Knowledge, attitudes, and practices of cervical Cancer screening among HIV-positive and HIV-negative women participating in human papillomavirus screening in rural Zimbabwe.

BACKGROUND: Women in low- and middle-income countries are at the highest risk of cervical cancer yet have limited access to and participation in cervical cancer screening programs. Integrating self-collected, community-based screening offers a potential primary screening method in areas of limited resources. In this paper, we present a study evaluating knowledge, attitudes, and practices of cervical cancer and Human Papilloma Virus (HPV) in rural Zimbabwe. METHODS: We performed a community-based cross-sectional knowledge, attitudes and practices of HPV and cervical cancer study in rural Zimbabwe from January 2017-May 2017. Women were selected for the study via random number generation from complete lists of inhabitants in the study area if they satisfied the inclusion criteria (≥30-years-old, ≤65-years-old, not pregnant, intact uterus). If selected, they participated in a 19-question structured knowledge, attitudes and practices survey. The questionnaire included questions on demographics, education, knowledge of HPV, cervical cancer, and risk factors. Chi-squared tests were evaluated comparing knowledge, attitudes and practices relating to HPV and cervical cancer screening with actual infection with HPV. Women were also offered a voluntary HIV and self-collected HPV screening. RESULTS: Six hundred seventy-nine women were included in the knowledge, attitudes and practices survey. Most women (81%) had heard of cervical cancer while the majority had not heard of HPV (12%). The number of women that had been screened previously for cervical cancer was low (5%). There were no significant differences between and within groups regarding knowledge of cervical cancer and actual overall infection with HR-HPV, HPV 16, and HPV 18/45 test results. CONCLUSIONS: Most women in rural Zimbabwe have heard of cervical cancer, but the number that had been screened was low. Extending existing outreach services to include cervical cancer screening, potentially including HPV screening, should include cervical cancer/HPV education and screening triage. This approach would serve to bridge the gap between knowledge and screening availability to address some of the barriers to cervical cancer care still affecting women in many regions of the world.

Antenatal depression: an examination of prevalence and its associated factors among pregnant women attending Harare polyclinics.

BACKGROUND: Antenatal depression is the most prevalent common mental health disorder affecting pregnant women. Here, we report the prevalence of and associated factors for antenatal depression among pregnant women attending antenatal care services in Harare, Zimbabwe. METHODS: From January-April 2018, 375 pregnant women, aged 16-46 years, residing mostly in Harare's high-density suburbs were recruited from two randomly-selected polyclinics. Antenatal depression was measured using the Structured Clinical Interview for DSM-IV. Sociodemographic data including; maternal age, education, marital status, economic status, obstetric history and experiences with violence were also collected. Chi-square tests and multivariate logistic regression analysis were used to determine the association between antenatal depression and participants' characteristics. RESULTS: The prevalence of antenatal depression was 23.47% (95% CI: 19.27-28.09). Multivariate logistic regression analysis revealed intimate partner violence (IPV) [OR 2.45 (95% CI: 1.47-4.19)] and experiencing negative life events [OR 2.02 (95% CI: 1.19-3.42)] as risk factors for antenatal depression, with being married/cohabiting [OR 0.45 (95% CI: 0.25-0.80)] being a protective factor. CONCLUSION: The prevalence of antenatal depression is high with associated factors being interpersonal. Context-specific interventions are therefore needed to address the complexity of the factors associated with antenatal depression.

Human papillomavirus genotype distribution in genital warts among women in Harare-Zimbabwe.

