The economic burden of cervical cancer on women in Uganda: Findings from a cross-sectional study conducted at two public cervical cancer clinics.

There is limited research on how a cervical cancer diagnosis financially impacts women and their families in Uganda. This analysis aimed to describe the economic impact of cervical cancer treatment, including how it differs by socio-economic status (SES) in Uganda. We conducted a cross-sectional study from September 19, 2022 to January 17, 2023. Women were recruited from the Uganda Cancer Institute and Jinja Regional Referral Hospital, and were eligible if they were ≥ of 18 years and being treated for cervical cancer. Participants completed a survey that included questions about their out-of-pocket costs, unpaid labor, and family's economic situation. A wealth index was constructed to determine their SES. Descriptive statistics were reported. Of the 338 participants, 183 were from the lower SES. Women from the lower SES were significantly more likely to be older, have ≤ primary school education, and have a more advanced stage of cervical cancer. Over 90% of participants in both groups reported paying out-of-pocket for cervical cancer. Only 15 participants stopped treatment because they could not afford it. Women of a lower SES were significantly more likely to report borrowing money (higher SES n = 47, 30.5%; lower SES n = 84, 46.4%; p-value = 0.004) and selling possessions (higher SES n = 47, 30.5%; lower SES n = 90, 49.7%; p-value = 0.006) to pay for care. Both SES groups reported a decrease in the amount of time that they spent caring for their children since their cervical cancer diagnosis (higher SES n = 34, 31.2%; lower SES n = 36, 29.8%). Regardless of their SES, women in Uganda incur out-of-pocket costs related to their cervical cancer treatment. However, there are inequities as women from the lower SES groups were more likely to borrow funds to afford treatment. Alternative payment models and further economic support could help alleviate the financial burden of cervical cancer care in Uganda.

The social and economic impacts of cervical cancer on women and children in low- and middle-income countries: A systematic review.

BACKGROUND: There is limited knowledge on the social and economic impacts of a diagnosis of cervical cancer on women and children in low- and middle-income countries (LMICs). OBJECTIVES: To determine the social and economic impacts associated with cervical cancer among women and children living in LMICs. SEARCH STRATEGY: The MEDLINE, PsychInfo, CINAHL, Pais International, and CAB Global Health databases were systematically searched to retrieve studies up to June 2021. SELECTION CRITERIA: Studies were included if they reported on either the social or economic impacts of women or children in a LMIC. DATA COLLECTION AND ANALYSIS: Data was independently extracted by two co-authors. The authors performed a quality assessment on all included articles. MAIN RESULTS: In all, 53 studies were included in the final review. Social impacts identified included social support, education, and independence. Economic impacts included employment and financial security. No study reported the economic impact on children. Studies that utilized quantitative methods typically reported more positive results than those that utilized qualitative methods. CONCLUSIONS: Additional mixed-methods research is needed to further understand the social support needs of women with cervical cancer. Furthermore, research is needed on the impact of a mother's diagnosis of cervical cancer on her children.

Coping during the COVID-19 pandemic: A mixed methods approach to understand how social factors influence coping ability.

The COVID-19 pandemic and public health protection measures aimed at mitigating the transmission of the virus have both resulted in tremendous physical and mental health impacts. The study at hand used a gender-based analysis and social determinants of health approach to investigate which communities had trouble coping during times of strict protection measures and symptoms and strategies employed during the COVID-19 pandemic. Participants were recruited from previously established cohorts as a part of the COVID-19 Rapid Evidence Study of a Provincial Population-Based Cohort for Gender and Sex (RESPPONSE) study. Being a young adult, female, woman, gender diverse, low-income earner or LGBTQ/2S+ was significantly associated with not being able to cope during the first wave of the pandemic. The effects for females, women, and gender diverse were attenuated yet still significant when controlling for various covariates. Those who reported not coping were more likely to present maladaptive coping symptoms and strategies. Our findings demonstrate the need to support marginalized communities in coping with the current ongoing COVID-19 pandemic and build proactive support for future pandemics.

