Type-specific incidence, persistence and factors associated with human papillomavirus infection among female sex workers in Benin and Mali, West Africa.

OBJECTIVES: This study in female sex workers (FSWs) aimed to: (1) estimate type-specific incidence and persistence of human papillomavirus (HPV) infection in Cotonou (Benin) and Bamako (Mali); and (2) identify the factors associated with type-specific incidence and persistence of high-risk HPV (HR-HPV) infection. METHODS: A 1-year prospective cohort study on cervical cancer screening, and HPV and human immunodeficiency virus (HIV) infections was conducted among FSWs in Cotonou and Bamako from 2017 to 2019. Poisson regression models assessed factors associated with the incidence of HR-HPV infection, while log-binomial regression was performed to identify factors associated with the persistence of HR-HPV infection. Adjusted relative risks (ARR) and 95% confidence intervals (95% CI) were estimated. RESULTS: The incidence of HR-HPV infection was 46.98 per 1000 women-months (predominant types HPV16, HPV35 and HPV59). Factors associated with the incidence of HR-HPV infection were age <20 years (ARR 15.10; 95% CI 3.29-69.19), age at sexual debut <18 years (ARR 6.92; 95% CI 1.97-24.27) and sex work duration ≤1 year (ARR 7.40; 95% CI 1.84-29.69). The persistence of HR-HPV infection at 12 months was 38.7% (most persistent types HPV59, HPV52 and HPV51). Persistence of HR-HPV infection was higher in women with chlamydia (P = 0.031), HIV infection (P < 0.001) and multiple-type HPV infections (P < 0.001). CONCLUSION: FSWs in West Africa are at high risk of incident and persistent HR-HPV infection, suggesting an urgent need for cervical cancer screening in this population.

A population-based combination strategy to improve the cervical cancer screening coverage rate in Bamako, Mali.

INTRODUCTION: Cervical cancer screening coverage rate is <5% in Sub-Saharan Africa and <2% in French- speaking African countries. In 2016, we implemented strategies to improve cervical cancer screening in Bamako, the "Weekend70 program". The present study objectives are to determine the effect of this program on women's participation in cervical cancer screening in Bamako, and to estimate the cervical cancer screening coverage rate in Bamako. MATERIAL AND METHODS: From 1 January 2016 to 31 July 2020, we conducted an operational research by developing several strategies to improve the cervical cancer screening coverage rate among adolescents and women ≥15 years old in Bamako, Mali. The strategies consisted of awareness-raising activities, strengthening of screening practices in healthcare facilities and cost-free cervical cancer screening during the weekend. Descriptive statistics were presented. The cervical cancer coverage rate was calculated by dividing the number of women screened by the total number of women ≥20 years old, based on Mali demographic data. RESULTS: The total number of women screened was 289 924. Residents from Bamako represented 91.9% (266 436/289 924) vs 8.1% (23 488/289 924) who lived outside Bamako. The mean age was 33.2 (± 11.5) years old. Around 46.1% of participants attending the cervical cancer screening were between 30 and 49 years old (World Health Organization prioritized target age for cervical cancer screening). Women ≥60 years old represented <5%. Cervical cancer screening participation increased significantly, from <800 women screened per week before the implementation of the program to a peak of 4100 women screened per week during the "Weekend70 program". Overall, the cervical cancer screening coverage rates at the end of the study among women ≥20 years old was 47.3%, and 56.9% in the WHO target population. CONCLUSION: In an impoverished context, a multi-component strategy significantly increases cervical cancer screening participation.

Human papillomavirus genotype distribution and factors associated among female sex workers in West Africa.

OBJECTIVES: This study aimed to: (1) Estimate HPV prevalence and genotype distribution among female sex workers (FSWs) in Mali and Benin as well as the prevalence of multiple HPV type infections in this group, and (2) Identify potential risk factors associated with high-risk (HR) HPV infections. METHODS: We analyzed baseline data of 665 FSWs aged ≥ 18 years recruited during a prospective cohort of cervical cancer screening in Cotonou (Benin) and Bamako (Mali) from 2017 to 2018. The Linear Array HPV genotyping test was used to identify HPV genotypes. Descriptive statistics and multivariate log-binomial regression were used. Adjusted prevalence ratios (APR) with 95% confidence intervals (95%CI) were estimated to identify risk factors associated with HR-HPV infections. RESULTS: HPV data were available for 659 FSWs (Benin: 309; Mali: 350). The mean age was 35.0 years (± 10.7) in Benin and 26.8 years (± 7.6) in Mali. The overall HPV prevalence rates were 95.5% in Benin and 81.4% in Mali. About 87.7% and 63.4% of FSWs harbored ≥ 2 HPV types in Benin and Mali, respectively. The top three prevalent HR-HPV among FSWs in Benin were: HPV58 (37.5%), HPV16 (36.6%) and HPV52 (28.8%). Corresponding patterns in Mali were HPV16 (15.7%), HPV51 (14.3%) and HPV52 (12.9%). In Benin, the main factors associated with HR-HPV were vaginal douching (APR = 1.17; 95%CI:1.02-1.34) and gonococcal infection (APR = 1.16; 95%CI:1.04-1.28), while in Mali they were sex work duration ≤ 1 year (APR = 1.35; 95%CI:1.10-1.65) and HIV infection (APR = 1.26; 95%CI: 1.06-1.51). CONCLUSION: Our study found a very high prevalence of HPV infection as well as high frequency of multiple HPV type infections in FSWs in two countries in West Africa. These findings suggest the necessity to emphasize cervical cancer prevention in this high-risk group.