This study aimed to determine the prevalence of HPV genotypes in genital warts among women in Harare, Zimbabwe. Women aged 18-45 years attending gynaecology and genitourinary clinics with a clinical diagnosis of genital-warts were recruited. HPV-DNA was extracted from tissue biopsies. HPV-DNA testing and typing was done by Southern Dot Blot Hybridisation. A hundred samples from 100 women were analysed. Median age of participants was 30.3 years (range 18-45 years). Seventy-eight percent of participants were HIV infected. HPV prevalence was 98%. Low risk genotypes predominated at 86% prevalence. The most prevalent genotypes were 11 (47%), 6 (42%) and 16 (14%). This is the first study on HPV genotype distribution among women with genital warts in Zimbabwe. The high prevalence of HR-HPV 16 in clinically benign lesions shows that warts should have histological analysis to exclude pre-malignancy and malignancy.Impact statementWhat is already known on this subject? Genital warts (GWs), also known as condylomata acuminata (EAC), are a clinical manifestation of persistent infection with 'low risk' or non-oncogenic HPV genotypes. HPV 6 and 11 are examples of low risk genotypes, and both are associated with 90% of GWs. Data on HPV genotypes causing genital warts in the population under study are scarce.What do the results of this study add? A high prevalence (98%) of HPV DNA in genital warts, confirms that the biopsied lesions were HPV related. Over and above the high prevalence of low risk HPV 11 (47%) and HPV 6 (42%), the women had 14% prevalence of HPV 16, an oncogenic genotype, in genital warts. Seventy-eight percent of the participants were HIV infected. The HIV infected women had a 33.3% prevalence of HR-HPV as compared to the 15.8% prevalence in the HIV uninfected women.What are the implications of these findings for clinical practice and/or further research? The population under study will benefit more if an HPV vaccine that includes anti-HPV 6 and 11 is used. The high prevalence of the HR-HPV in apparently benign lesions shows that warts should have histological analysis to exclude vulvar cancer and vulvar intraepithelial neoplasia. All women presenting with genital warts should be offered an HIV test.

Tenofovir Gel for Prevention of Herpes Simplex Virus Type 2 Acquisition: Findings From the VOICE Trial.

BACKGROUND: Genital infection with herpes simplex virus type 2 (HSV-2) is common and increases risk of human immunodeficiency virus (HIV) transmission and acquisition. Pericoital use of tenofovir (TFV) gel provided protection from HSV-2 acquisition in the CAPRISA 004 study. METHODS: We measured estimate of effect of vaginal TFV 1% gel in preventing HSV-2 acquisition among women in VOICE, randomized, double-blinded, placebo-controlled trial assessing daily use of oral and vaginal TFV for HIV-1 preexposure prophylaxis. The TFV level in plasma at the first quarterly visit was used as a measure of gel use. RESULTS: Of 566 participants at risk for HSV-2 acquisition, 532 (94%) had first-quarter plasma TFV and end-of-study HSV-2 serologic data available. Over a follow-up period of 501 person-years, 92 incident cases of HSV-2 acquisition occurred: 77 were in women with no TFV detected in plasma, and 15 occurred in women with TFV detected in plasma (incidence, 20.6 cases/100 person-years [95% confidence interval [CI], 16.2-25.7] vs 11.9 cases/100 person-years [95% CI, 6.6-19.6], respectively). TFV detection in plasma was associated with a trend toward a reduced risk of HSV-2 seroconversion, with an unadjusted hazard ratio (HR) of 0.59 (95% CI, .34-1.02; P = .060) and a HR adjusted for site, age, having ≥2 male sex partners in the past 3 months, use of hormonal contraception, having anal sex in the past 3 months, and HIV status of 0.60 (95% CI, .33-1.08; P = .086). CONCLUSIONS: Detection of TFV in plasma among TFV gel users was associated with a trend toward a reduced risk of HSV-2 acquisition, after controlling for sexual behavior and HIV-1 acquisition.

Trends in the incidence of cancer in the black population of Harare, Zimbabwe 1991-2010.