Understanding the public health value and defining preferred product characteristics for therapeutic human papillomavirus (HPV) vaccines: World Health Organization consultations, October 2021-March 2022.

The World Health Organization (WHO) global strategy to eliminate cervical cancer (CxCa) could result in >62 million lives saved by 2120 if strategy targets are reached and maintained: 90% of adolescent girls receiving prophylactic human papillomavirus (HPV) vaccine, 70% of women receiving twice-lifetime cervical cancer screening, and 90% of cervical pre-cancer lesions and invasive CxCa treated. However, the cost and complexity of CxCa screening and treatment approaches has hampered scale-up, particularly in low- and middle-income countries (LMICs), and new approaches are needed. Therapeutic HPV vaccines (TxV), which could clear persistent high-risk HPV infection and/or cause regression of pre-cancerous lesions, are in early clinical development and might offer one such approach. During October 2021 to March 2022, WHO, in collaboration with the Bill and Melinda Gates Foundation, convened a series of global expert consultations to lay the groundwork for understanding the potential value of TxV in the context of current CxCa prevention efforts and for defining WHO preferred product characteristics (PPCs) for TxV. WHO PPCs describe preferences for vaccine attributes that would help optimize vaccine value and use in meeting the global public health need. This paper reports on the main discussion points and findings from the expert consultations. Experts identified several ways in which TxV might address challenges in current CxCa prevention programmes, but emphasized that the potential value of TxV will depend on their degree of efficacy and how quickly they can be developed and implemented relative to ongoing scale-up of existing interventions. Consultation participants also discussed potential use-cases for TxV, important PPC considerations (e.g., vaccine indications, target populations, and delivery strategies), and critical modelling needs for predicting TxV impact and cost-effectiveness.

Characterizing female infectious syphilis cases in British Columbia to identify opportunities for optimization of care.

Introduction: The rate of infectious syphilis continues to increase among females in British Columbia (BC) and Canada, raising concerns of increased incidence of congenital syphilis. We characterized syphilis cases among females in BC to identify opportunities to prevent syphilis and optimize its care. Methods: All cases of infectious syphilis diagnosed in BC between March 13, 2018 and December 31, 2020 and reported as female gender were reviewed. Demographics, risk factors and concurrent conditions were collected from a provincial surveillance system. Subgroup analyses comparing cases with and without housing instability, substance use, mental illness and a recent sexually transmitted infection (STI) were conducted to understand differences between these subgroups. Statistical associations were calculated using chi-square or t-tests. Results: There were 226 reported cases of female infectious syphilis in BC during this period: 38 (16.8%) in 2018; 74 (32.7%) in 2019; and 114 (50.4%) in 2020. Mean age was 32 years (range 15-75 years). Of those who reported concurrent conditions, most cases had experiences with housing instability (71.1%), substance use (68.2%) and mental illness (83.9%), while 42.9% had a recent STI. Cases who reported housing instability or substance use were significantly more likely to have experiences with a recent STI, street involvement, transactional sex, mental illness and income assistance (all p<0.01). Conclusion: Our findings highlight the importance of fostering an enabling environment for syphilis care. Concurrent services to support individuals with syphilis as well as housing instability, substance use and mental illness, may help prevent syphilis and improve wellbeing.

Accessing needed sexual health services during the COVID-19 pandemic in British Columbia, Canada: a survey of sexual health service clients.

