The impact of text message reminders on cryotherapy uptake among women testing positive for HPV in western Kenya: a prospective cohort study.

BACKGROUND: Mobile health (mHealth) has become an increasingly popular strategy to improve healthcare delivery and health outcomes. Communicating results and health education via text may facilitate program planning and promote better engagement in care for women undergoing human papillomavirus (HPV) screening. We sought to develop and evaluate an mHealth strategy with enhanced text messaging to improve follow-up throughout the cervical cancer screening cascade. METHODS: Women aged 25-65 participated in HPV testing in six community health campaigns (CHCs) in western Kenya as part of a single arm of a cluster-randomized trial. Women received their HPV results via text message, phone call, or home visit. Those who opted for text in the first four communities received "standard" texts. After completing the fourth CHC, we conducted two semi-structured focus group discussions with women to develop an "enhanced" text strategy, including modifying the content, number, and timing of texts, for the subsequent two communities. We compared the overall receipt of results and follow-up for treatment evaluation among women in standard and enhanced text groups. RESULTS: Among 2368 women who were screened in the first four communities, 566 (23.9%) received results via text, 1170 (49.4%) via phone call, and 632 (26.7%) via home visit. In the communities where enhanced text notification was offered, 264 of the 935 screened women (28.2%) opted for text, 474 (51.2%) opted for phone call, and 192 (20.5%) for home visit. Among 555 women (16.8%) who tested HPV-positive, 257 (46.3%) accessed treatment, with no difference in treatment uptake between the standard text group (48/90, 53.3%) and the enhanced text group (22/41, 53.7%). More women in the enhanced text group had prior cervical cancer screening (25.8% vs. 18.4%; p < 0.05) and reported living with HIV (32.6% vs. 20.2%; p < 0.001) than those in the standard text group. CONCLUSIONS: Modifying the content and number of texts as an enhanced text messaging strategy was not sufficient to increase follow-up in an HPV-based cervical cancer screening program in western Kenya. A one-size approach to mHealth delivery does not meet the needs of all women in this region. More comprehensive programs are needed to improve linkage to care to further reduce structural and logistical barriers to cervical cancer treatment.

A Qualitative Exploration of Barriers to Treatment Among HPV-Positive Women in a Cervical Cancer Screening Study in Western Kenya.

BACKGROUND: Cervical cancer screening through self-collected high-risk human papillomavirus (HPV) testing has increased screening uptake, particularly in low-resource settings. Improvement ultimately depends, however, on women with positive results accessing follow-up treatment. Identifying the barriers to timely treatment is needed to tailor service delivery for maximum impact. MATERIALS AND METHODS: This qualitative study was conducted within a self-collected HPV screening trial in Migori County, Kenya. HPV-positive women were referred for no-cost cryotherapy treatment at the county hospital. Women not attending within 60 days of receiving HPV-positive results were randomly selected for in-depth interviews (IDIs). IDIs were coded and analyzed to develop an analytical framework and identify treatment barriers. RESULTS: Eighty-one women were interviewed. IDIs showed a poor understanding of HPV and cervical cancer, impacting comprehension of screening results and treatment instructions. All 81 had not undergone treatment but reported intending to in the future. Eight reported seeking treatment unsuccessfully or not qualifying, primarily due to pregnancy. Transportation costs and long distances to the hospital were the most reported barriers to treatment. Other obstacles included work, household obligations, and fear of treatment. Impacts of social influences were mixed; some women reported their husbands prevented seeking treatment, others reported their husbands provided financial or emotional support. Few women experienced peer support. CONCLUSIONS: Women faced many barriers to treatment following HPV screening in rural Kenya. Transportation barriers highlight a need for local treatment capacity or screen-and-treat approaches. Ensuring women understand their results and how to seek treatment is essential to improving cervical cancer screening in low-resource settings.

Development and initial validation of a pictorial survey to assess for symptomatic pelvic organ prolapse and urinary incontinence in western Kenya.

INTRODUCTION AND HYPOTHESIS: Visual tools are a valuable tool for ascertaining patient symptoms, especially in populations with low literacy rates. The objective was to develop and validate a pictorial scale for assessing symptomatic pelvic organ prolapse (POP) and urinary incontinence among women in western Kenya. METHODS: Illustrations of POP, stress urinary incontinence (SUI), and urgency urinary incontinence (UUI) were developed by an artist. Virtual Zoom interviews were conducted with gynecology providers in Kisumu soliciting feedback on the illustrations. Cognitive interviews with patients were then conducted. Validation of the illustrations was performed against the gold standard of clinical history and examination amongst patients presenting for outpatient care at three Kisumu hospitals. RESULTS: Sixteen provider interviews were conducted. The illustrations were revised to reflect each disorder more clearly, and performed well during cognitive interviews with 8 patients (aged 21 to 76). One hundred patients were included in the validation study. Nine patients had symptomatic POP, whereas 32 had UUI and 25 had SUI. Sensitivity and specificity for the SUI illustration was 80% (95% CI 61-91%) and 97% (95% CI 72-98%) and for UUI they were 81% (95% CI 65-91%) and 99% (95% CI 92-100%) respectively. POP illustrations had lower sensitivity and specificity, with the best performing illustration having sensitivity of 67% (95% CI 35-88%) and specificity of 99% (95% CI 94-100%), which improved when only bulge or pressure symptoms were included. CONCLUSIONS: We present a newly developed pictorial scale to assess for clinical urinary incontinence and POP that may be adapted and evaluated in other settings for clinical and research purposes.

Uptake and correlates of cervical cancer screening among women attending a community-based multi-disease health campaign in Kenya.