Incidence rates of different cancers have been calculated for the black population of Harare, Zimbabwe for a 20-year period (1991-2010) coinciding with continuing social and lifestyle changes, and the peak, and subsequent wane, of the HIV-AIDS epidemic. The overall risk of cancer increased during the period in both sexes, with rates of cervix and prostate cancers showing particularly dramatic increases (3.3% and 6.4% annually, respectively). By 2004, prostate cancer had become the most common cancer of men. The incidence of cancer of the esophagus, formerly the most common cancer of men, has remained relatively constant, whereas rates of breast and cervix cancers, the most common malignancies of women, have shown significant increases (4.9% and 3.3% annually, respectively). The incidence of Kaposi sarcoma increased to a maximum around 1998-2000 and then declined in all age groups, and in both sexes The incidence of squamous cell cancers of the conjunctiva is relatively high, with temporal trends similar to those of Kaposi sarcoma. Non-Hodgkin lymphoma, the fifth most common cancer of men and fourth of women, showed a steady increase in incidence throughout the period (6.7-6.9% annually), although rates in young adults (15-39) have decreased since 2001. Cancer control in Zimbabwe, as elsewhere in sub-Saharan Africa, involves meeting the challenge of emerging cancers associated with westernization of lifestyles (large bowel, breast and prostate), while the incidence of cancers associated with poverty and infection (liver, cervix and esophagus) shows little decline, and the residual burden of the AIDS-associated cancers remains significant.

Cancer survival in Harare, Zimbabwe, 1993-1997.

The Zimbabwe national cancer registry was established in 1985 as a population-based cancer registry covering Harare city. Cancer is not a notifiable disease, and registration of cases is done by active methods. The registry contributed data on randomly drawn sub-samples of Harare resident cases among 17 common cancer sites or types registered during 1993-1997 from black and white populations. Follow-up was carried out predominantly by active methods with median follow-up ranging from 1-54 months for different cancers. The proportion with histologically verified diagnosis for various cancers ranged from 20-100%; death certificate only (DCO) cases comprised 0-34%; 58-97% of total registered cases were included for survival analysis. Complete follow-up at five years ranged from 94-100%. Five-year age-standardized relative survival rates of selected cancers among both races combined were cervix (42%), breast (68%), Kaposi sarcoma (4%), liver (3%), oesophagus (12%), stomach (20%) and lung (14%). Survival was markedly higher among white than black populations for most cancers with adequate cases. Five-year relative survival by age group was fluctuating, with no definite pattern or trend.

Compliance and loss to follow up of HIV negative and positive mothers recruited from a PMTCT programme in Zimbabwe.

OBJECTIVE: To describe the methodological challenges of a nine months follow up study of mothers recruited from a national Prevention of Mother To Child Transmission (PMTCT) programme with regards to defaulters, drop outs and compliance. DESIGN: Nested case control study. SETTING: Three peri-urban clinics in Zimbabwe namely: Epworth, St Mary's, Seke North. METHOD: Pregnant women who enrolled at 36 weeks of gestation were recruited for a follow up of mother and child from delivery, six weeks, four and nine months post partum. Follow up trend of these women was compared between the HIV positive and negative mothers with regards to defaulting, drop outs, full and partial compliance. Statistical significance was computed using the Chi-square test. RESULTS: Of the enrolled 1050 pregnant women with a known HIV status (594 HIV negative and 456 HIV positive) 851 (457 HIV negative and 394 HIV positive) showed up at one or more visits scheduled up to nine months. The denominator was dropping at each point and time. The overall dropout rate was 19% without a significant difference between the HIV positive and negative women at delivery. At six weeks the drop out rate was 35 (7.7%) for the HIV positive versus 75 (12.9%) p=0.010 and at four months 12 (2.9%) versus 39 (7.7%) p=0.002 respectively. However, at nine months the drop out rate was not different (p=0.747). The defaulter rate was significantly different at every stage between the HIV positive and negative mothers from delivery to six weeks, becoming even more significant at the four and nine months visit (p=<0.001). The overall full compliance at nine months was 46.1% with a significant difference between the HIV positive (55.6%) versus (37.9%) for the HIV negative (p=<0.001). CONCLUSION: Drop out is highest among the HIV negative as opposed to the HIV positive with the peak period being at "six weeks". There is high defaulting among the HIV negative compared to the HIV positive with the peak being at "four months". The study has shown that the HIV negative women are more likely to drop out whereas the HIV positive were twice as likely to fully comply. It is surprising that the peak drop out period, "six weeks visit" is a cardinal existing national scheduled visit where both mother and baby undergo a full medical examination with the mother having a pap smear taken.