OBJECTIVES: We assessed COVID-19 pandemic impacts on accessing needed sexual health services, and acceptability of alternative service delivery models, among sexual health service clients in British Columbia (BC), Canada. METHODS: We administered an online survey on 21 July-4 August 2020 to clients using a provincial STI clinic or internet-based testing service, GetCheckedOnline, in the year prior to March 2020. We used logistic regression to identify factors associated with having unmet sexual health needs (ie, not accessing needed services) during March-July 2020 and the likelihood of using various alternative service models, if available. RESULTS: Of 1198 survey respondents, 706 (59%) reported needing any sexual health service since March 2020; of these 706, 365 (52%) did not access needed services and 458 (66%) had avoided or delayed accessing services. GetCheckedOnline users (univariate OR (uOR)=0.62; 95% CI 0.43 to 0.88) or clients with more urgent needs (eg, treatment for new STI, uOR 0.40 (95% CI 0.21 to 0.7)) had lower odds of unmet sexual health needs. The most common factors reported for avoiding or delaying access were public messaging against seeking non-urgent healthcare (234/662, 35%), concern about getting COVID-19 while at (214/662, 32%) or travelling to (147/662, 22%) a clinic or lab and closure of usual place of accessing services (178/662, 27%). All factors were positively associated with having unmet sexual health needs, with public messaging showing the strongest effect (adjusted OR=4.27 (95% CI 2.88 to 6.42)). Likelihood of using alternative sexual health service models was high overall, with the most appealing options being home self-collection kits (634/706, 90%), receiving test kits or antibiotics at home (592/700, 85%) and express testing (565/706, 80%). CONCLUSIONS: Of BC sexual health service clients needing services during March-July 2020, many had unmet needs. Offering alternative service delivery methods may help to improve access during and beyond the COVID-19 pandemic.

Gender, Power, and Health: Measuring and Assessing Sexual Relationship Power Equity Among Young Sub-Saharan African Women and Men, a Systematic Review.

Gender inequity, including low sexual relationship power (SRP), is an important determinant of intimate partner violence (IPV) and negative sexual, reproductive, and mental health. Different versions of the Sexual Relationship Power Scale (SRPS) are commonly used within youth studies to examine how gender inequities, including controlling behaviors, in heterosexual relationships impact the lives of young people in sub-Saharan Africa. This review aims to (1) describe definitions and measures of SRP within sub-Saharan African youth studies and (2) review and summarize associations between SRP equity, IPV, and sexual, reproductive, and mental health. After searching Pubmed, Ovid Med, Psych info, Web of Science, Google Scholar, and relevant research forums, 304 papers were identified, of which 29 papers based on 15 distinct studies (published 2004-2019) met our criteria for being youth-specific, conducted in sub-Saharan Africa, and including a quantitative measure of SRP. Details of each SRPS are described, including any adaptations and psychometric properties, as well as associations with IPV, sexual, reproductive, and mental health behaviors and outcomes. Results indicate that there are variations to the SRPS, and a paucity of evidence has detailed the psychometric properties of such measures within sub-Saharan African youth studies. Measures of SRP equity are associated with experiences (among women) and perpetration of (among men) IPV as numerous pathways to HIV risk; however, the evidence remains mixed. In order to address overlapping epidemics of violence against women and HIV, efforts are needed to ensure that measures, including the SRPS, are valid and reliable among highly affected populations.

Cost-effectiveness analysis of primary human papillomavirus testing in cervical cancer screening: Results from the HPV FOCAL Trial.

The Human Papillomavirus FOr CervicAL cancer (HPV FOCAL) trial is a large randomized controlled trial comparing the efficacy of primary HPV testing to cytology among women in the population-based Cervix Screening Program in British Columbia, Canada. We conducted a cost-effectiveness analysis based on the HPV FOCAL trial to estimate the incremental cost per detected high-grade cervical intraepithelial neoplasia of grade 2 or worse lesions (CIN2+). A total of 19,009 women aged 25 to 65 were randomized to one of two study groups. Women in the intervention group received primary HPV testing with reflex liquid-based cytology (LBC) upon a positive finding with a screening interval of 48 months. Women in the control group received primary LBC testing, and those negative returned at 24 months for LBC and again at 48 months for exit screening. Both groups received HPV and LBC co-testing at the 48-month exit. Incremental costs during the course of the trial were comparable between the intervention and control groups. The intervention group had lower overall costs and detected a larger number of CIN2+ lesions, resulting in a lower mean cost per CIN2+ detected ($7551) than the control group ($8325), a difference of -$773 [all costs in 2018 USD]. Cost per detected lesion was sensitive to the costs of sample collection, HPV testing, and LBC testing. The HPV FOCAL Trial results suggest that primary HPV testing every 4 years produces similar outcomes to LBC-based testing every 2 years for cervical cancer screening at a lower cost.

