countries to help quantify the potential value of surgery. METHODS: We searched Medline for all relevant articles published between Jan 1, 1996 and Jan 31, 2013, and searched the reference lists of retrieved articles. We converted all results to 2012 US$. We extracted cost-effectiveness ratios (CERs) and appraised economic assessments for their methodological quality using the 10-point Drummond checklist. FINDINGS: Of the 584 identified studies, 26 met full inclusion criteria. Together, these studies gave 121 independent CERs in seven categories of surgical interventions. The median CER of circumcision ($13·78 per disability-adjusted life year [DALY]) was similar to that of standard vaccinations ($12·96-25·93 per DALY) and bednets for malaria prevention ($6·48-22·04 per DALY). Median CERs of cleft lip or palate repair ($47·74 per DALY), general surgery ($82·32 per DALY), hydrocephalus surgery ($108·74 per DALY), and ophthalmic surgery ($136 per DALY) were similar to that of the BCG vaccine ($51·86-220·39 per DALY). Median CERs of caesarean sections ($315·12 per DALY) and orthopaedic surgery ($381·15 per DALY) are more favourable than those of medical treatment for ischaemic heart disease ($500·41-706·54 per DALY) and HIV treatment with multidrug antiretroviral therapy ($453·74-648·20 per DALY). INTERPRETATION: Our findings suggest that many essential surgical interventions are cost-effective or very cost-effective in resource-poor countries. Quantification of the economic value of surgery provides a strong argument for the expansion of global surgery's role in the global health movement. However, economic value should not be the only argument for resource allocation--other organisational, ethical, and political arguments can also be made for its inclusion.