HIV and cancer of the cervix.

Cancer of the cervix is the second most common cause of cancer-related death in women worldwide, and in some low resource countries accounts for the highest cancer mortality in women. The highest burden of the HIV/AIDS epidemic is currently in sub-Saharan Africa, where more than half of the people infected are women who have no access to cervical cancer screening. The association between HIV and invasive cervical cancer is complex, with several studies now clearly demonstrating an increased risk of pre-invasive cervical lesions among HIV-infected women. However, there have not been significantly higher incidence rates of invasive cervical cancer associated with the HIV epidemic. The highest numbers of HIV-infected women are in poorly-resourced countries, where the natural progression of HIV disease in the absence of highly active antiretroviral treatment sometimes results in deaths from opportunistic infections before the onset of invasive cervical cancer. This chapter will discuss the association of HIV and cervical intraepithelial neoplasia, the treatment of pre-invasive lesions, and invasive cervical cancer in HIV-infected women. The role of screening and the impact of antiretroviral treatment on the progression of pre-invasive and invasive cancer will also be discussed.

Effect of HIV Disease in Treatment Outcome of Cervical Squamous Intraepithelial Lesions Among Zimbabwean Women.

OBJECTIVE.: To compare the treatment outcome of cervical intraepithelial neoplasia (CIN 2,3) on HIV-infected and uninfected women treated by cryotherapy or loop electrosurgical excision procedure (LEEP). METHODS.: A total of 147 women were recruited into the study between April 1997 and May 1998. Cryotherapy was performed in 75 women and LEEP in 72 women after randomization. RESULTS.: A total of 109 (74.1%) women tested positive and 38 (25.9%) tested negative for HIV-1. At 12 months follow-up visit, cryotherapy had 59.5% cure rate on HIV-positive women and 84.2% success among HIV-negative women (p = .057). LEEP had 86% cure rate on HIV-positive and 100% cure rate on HIV-negative women (p = .328). CONCLUSION.: HIV-1-infected women harboring cervical squamous intraepithelial lesions have a high failure rate (40.5%) when treated by cryotherapy.

Cancer of the cervix: knowledge, beliefs and screening behaviours of health workers in Mudzi District in Mashonaland East Province, Zimbabwe.

OBJECTIVE: To assess the knowledge, beliefs and screening behaviours on cervical cancer among health workers in Mudzi District. DESIGN: Cross sectional survey. SETTINGS: Mudzi District Hospital and all the 20 rural health centres in Mudzi District of Mashonaland East. SUBJECTS: Sixty health workers in Mudzi District. MAIN OUTCOME MEASURES: Knowledge of cervical cancer risk factors, screening methods and treatment options. Beliefs and screening behaviours. RESULTS: The knowledge levels were lower for many of the predisposing factors of cervical cancer except for the use of vaginal herbs or chemicals, which 85% of the health workers knew. Though 50% of the respondents knew of the Pap smear as a screening method for cervical cancer, 86.6% did not know the human papiloma virus screening and 90% did not know of the visual inspection of the cervix using acetic acid. There were also very low knowledge levels for most of the treatment options for pre-cancer with all health workers not knowing the leep and the Laser options. The majority 73.3% believed that they where not at risk of developing cervical cancer. Most of the respondents, 81.7%, had not undergone any form of cervical cancer screening. However, the main reason for non screening was that there were no cervical cancer screening facilities in Mudzi District. CONCLUSION: The study revealed low knowledge levels, negative beliefs about the risk of developing cervical cancer and poor screening behaviours among health workers in Mudzi District. Training in cervical cancer is, therefore, recommended for the health workers. However, the training should be combined with setting up facilities for cervical cancer screening.

Association of cervical SIL and HIV-1 infection among Zimbabwean women in an HIV/STI prevention study.