Applying a health equity tool to assess a public health nursing guideline for practice in sexually transmitted infection assessment in British Columbia.

SETTING: There is a multitude of health equity tools but little guidance on how to effectively use these tools in public health nursing practice. In BC, public health nurses who are certified in sexually transmitted infection care utilize guidelines authorized by the nursing regulatory body. INTERVENTION: As part of the Equity Lens in Public Health (ELPH) research project, an assessment of the nursing guideline, Sexually Transmitted Infection (STI) Assessment Decision Support Tool, was undertaken using the Assessing Equity in Clinical Practice Guidelines health equity assessment tool. The chosen tool is intended for use by health care providers, is broadly applicable to clinical practice guidelines, can be used retrospectively, and falls within the category of equity checklists and audits. OUTCOMES: Overall, the tool was useful in assessing the inclusion and omission of an equity focus in the guideline. However, there were several challenges: the identification of an appropriate health equity tool; the absence of an evaluation of the chosen tool; the tool's focus on chronic disease versus communicable disease; and the difficulty of obtaining client perspectives. IMPLICATIONS: For an improved equity lens in the STI Assessment Decision Support Tool, future revisions should be equity focused and include perspectives from affected populations, an emphasis on the determinants of health that perpetuate inequities for populations who experience a disproportionate burden of STI, information on provincially available resources, and service delivery models that improve timely and equitable access to treatment and care.

Age at last screening and remaining lifetime risk of cervical cancer in older, unvaccinated, HPV-negative women: a modelling study.

BACKGROUND: There is a paucity of empirical evidence to inform the age at which to stop cervical cancer screening. The recommended age to stop screening generally varies between age 50-70 years worldwide. However, cervical cancer incidence and mortality remain high in older women. We used a Markov model of cervical cancer screening to estimate the remaining lifetime risk of cervical cancer at different ages and with different exit screening tests, with the aim of informing recommendations of the age at which to stop cervical cancer screening in developed countries. METHODS: For this modelling study, we developed a state transition (Markov) model of cervical cancer natural history and screening. We developed, calibrated, and validated our model using Canadian provincial registries and survey data. To simulate an age-structured population in the model, a new cohort of 236 564 women (one fifth of the population of Canadian women aged 20-24 years in 2012) entered the model every year and were successively modelled in parallel. Successive cohorts entered the model at age 10 years, creating an age-structured population of women aged 10-100 years. Women who had a total hysterectomy were excluded from the analyses. We calibrated our model to human papillomavirus (HPV) infection and cancer incidence with data from Statistics Canada, which compiles the data from 13 individual provincial registries. We chose a three-stage progressive cervical intraepithelial neoplasia model to include differences in management and treatment decisions depending on lesion severity. We modelled infections with four high-risk HPV groups: HPV16 and HPV18; HPV31, HPV33, HPV45, HPV52, and HPV58; HPV35, HPV39, HPV51, HPV56, HPV59, HPV66, and HPV68; and a generic group of other potentially oncogenic HPVs. We estimated 5-year, 10-year, and remaining lifetime risk of cervical cancer for older, unvaccinated women who stopped screening at different ages and underwent different screening tests. FINDINGS: Cervical cancer incidence excluding women with hysterectomies underestimated the incidence of cervical cancer in women with a cervix by up to 71% in women aged 80-84 years. Our model predicted that women without HPV vaccination who have been never screened have a 1 in 45 (95% percentile interval 1 in 32 to 1 in 64) lifetime risk of cervical cancer. Perfect adherence (100% of women screened) to cytology screening every 3 years between the ages of 25 years and 69 years could reduce the lifetime risk of cervical cancer to 1 in 532 women (95% percentile interval 1 in 375 to 1 in 820) without HPV vaccination. Increasing the age at which women stopped cytology screening from 55 years to 75 years led to incremental decreases in cancer risk later in life. A 70-year old woman whose screening history was unknown had an average remaining lifetime risk of 1 in 588 (<1%; 95% percentile interval 1 in 451 to 1 in 873) if she stopped screening. Her remaining lifetime risk at age 70 years was reduced to 1 in 1206 (2·0 times reduction; 95% percentile interval 1 in 942 to 1 in 1748) if she had a negative cytology test, 1 in 6525 (12·9 times reduction; 95% percentile interval 1 in 3167 to 1 in 18 664) if she had a negative HPV test, and 1 in 9550 (18·1 times reduction; 95% percentile interval 1 in 4928 to 1 in 23 228) if she had a negative co-test for cytology and HPV. INTERPRETATION: Cervical cancer risk reductions might be achieved by screening with cytology up to age 75 years, although with diminishing returns. A negative exit oncogenic HPV test or negative HPV test plus cytology correlates with a low remaining lifetime cervical cancer risk for unvaccinated women with a cervix after the age of 55 years. FUNDING: Canadian Institutes of Health Research.