INTRODUCTION: Despite the increased risk of cervical cancer among HIV-positive women, many HIV-care programs do not offer integrated cervical cancer screening. Incorporating self-collected Human Papillomavirus (HPV) testing into HIV programs is a potential strategy to identify women at higher risk for cervical cancer while leveraging the staffing, infrastructure and referral systems for existing services. Community-based HIV and HPV testing has been effective and efficient when offered in single-disease settings. METHODS: This cross-sectional study was conducted within a community outreach and multi-disease screening campaigns organized by the Family AIDS Care and Education Services in Kisumu County, Kenya. In addition to HIV testing, the campaigns provided screening for TB, malaria, hypertension, diabetes, and referrals for voluntary medical male circumcision. After these services, women aged 25-65 were offered self-collected HPV testing. Rates and predictors of cervical cancer screening uptake and of HPV positivity were analyzed using tabular analysis and Fisher's Exact Test. Logistic regression was performed to explore multivariate associations with screening uptake. RESULTS: Among the 2016 women of screening age who attended the outreach campaigns, 749 women (35.6%) were screened, and 134 women (18.7%) were HPV-positive. In bivariate analysis, women who had no children (p < 0.01), who were not pregnant (p < 0.01), who were using contraceptives (p < 0.01), who had sex without using condoms (p < 0.05), and who were encouraged by a family member other than their spouse (p < 0.01), were more likely to undergo screening. On multivariable analysis, characteristics associated with higher screening uptake included: women aged 45-54 (OR 1.62, 95% CI 1.05-2.52) compared to women aged 25-34; no children (OR 1.65, 95% CI 1.06-2.56); and family support other than their spouse (OR 1.53, 95% CI 1.09-2.16). Women who were pregnant were 0.44 times (95% CI 0.25-0.76) less likely to get screened. Bivariate analyses with participant characteristics and HPV positivity found that women who screened HPV-positive were more likely to be HIV-positive (p < 0.001) and single (p < 0.001). CONCLUSIONS: The low screening uptake may be attributed to implementation challenges including long waiting times for service at the campaign and delays in procuring HPV test kits. However, given the potential benefits of integrating HPV testing into HIV outreach campaigns, these challenges should be examined to develop more effective multi-disease outreach interventions.

Developing a framework to describe stigma related to cervical cancer and HPV in western Kenya.

BACKGROUND: Despite a high prevalence of human papillomavirus (HPV) and cervical cancer in low and middle-income countries, stigma remains an issue. Addressing HPV and cervical cancer stigma could significantly improve health outcomes for these conditions. The objective of this study was to identify the manifestations of stigma and their potential impacts on health-seeking behavior. METHODS: Twenty-six in-depth interviews were conducted with women living with HIV, HIV-negative women, community health volunteers, and health care providers in Kisumu, Kenya in 2019. The interviews were designed to draw out existing attitudes or experiences related to stigma within the community. We conducted a thematic analysis of the interviews to identify internalized, anticipated, and discriminatory attitudes. RESULTS: Within internalized attitudes, a prominent observed theme was a fear of death associated with a positive HPV test. This stemmed from a lack of understanding of differences between HPV and cervical cancer and posed a significant barrier for women deciding to seek screening or to continue with treatment. Discriminatory attitudes of community members, including assumptions of promiscuity, infidelity, or HIV status, were perceived to prevent women from accessing screening and treatment opportunities. The interviews also exhibited a limited awareness of HPV in this region, which may have contributed to a lack of enacted stigma towards people living with HPV or cervical cancer. CONCLUSION: Stigma has the potential to lead to decreased screening and treatment uptake through its drivers. This includes a decreased perception of personal risk due to a lack of knowledge, which results in increased HPV-risk behaviors. Future research must focus on creating and integrating stigma-reducing interventions, primarily to encourage women to seek out primary and secondary preventative measures.

Barriers and Facilitators to Cervical Cancer Screening in Western Kenya: a Qualitative Study.

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.

Primary HPV and Molecular Cervical Cancer Screening in US Women Living With Human Immunodeficiency Virus.

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.

Achieving equity in cervical cancer screening in low- and middle-income countries (LMICs): Strengthening health systems using a systems thinking approach.

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.

Knowledge, attitudes, and practices regarding cervical cancer screening among women in metropolitan Lima, Peru: a cross-sectional study.

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.

Digital Health Strategies for Cervical Cancer Control in Low- and Middle-Income Countries: Systematic Review of Current Implementations and Gaps in Research.

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.

"A Résumé for the Baby": Biosocial Precarity and Care of Substance-Using, Pregnant Women in San Francisco.

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 "résumé 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.

A Qualitative Exploration of Women's Experiences with a Community Health Volunteer-Led Cervical Cancer Educational Module in Migori County, Kenya.

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.

Female perspectives on male involvement in a human-papillomavirus-based cervical cancer-screening program in western Kenya.

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.

Perspectives of women participating in a cervical cancer screening campaign with community-based HPV self-sampling in rural western Kenya: a qualitative study.

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.

Guidelines for Cervical Cancer Screening in Immunosuppressed Women Without HIV Infection.

EXECUTIVE SUMMARY: 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. RESULTS: 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. RECOMMENDATIONS: 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.

Evaluating a community-based cervical cancer screening strategy in Western Kenya: a descriptive study.

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.

Cost of HPV screening at community health campaigns (CHCs) and health clinics in rural Kenya.

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.

Study protocol for a cluster-randomized trial to compare human papillomavirus based cervical cancer screening in community-health campaigns versus health facilities in western Kenya.

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 .

WOMEN'S EMPOWERMENT AND FAMILY PLANNING: A REVIEW OF THE LITERATURE.

This 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.

Cervical Cancer Stigma in Rural Kenya: What Does HIV Have to Do with It?

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 < 0.001). Reducing cervical cancer stigma in the general population is an important part of promoting screening in sub-Saharan Africa.