A cross-sectional study was conducted on women attending family planning clinics in Harare, Zimbabwe to determine the prevalence of cervical neoplasia among HIV-1 positive women relative to an HIV-1 negative control group. Five hundred and fifty four women were recruited and the prevalence of HIV-1 was 36.8%. Cervical cytology was abnormal in 25.6% of HIV-infected women compared to only 6.7% HIV-1 seronegative women. Cervical neoplasia was significantly associated with HIV infection (chi(2)=42.4, P<0.001). Cellular changes typical of HPV infection (koilocytocis) were recorded in 6.4% of HIV infected women compared with 1.7% of HIV-1-uninfected women (chi(2)=8.43, P=0.004). HIV-1-positive women had twice the risk of having abnormal cervical cells than HIV-negative women (relative risk 2.47, odds ratio 10.14, P<0.001). Therefore the introduction of national cervical screening programme in HIV-1 endemic countries like Zimbabwe where the highest burden of pre-malignant lesions is among HIV-1-infected women needs careful planning because these women have other competing health needs including high rates of opportunistic infections.

Situational analysis for diagnosis and treatment of cervical cancer in mainland Tanzania.

OBJECTIVE: To determine factors influencing early diagnosis and treatment of cervical cancer in Tanzania women. DESIGN: A cross-sectional study. SETTING: Forty primary health care facilities, twenty district/regional and four referral (tertiary) hospitals in mainland Tanzania. RESULTS: The most basic equipment for cytology-based cervical cancer were available at all health care facilities. However, screening against cervical cancer was appallingly inadequate at all levels of health care delivery system. Apart from medical doctors at tertiary level, other medical personnel including nurses were poorly or hardly utilised for cervical cancer screening. Treatment facilities for pre-cancerous lesions in most district, regional and even tertiary hospitals were inadequate or non-existent despite being very simple, cheap and yet very effective. There was total lack of organised institutional or national policy guidelines on cervical cancer screening in Tanzania. CONCLUSION: There is an urgent need to introduce systematic screening against cervical cancer and treatment of precursor lesions at all levels of health care delivery system in Tanzania. A national policy guideline should be urgently drawn addressing specifically frequency of screening and at what age to start screening.

Situation analysis for cervical cancer diagnosis and treatment in east, central and southern African countries.

OBJECTIVE: To determine the factors influencing cervical cancer diagnosis and treatment in countries of East, Central and Southern Africa (ECSA). METHODS: Data were collected from randomly selected primary health care centres, district and provincial hospitals, and tertiary hospitals in each participating country. Health care workers were interviewed, using a questionnaire; the facilities for screening, diagnosing, and treating cervical cancer in each institution were recorded, using a previously designed checklist. FINDINGS: Although 95% of institutions at all health care levels in ECSA countries had the basic infrastructure to carry out cervical cytology screening, only a small percentage of women were actually screened. Lack of policy guidelines, infrequent supply of basic materials, and a lack of suitable qualified staff were the most common reasons reported. CONCLUSIONS: This study demonstrates that there is an urgent need for more investment in the diagnosis and treatment of cervical cancer in ECSA countries. In these, and other countries with low resources, suitable screening programmes should be established.

Adjunctive testing for cervical cancer in low resource settings with visual inspection, HPV, and the Pap smear.

OBJECTIVE: To test whether the performance of visual inspection using acetic acid (VIA) could be improved through adjunctive testing and to determine whether the combination of visual inspection of the cervix and HPV testing could prove useful for identifying those at highest risk of cervical precancer. METHODS: Between October 1995 and August 1997, 2199 women willing to be screened for cervical cancer in peri-urban clinics in Harare, Zimbabwe received VIA, Pap smear and HPV as screening tests. The presence or absence of (pre)cancer was confirmed via colposcopy with biopsy as indicated for >97% of all women. Computerized simulations of sequential testing scenarios provided estimates of the joint (net) test qualities of different paired combinations of the three tests and allowed for comparisons with the individual test qualities. RESULTS: Using HGSIL/CIN II-III as the reference threshold of disease, the net sensitivity and specificity of VIA and HPV when used sequentially were 63.6 and 81.9%, respectively, compared to 43.3 and 91%, respectively, when Pap smears were followed by HPV testing. VIA followed by the Pap smear yielded a net sensitivity of 37.5% and net specificity of 94.3%. CONCLUSIONS: For programs with limited resources but with the capacity for HPV testing, sequential testing involving the use of VIA followed by HPV could yield fewer false positives than the use of VIA alone at a cost of relatively few additional false negatives.