Community-based HPV self-collection versus visual inspection with acetic acid in Uganda: a cost-effectiveness analysis of the ASPIRE trial.

BACKGROUND: Cervical cancer is the leading cause of cancer death for women in Uganda, despite the potential for prevention through organised screening. Community-based self-collected human papillomavirus (HPV) testing has been proposed to reduce barriers to screening. OBJECTIVE: Our objective was to evaluate the cost-effectiveness of the Advances in Screening and Prevention of Reproductive Cancers (ASPIRE) trial, conducted in Kisenyi, Uganda in April 2014 (n=500). The trial compared screening uptake and compliance with follow-up in two arms: (1) community-based (ie, home or workplace) self-collected HPV testing (facilitated by community health workers) with clinic-based visual inspection with acetic acid (VIA) triage of HPV-positive women ('HPV-VIA') and (2) clinic-based VIA ('VIA'). In both arms, VIA was performed at the local health unit by midwives with VIA-positive women receiving immediate treatment with cryotherapy. DESIGN: We informed a Monte Carlo simulation model of HPV infection and cervical cancer with screening uptake, compliance and retrospective cost data from the ASPIRE trial; additional cost, test performance and treatment effectiveness data were drawn from observational studies. The model was used to assess the cost-effectiveness of each arm of ASPIRE, as well as an HPV screen-and-treat strategy ('HPV-ST') involving community-based self-collected HPV testing followed by treatment for all HPV-positive women at the clinic. OUTCOME MEASURES: The primary outcomes were reductions in cervical cancer risk and incremental cost-effectiveness ratios (ICERs), expressed in dollars per year of life saved (YLS). RESULTS: HPV-ST was the most effective and cost-effective screening strategy, reducing the lifetime absolute risk of cervical cancer from 4.2% (range: 3.8%-4.7%) to 3.5% (range: 3.2%-4%), 2.8% (range: 2.4%-3.1%) and 2.4% (range: 2.1%-2.7%) with ICERs of US$130 (US$110-US$150) per YLS, US$240 (US$210-US$280) per YLS, and US$470 (US$410-US$550) per YLS when performed one, three and five times per lifetime, respectively. Findings were robust across sensitivity analyses, unless HPV costs were more than quadrupled. CONCLUSIONS: Community-based self-collected HPV testing followed by treatment for HPV-positive women has the potential to be an effective and cost-effective screening strategy.

Early use of the HPV 2-dose vaccination schedule: Leveraging evidence to support policy for accelerated impact.

Although human papillomavirus (HPV) vaccines were initially licensed based on efficacy after three-dose regimens in women aged 15-26 years, it was recognized early in clinical development that comparable immunogenicity could be obtained after just two doses when administered to younger girls. In both Canada and Mexico, public health authorities made the decision to administer two doses 6 months apart with a planned additional dose at 60 months, while simultaneously doing further study to determine if the third dose would confer meaningful additional benefit. This delayed third dose approach permitted a more cost-effective program with opportunities for improved compliance while minimizing injections and leaving open the opportunity to provide a full three-dose vaccination series. It required close cooperation across many governmental and civil society leadership bodies and real-time access to emerging data on HPV vaccine effectiveness. Although still limited, there is increasing evidence that even one-dose vaccination is sufficient to provide prolonged protection against HPV infection and associated diseases. Ongoing clinical trials and ecological studies are expected to consolidate existing data regarding one dose schedule use. However, to accelerate the preventive effect of HPV vaccination some jurisdictions, in particular those with limited resources may already consider the initiation of a one dose vaccination with the possibility of giving the second dose later in life if judged necessary. Such an approach would facilitate vaccination implementation and might permit larger catch-up vaccination programs in older girls (or as appropriate, girls and boys), thereby accelerating the impact on cervical cancer and other HPV-associated diseases.