Household roles and care-seeking behaviours in response to severe childhood illness in Mali.

Malaria is a major cause of under-five mortality in Mali and many other developing countries. Malaria control programmes rely on households to identify sick children and either care for them in the home or seek treatment at a health facility in the case of severe illness. This study examines the involvement of mothers and other household members in identifying and treating severely ill children through case studies of 25 rural Malian households. A wide range of intra-household responses to severe illness were observed among household members, both exemplifying and contravening stated social norms about household roles. Given their close contact with children, mothers were frequently the first to identify illness symptoms. However, decisions about care-seeking were often taken by fathers and senior members of the household. As stewards of the family resources, fathers usually paid for care and thus significantly determined when and where treatment was sought. Grandparents were frequently involved in diagnosing illnesses and directing care towards traditional healers or health facilities. Relationships between household members during the illness episode were found to vary from highly collaborative to highly conflictive, with critical effects on how quickly and from where treatment for sick children was sought. These findings have implications for the design and targeting of malaria and child survival programming in the greater West African region.

Treatment actions and treatment failure: case studies in the response to severe childhood febrile illness in Mali.

BACKGROUND: Appropriate home management of illness is vital to efforts to control malaria. The strategy of home management relies on caregivers to recognize malaria symptoms, assess severity and promptly seek appropriate care at a health facility if necessary. This paper examines the management of severe febrile illness (presumed malaria) among children under the age of five in rural Koulikoro Region, Mali. METHODS: This research examines in-depth case studies of twenty-five households in which a child recently experienced a severe febrile illness, as well as key informant interviews and focus group discussions with community members. These techniques were used to explore the sequence of treatment steps taken during a severe illness episode and the context in which decisions were made pertaining to pursing treatments and sources of care, while incorporating the perspective and input of the mother as well as the larger household. RESULTS: Eighty-one participants were recruited in 25 households meeting inclusion criteria. Children's illness episodes involved multiple treatment steps, with an average of 4.4 treatment steps per episode (range: 2-10). For 76% of children, treatment began in the home, but 80% were treated outside the home as a second recourse. Most families used both traditional and modern treatments, administered either inside the home by family members, or by traditional or modern healers. Participants' stated preference was for modern care, despite high rates of reported treatment failure (52%, n=12), however, traditional treatments were also often deemed appropriate and effective. The most commonly cited barrier to seeking care at health facilities was cost, especially during the rainy season. Financial constraints often led families to use traditional treatments. CONCLUSIONS: Households have few options available to them in moments of overlapping health and economic crises. Public health research and policy should focus on the reducing barriers that inhibit poor households from promptly seeking appropriate health care. Enhancing the quality of care provided at community health facilities and supporting mechanisms by which treatment failures are quickly identified and addressed can contribute to reducing subsequent treatment delays and avoid inappropriate recourse to traditional treatments.

(Re)defining reproductive health with and for the community: an example of participatory research from Mali.

Qualitative research was carried out in central Mali to inform the development of curricula for an intervention to improve young people's reproductive health. Both the young people and 'societal gatekeepers' (including religious leaders and traditional healers) perceived reproductive health to comprise the social dynamics in which reproductive health decision-making is embedded and not just the biological aspects of sexual relations and fertility. Their definitions of reproductive health reflected social taboos about pre-marital sex, infidelity and illegitimate children, and comprised holistic notions of bodily and spiritual cleanliness. It is argued that the 'Cairo' definition sees many of the social factors identified by respondents as comprising the context or background of reproductive health. The findings presented here indicate that local populations may see them as integral to the concept itself. It is discussed how the 'Cairo' definition of reproductive health needs to be made culturally specific in order to facilitate programme design and implementation.