Determinants of reproductive tract infections among asymptomatic women in Harare, Zimbabwe.

OBJECTIVES: To determine the prevalence of and risk factors for reproductive tract infections (RTI) among asymptomatic women attending primary health care clinics in Harare, Zimbabwe. DESIGN: A cross sectional study. MAIN OUTCOME MEASURES: Prevalent RTI, HIV and socio-demographic data. SETTING: Two primary health care clinics in Harare. SUBJECTS: 393 consecutive, consenting women aged 15 to 49 years, presenting at the clinics for antenatal care, family planning, or bringing their children to attend preventive care clinics. RESULTS: More than half of the women had at least one ongoing RTI. Voluntary reporting of symptoms was almost non-existent. Prevalence of HIV was 29.3% and that of classical STIs was 15.4% Trichomoniasis vaginalis, 3.9% syphilis, 3.9% Chlamydia trachomatis and 1.8% Neisseria gonorrhoea. Bacteria vaginosis was diagnosed in 30.3% of the women and candidiasis in 25.4%. Presence of any RTI was significantly associated with lower level of education, sexual debut < 20 years, a non-monogamous partner, and use of a condom during the last sexual encounter. Independent factors associated with cervical infections were young age (< 20 years), being unmarried, current dysuria, warts, clinical signs of purulent or yellowish discharge, lower abdominal pain and cervical friability. Vaginitis was associated with sexual debut or marriage < 20 years, a partner who was a frequent traveller, history of STI, and presence of abnormal vaginal discharge. CONCLUSION: In view of the high prevalence of RTI and HIV and the low reporting of symptoms by infected women, it is recommended that strategies that improve women's awareness of urogenital symptoms be adopted, along with pro-active inquiry of genital symptoms by the health care workers, and treatment of RTIs, in order to reduce the unnecessary burden of RTIs.

A randomised clinical trial of loop electrosurgical excision procedure (LEEP) versus cryotherapy in the treatment of cervical intraepithelial neoplasia.

The objective of the treatment of cervical intraepithelial neoplasia (CIN) is the prevention of invasive carcinoma of the cervix, which still remains the most common cancer in Zimbabwean women, as in most other low-resource countries where screening facilities are grossly inadequate. We conducted a randomised prospective study to compare CIN treatment outcome after cryotherapy and loop electrosurgical excision procedure (LEEP) in 400 women with histologically confirmed high grade squamous intra-epithelial lesions (HGSIL). Treatment outcome measures were immediate complications, persistent disease and recurrent disease evaluated at follow-up visits. Eighty-two per cent of the women (159 cryotherapy, 168 LEEP) completed their 6-month and 12-month follow-up visits. LEEP had a significantly higher overall cure rate of 96.4% (absence of persistent or recurrent disease) compared to 88.3% cryotherapy (P=0.026). Although cryotherapy was not superior to LEEP, its cure rate (88.3%) is acceptable and therefore provides a viable treatment option for low resource countries such as Zimbabwe where the majority of women at risk for cervical cancer reside in rural areas.

Effect of intravaginal practices on the vaginal and cervical mucosa of Zimbabwean women.

