Comparative effectiveness of implementation strategies for Accelerating Cervical Cancer Elimination through the integration of Screen-and-treat Services (ACCESS study): protocol for a cluster randomized hybrid type III trial in Nigeria.

BACKGROUND: Despite the increased risk of cervical cancer (CC) among women living with HIV (WLHIV), CC screening and treatment (CCST) rates remain low in Africa. The integration of CCST services into established HIV programs in Africa can improve CC prevention and control. However, the paucity of evidence on effective implementation strategies (IS) has limited the success of integration in many countries. In this study, we seek to identify effective IS to enhance the integration of CCST services into existing HIV programs in Nigeria. METHODS: Our proposed study has formative and experimental activities across the four phases of the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework. Through an implementation mapping conducted with stakeholders in the exploration phase, we identified a core package of IS (Core) and an enhanced package of IS (Core+) mostly selected from the Expert Recommendations for Implementing Change. In the preparation phase, we refined and tailored the Core and Core+ IS with the implementation resource teams for local appropriateness. In the implementation phase, we will conduct a cluster-randomized hybrid type III trial to assess the comparative effectiveness of Core versus Core+. HIV comprehensive treatment sites (k = 12) will be matched by region and randomized to Core or Core+ in the ratio of 1:1 stratified by region. In the sustainment phase, we will assess the sustainment of CCST at each site. The study outcomes will be assessed using RE-AIM: reach (screening rate), adoption (uptake of IS by study sites), IS fidelity (degree to which the IS occurred according to protocol), clinical intervention fidelity (delivery of CC screening, onsite treatment, and referral according to protocol), clinical effectiveness (posttreatment screen negative), and sustainment (continued integrated CCST service delivery). Additionally, we will descriptively explore potential mechanisms, including organizational readiness, implementation climate, CCST self-efficacy, and implementation intentions. DISCUSSION: The assessment of IS to increase CCST rates is consistent with the global plan of eliminating CC as a public health threat by 2030. Our study will identify a set of evidence-based IS for low-income settings to integrate evidence-based CCST interventions into routine HIV care in order to improve the health and life expectancy of WLHIV. TRIAL REGISTRATION: Prospectively registered on November 7, 2023, at ClinicalTrials.gov no. NCT06128304. https://classic. CLINICALTRIALS: gov/ct2/show/study/NCT06128304.

The impact of community health educators on uptake of cervical and breast cancer prevention services in Nigeria.

OBJECTIVE: To determine the impact of trained community health educators on the uptake of cervical and breast cancer screening, and HPV vaccination in rural communities in southeast Nigeria. METHODS: A prospective population-based intervention study, with a before-and-after design, involved four randomly selected communities in southeast Nigeria from February 2014 to February 2016. Before the intervention, baseline data were collected on the uptake of cervical and breast cancer prevention services. The intervention was house-to-house education on cervical cancer and breast cancer prevention. Postintervention outcome measures included the uptake of cervical and breast cancer screening, and HPV vaccination within 6 months of intervention. RESULTS: In total, 1327 women were enrolled. Before the intervention, 42 (3.2%) women had undergone cervical cancer screening; afterwards, 897 (67.6%) women had received screening (P<0.001). Clinical breast examination was performed for 59 (4.4%) women before and 897 (67.6%) after the intervention (P<0.001). Only 2 (0.9%) of 214 children eligible for HPV vaccination had received the vaccine before versus 71 (33.2%) after the intervention (P<0.001). CONCLUSION: The use of community health educators for house-to-house cervical and breast cancer prevention education was associated with significant increases in the uptake of cervical cancer screening, clinical breast examination, and HPV vaccination.

Cervical Cancer Screening among HIV-Positive Women in Nigeria: An Assessment of Use and Willingness to Pay in the Absence of Donor Support.