Anticipating the potential for positive uptake and adaptation in the implementation of a publicly funded online STBBI testing service: a qualitative analysis.

BACKGROUND: Online health services are a rapidly growing aspect of public health provision, including testing for sexually transmitted and other blood-borne infections (STBBI). Generally, healthcare providers, policymakers, and clients imbue online approaches with great positive potential (e.g., encouraging clients' agency; providing cost-effective services to more clients). However, the promise of online health services may vary across contexts and be perceived in negative or ambiguous ways (e.g., risks to 'gold standard' care provision; loss of provider control over an intervention; uncertainty related to budget implications). This study examines attitudes and perceptions regarding the development of a novel online STBBI testing service in Vancouver, Canada. We examine the perceptions about the intervention's potential by interviewing practitioners and planners who were engaged in the development and initial implementation of this testing service. METHODS: We conducted in-depth interviews with 37 healthcare providers, administrators, policymakers, and community-based service providers engaged in the design and launch of the new online STBBI testing service. We also conducted observations during planning and implementation meetings for the new service. Thematic analysis techniques were employed to identify codes and broader discursive themes across the interview transcripts and observation notes. RESULTS: Some study participants expressed concern that the potential popularity of the new testing service might increase demand on existing sexual health services or become fiscally unsustainable. However, most participants regarded the new service as having the potential to improve STBBI testing in several ways, including reducing waiting times, enhancing privacy and confidentiality, appealing to more tech-savvy sub-populations, optimizing the redistribution of demands on face-to-face service provision, and providing patient-centred technology to empower clients to seek testing. CONCLUSIONS: Participants perceived this online STBBI testing service to have the potential to improve sexual health care provision. But, they also anticipated actions-and-reactions, revealing a need to monitor ongoing implementation dynamics. They also identified the larger, potentially system-transforming dimension of the new technology, which enables new system drivers (consumers) and reduces the amount of control health care providers have over online STBBI testing compared to conventional in-person testing.

A syndemic approach to assess the effect of substance use and social disparities on the evolution of HIV/HCV infections in British Columbia.

BACKGROUND: Co-occurrence of social conditions and infections may affect HIV/HCV disease risk and progression. We examined the changes in relationship of these social conditions and infections on HIV and hepatitis C virus (HCV) infections over time in British Columbia during 1990-2013. METHODS: The BC Hepatitis Testers Cohort (BC-HTC) includes ~1.5 million individuals tested for HIV or HCV, or reported as a case of HCV, HIV, HBV, or tuberculosis linked to administrative healthcare databases. We classified HCV and HIV infection status into five combinations: HIV-/HCV-, HIV+monoinfected, HIV-/HCV+seroconverters, HIV-/HCV+prevalent, and HIV+/HCV+. RESULTS: Of 1.37 million eligible individuals, 4.1% were HIV-/HCV+prevalent, 0.5% HIV+monoinfected, 0.3% HIV+/HCV+ co-infected and 0.5% HIV-/HCV+seroconverters. Overall, HIV+monoinfected individuals lived in urban areas (92%), had low injection drug use (IDU) (4%), problematic alcohol use (4%) and were materially more privileged than other groups. HIV+/HCV+ co-infected and HIV-/HCV+seroconverters were materially most deprived (37%, 32%), had higher IDU (28%, 49%), problematic alcohol use (14%, 17%) and major mental illnesses (12%, 21%). IDU, opioid substitution therapy, and material deprivation increased in HIV-/HCV+seroconverters over time. In multivariable multinomial regression models, over time, the odds of IDU declined among HIV-/HCV+prevalent and HIV+monoinfected individuals but not in HIV-/HCV+seroconverters. Declines in odds of problematic alcohol use were observed in HIV-/HCV+seroconverters and coinfected individuals over time. CONCLUSIONS: These results highlight need for designing prevention, care and support services for HIV and HCV infected populations based on the evolving syndemics of infections and social conditions which vary across groups.