OBJECTIVES: Lesions on the vaginal and cervical mucosa may facilitate transmission of HIV and other sexually transmitted diseases (STDs). We evaluated the relationship between intravaginal practices and the presence of colposcopic lesions in Zimbabwean women. METHODS: Users and nonusers of intravaginal practices were seen at enrollment, and at 1 and 6 months. Interviewing, counseling, and pelvic and colposcopic examinations were performed at each study visit. Specimens were collected at enrollment and 6 months. RESULTS: Colposcopic lesions were found at least once in 83% of the participants (n = 162), and in 66% of all exams (n = 430). Most lesions were classified as related to infection with human Papillomavirus (HPV) (58%) or another pathogen (20%), but 11% of lesions could have been caused by intravaginal practices (signal lesions). Intravaginal practices were not associated with an increased incidence in signal lesions (95 and 124 lesions per 100 person-years of follow-up for users and nonusers respectively; p = .290), nor with the presence of signal lesions in multivariate baseline (odds ratio [OR], 1.32; 95% confidence interval [CI], 0.37-4.72; p = .666) and six month transition models (OR, 1.67; 95% CI, 0.59-4.70; p = .333). CONCLUSIONS: No associations between intravaginal practices and colposcopic lesions were found in this study. However, the potential effect of intravaginal practices on the cervical and vaginal mucosa, and on subsequent HIV and STD transmission, warrants further study. The usefulness of colposcopy as a research tool in areas with high prevalences of HIV and HPV is questioned.

Intravaginal practices, vaginal flora disturbances, and acquisition of sexually transmitted diseases in Zimbabwean women.

One hundred sixty-nine Zimbabwean women were studied to determine whether the use of intravaginal practices (cleaning with the fingers, wiping the vagina, and inserting traditional substances) are associated with disturbances of vaginal flora and acquisition of sexually transmitted diseases (STDs). Subjects were interviewed and received counseling and a pelvic examination at enrollment, 1 month, and 6 months, and vaginal specimens were collected at enrollment and at 6 months. Users were more likely than nonusers to have vaginal flora disturbances but were not more likely to acquire an STD (relative risk [RR], 2.15; P=.188). Certain vaginal flora disturbances were associated with increased STD incidence and HIV prevalence. The absence of lactobacilli from the vaginal flora was associated with being positive for human immunodeficiency virus in baseline (odds ratio [OR], 0.24; P=.001) and 6-month transition multivariate models (OR, 0.39; P=.025). The presence of clue cells at baseline was associated with a higher incidence of STDs (RR, 1. 94; P=.025).

HPV-based cervical cancer screening in a population at high risk for HIV infection.

We determined the utility of an assay for 13 cancer-associated HPV types in primary cervical cancer screening of Zimbabwe women at high risk of HIV infection. HIV antibody status was determined by ELISA of oral mucosal specimens, and HPV DNA in the genital tract was identified by hybridization of cervical scrapes with probe B of Hybrid Capture II. Among the 466 women investigated, the prevalence of HPV, low-grade squamous intraepithelial lesions (LGSIL) and high-grade SIL (HGSIL) were 47.2%, 13.9% and 12%. Fifty-three and one-half percent of the women were HIV-seropositive. As compared with HIV-seronegative women, HIV-infected women had a greater than 2-fold HPV prevalence (64.3% vs. 27.6%), a greater than 7-fold amount of HPV DNA (RLU of 82.6 vs. 10.7) in HPV(+) women assessed as normal on the reference standard, and a nearly 3-fold greater HGSIL prevalence (17.3% vs. 5.9%). The strong link between HGSIL and HPV DNA positivity was seen in both HIV-infected and HIV-seronegative women. The amount of HPV DNA increased with disease severity in both HIV-seronegative and HIV-infected women. The sensitivity and specificity of the HPV test for HGSIL were, respectively, 90.7% (95% confidence limit 77.9-97.4%) and 41.3% (34.5-48.3%) in HIV-infected women and 61.5% (31.6-86.1%) and 74.5% (68.0-80.3%), respectively, in HIV(-) women. The usefulness of the HPV test as a screening test for cervical cancer in areas of high HPV prevalence will depend upon local health resource availability, disease priorities and policies regarding clinical case management.