INTRODUCTION: The sustainability of donor-supported cervical cancer screening for HIV-positive women in underresourced setting is a concern. The authors aimed to determine the willingness of HIV-positive women for out-of-pocket payment for the cancer screening, if necessary. METHODS: Questionnaires were administered to 400 HIV-positive women at the Adult HIV clinic, University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria. RESULTS: In all 11 (2.8%) respondents were aware of Pap smear, but only 1 (9.1%) of them had used it. After cervical cancer screening counseling, 378 (94.5%) respondents were willing to pay for Pap smear, irrespective of the cost. This willingness showed no trend across marital or educational groups. Younger age of respondents was not associated with willingness to pay for Pap smear (odds ratio = 1.24; confidence interval 95%: 0.52, 2.94). CONCLUSION: Willingness to pay for Pap smear by HIV-positive women in Enugu, Nigeria, is high. This has implication for the program sustainability.

Leiomyomatosis peritonealis disseminata in a Nigerian woman.

Leiomyomatosis peritonealis disseminata (LPD) is a rare condition. A 48-year-old multiparous woman was referred because of an incidental ultrasound finding suggestive of LPD. She had a 6-year past history of use of combined oral contraceptive pills. LPD was also suspected at laparotomy and confirmed by histology. She had total abdominal hysterectomy, bilateral salpingo ophorectomy and infracolic omentectomy. Patient was being followed-up. LSD is a rare gynecological condition which can pose a diagnostic challenge. Removal of estrogen sources as was done for the patient is the mainstay of treatment. Patient follow-up is very important because of the risk of malignant transformation.

Adenomyosis and uterine rupture during labour in a primigravida: an unusual obstetric emergency in Nigeria.

The primigravid uterus is believed to be immune to rupture during labour. This may not be true for those who have had prior adenomyomectomy, hence this report. The patient was a 28-year-old nullipara who became pregnant 11 months after an adenomyomectomy. Twelve hours after vaginal delivery at term, she developed haemoperitoneum of unclear cause. Emergency laparotomy and subsequent histology showed a fundal complete uterine rupture through the adenomyomectomy site, which was repaired. It is concluded that adenomyomectomy predisposes a pregnant uterus to rupture during labour. Therefore, such women should be offered elective caesarean delivery at term.

Improved awareness of Pap smear may not affect its use in Nigeria: a case study of female medical practitioners in Enugu, southeastern Nigeria.

Improved awareness of Pap test by Nigerian women may not necessarily increase its use. This hypothesis was tested using female medical practitioners in Enugu state, Nigeria. They were expected to be advocates of disease screening and therefore should lead by example. All respondents were aware of the Pap smear but only 18% had used it. The mean frequency of Pap smear was 1.8+/-1.2 (range 1-5). Repeat Pap tests were observed only among respondents that had screened as routine. The majority (32%) of those who never screened for cervical cancer had no reason. There may be more to the use of Pap smear among women in Nigeria than its awareness.

An unmet cancer screening need of HIV-positive women in southeastern Nigeria.

CONTEXT: HIV infection and cervical cancer are common in Nigeria. HIV-positive women have a higher risk for cervical neoplasm; therefore, counseling and regular cervical cancer screening are recommended. After post-HIV testing counseling, HIV-positive women should be aware of the Papanicolaou (Pap) smear. OBJECTIVE: To determine the coverage of cervical cancer screening information for HIV-positive women by the post-HIV testing counseling. METHODS: Questionnaires were administered to 150 HIV-positive women and 150 HIV-negative controls after post-HIV testing counseling at the voluntary counseling and testing clinic of University of Nigeria Teaching Hospital, Enugu, Nigeria. Proportions of responses were compared by using a chi-square test at a 95% confidence level. RESULTS: Thirty-three (22.0%) HIV-positive women and 57 (38%) HIV-negative women were aware of cervical cancer. The awareness of the Pap smear among HIV-positive women (4.0%) was lower than that of HIV-negative women (21.3%) (P < .001). However, this finding became insignificant after adjustment for educational status groups (P > .05). No respondent agreed to being informed of Pap smears during post-HIV testing counseling. After counseling on cervical cancer, 96.0% of the HIV-positive group and 98.7% of the HIV-negative group expressed willingness to undergo routine Pap screening. CONCLUSIONS: Cervical cancer screening information is not part of post-HIV testing counseling for women in Enugu, southeastern Nigeria.