Cost-effectiveness of cervical cancer screening methods in low- and middle-income countries: A systematic review.

The incidence of cervical cancer in low- and middle-income countries (LMICs) is five times higher than that observed in high-income countries (HICs). This discrepancy is largely attributed to the implementation of cytology-based screening programmes in HICs. However, due to reduced health system infrastructure requirements, HPV testing (self- and provider-collected) and visual inspection with acetic acid (VIA) have been proposed as alternatives that may be better suited to LMICs. Knowing the relative value of different screening options can inform policy and the development of sustainable prevention programs. We searched MEDLINE and EMBASE for English language publications detailing model-based cost-effectiveness analyses of cervical cancer screening methods in LMICs from 2000 to 2016. The main outcome of interest was the incremental cost-effectiveness ratio (ICER). Quantitative data were extracted to compare commonly evaluated screening methods and a descriptive review was conducted for each included study. Of the initial 152 articles reviewed, 19 met inclusion criteria. Generally, cytology-based screening was shown to be the least effective and most costly screening method. Whether provider-collected HPV testing or VIA was the more efficient alternative depended on the cost of the HPV test, loss to follow-up and VIA test performance. Self-collected HPV testing was cost-effective when it yielded population coverage gains over other screening methods. We conclude that HPV testing and VIA are more cost-effective screening methods than cytology in LMICs. Policy makers should consider HPV testing with self-collection of samples if it yields gains in population coverage.

Get Checked Where? The Development of a Comprehensive, Integrated Internet-Based Testing Program for Sexually Transmitted and Blood-Borne Infections in British Columbia, Canada.

BACKGROUND: Testing for sexually transmitted and blood-borne infections (STBBI) is an effective public health strategy that can promote personal control of one's health and prevent the spread of these infections. Multiple barriers deter access to testing including fear of stigmatization, inaccurate health care provider perceptions of risk, and reduced availability of clinic services and infrastructure. Concurrent increases in sexually transmitted infection (STI) rates and demands on existing clinical services make this an even more pressing concern. Web-based testing offers several advantages that may alleviate existing clinical pressures and facilitate appropriate testing access. OBJECTIVE: This paper describes the planning, development, and usability testing of a novel Web-based testing service, GetCheckedOnline (GCO), as a complementary testing option integrated within existing sexual health services within British Columbia (BC). METHODS: From 2009 to 2014, we engaged a multidisciplinary team in the design and development of GCO. We conducted 3 initial research studies to ascertain the opinions of youth, men who have sex with men (MSM), and STI clinic clients regarding Web-based testing and elicited perspectives of sexual health care providers through focus groups. We developed an informed consent process, risk assessment questions, and test recommendations based on provincial and national guidelines and evaluated these through consultations with clinical and community stakeholders. We also conducted a preliminary health equity impact assessment whose findings also informed the GCO program mode. Finally, from April 2011 to December 2012 we gathered qualitative data from 25 participants on the functionality and usability of a GCO prototype and incorporated their recommendations into a final model. RESULTS: GCO launched in the fall of 2014 across 6 pilot sites in Vancouver, BC. The service involves 3 main steps: (1) create an account, complete an assessment, and print a laboratory requisition, (2) provide blood and urine specimens at participating laboratory locations, and (3) receive test results on the Internet or by phone. During this pilot phase, we promoted GCO to existing STI clinic clients and MSM in the Greater Vancouver region. A rigorous mixed-method evaluation of GCO's uptake, acceptability, and health system impacts is currently underway. CONCLUSIONS: GCO is the first comprehensive Web-based STBBI testing program in Canada that is integrated with existing sexual health services, with the potential to reduce pressures on existing clinical services and reach populations facing the greatest barriers to testing. Our experience highlights the facilitators and challenges of developing and implementing novel complex eHealth interventions within the health care system, and underscores the importance of considering broader implementation contexts.

