Community perspectives on care options for HIV prevention trial participants.

There is on-going global debate and policy-setting concerning researchers' obligations to meet the health needs of people participating in HIV prevention trials in resource-poor settings. The perspectives of local community stakeholders on this issue are poorly understood as most of what is presented on behalf of communities where research takes place is anecdotal commentary. Using qualitative methods (130 in-depth interviews and 20 focus groups) we assessed perceived fairness of different strategies to meet the health needs of women who become HIV-infected during a hypothetical vaginal microbicide trial. Respondents included HIV prevention research participants, community stakeholders and health-care service providers in ten sites in seven countries (South Africa, Malawi, Tanzania, Zimbabwe, Zambia, India, US). Many respondents perceived referrals to be a potentially fair way to address care and treatment needs but concerns were also voiced about the adequacy of local health-care options and the ability of trial participants to access options. Most respondents viewed the provision of antiretroviral treatment by researchers to HIV-infected trial participants as unfair if treatment was not sustained beyond the end of the trial. The results underscore the importance of effectively linking trial participants to sustainable, community-based treatment and care.

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.

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.

A review of cervical cancer patients presenting in Harare and Parirenyatwa Hospitals in 1998.

OBJECTIVE: To document the socio-demographic profile, presenting symptoms, disease stage and treatment modality offered to all women attending Harare and Parirenyatwa Hospitals with a histological diagnosis of invasive cervical cancer in 1998. DESIGN: A cross sectional study. SETTING: Parirenyatwa Hospital and Harare Central Hospital. SUBJECTS: All women with a histological diagnosis of cervical cancer admitted between 11 January 1998 and 14 December 1998 were recruited into the study. RESULTS: A total of 196 patients, with a median age of 47 years (range 24 to 80 years) were recruited into the study. A high proportion (63.3%) of the women were from rural areas. The mean age at first pregnancy was 17.9 years (SD 2.8) and 112 (63.3%) first sought treatment at the primary health care centre. Persistent vaginal discharge was the most frequent (69.4%) presenting complaint. One hundred and ninety five patients (99.5%) had histological confirmation of invasive cervical cancer (91.8% squamous cell carcinoma, 7.7% adenocarcinoma). Clinical staging by The International Federation of Gynaecology and Obstetrics (FIGO) classification confirmed that the majority (80.3%) of the cancers had spread from the cervix into the parametrium and beyond (stage 2b and above) at the time of presentation. Radiation therapy was the most commonly used (77.0%) treatment modality. CONCLUSION: This study demonstrates that the burden of cervical cancer occurs around the peak age of 47 years and that the majority of women present with advanced disease. None of the women had ever been screened for cervical cancer. The planned introduction of a cervical cancer screening programme by visual inspection of the cervix with acetic acid (VIA), together with a health education campaign may result in a shift towards more women presenting with early curable cervical cancer cases.