Assessment of Capacity to Consent by Nurses Who Deliver Health Care to Patients Who Misuse Substances.

This qualitative study explored the current practice that nurses use to assess capacity to consent to health care (CTC-HC) in street outreach settings. Key informant interviews were conducted with a purposive sample of nurses from each of British Columbia's five regional health authorities, allowing nurses to describe their lived experiences with assessing CTC-HC. Content analysis was used to summarize information captured in the data. A total of 19 nurses participated in the study. Five themes emerged from the data: (a) internal guiding forces that contribute to the nurses' assessment, (b) external influences that contribute to the nurses' assessment, (c) measures that are important for assessing CTC-HC, (d) threshold setting, and (e) context (physical and interpersonal) within which assessment of capacity takes place. These elements will be incorporated into a capacity assessment tool that can be used in nursing best practices.

Current status of human papillomavirus vaccination.

PURPOSE OF REVIEW: In this article, we review the impact of the quadrivalent and bivalent prophylactic human papillomavirus (HPV) vaccines on HPV infection and disease, review alternative vaccine dosing schedules, the vaccination of men and the nine-valent HPV vaccine. RECENT FINDINGS: HPV vaccines have had dramatic impacts on the prevalence of targeted HPV types (6,11,16 and 18), genital warts and precancerous cervical lesions. Population coverage would be facilitated by adopting two-dose schedules, with recent findings that two-dose schedules in young adolescents are as immunogenic as three doses in young adults. Extension of vaccination to men, particularly for men who have sex with men, could further reduce population prevalence of HPV and provide direct protection to men against genital warts and anal, penile and oropharyngeal cancers. The nine-valent HPV vaccine has demonstrated equivalent protection against the four types in the quadrivalent vaccine and high efficacy against the next five commonest causes of cervical cancer (HPV types 31,33,45,52 and 58). If cost-effective, it may extend the spectrum of protection against cervical cancer available through vaccination. SUMMARY: HPV vaccination is an effective strategy for reducing the burden of HPV-related disease. New schedules, target populations and vaccines promise to expand this potential further.

The relationship between social, policy and physical venue features and social cohesion on condom use for pregnancy prevention among sex workers: a safer indoor work environment scale.

BACKGROUND: This study aims to report on a newly developed Safer Indoor Work Environmental Scale that characterises the social, policy and physical features of indoor venues and social cohesion; and using this scale, longitudinally evaluate the association between these features on sex workers' (SWs') condom use for pregnancy prevention. METHODS: Drawing on a prospective open cohort of female SWs working in indoor venues, a newly developed Safer Indoor Work Environment Scale was used to build six multivariable models with generalised estimating equations (GEE), to determine the independent effects of social, policy and physical venue-based features and social cohesion on condom use. RESULTS: Of 588 indoor SWs, 63.6% used condoms for pregnancy prevention in the last month. In multivariable GEE analysis, the following venue-based features were significantly correlated with barrier contraceptive use for pregnancy prevention: managerial practices and venue safety policies (adjusted OR (AOR)=1.09; 95% CI 1.01 to 1.17), access to sexual and reproductive health services/supplies (AOR=1.10; 95% CI 1.00 to 1.20), access to drug harm reduction (AOR=1.13; 95% CI 1.01 to 1.28) and social cohesion among workers (AOR=1.05; 95% CI 1.03 to 1.07). Access to security features was marginally associated with condom use (AOR=1.13; 95% CI 0.99 to 1.29). CONCLUSIONS: The findings of the current study highlight how work environment and social cohesion among SWs are related to improved condom use. Given global calls for the decriminalisation of sex work, and potential legislative reforms in Canada, this study points to the critical need for new institutional arrangements (eg, legal and regulatory frameworks; labour standards) to support safer sex workplaces.