Supporting US healthcare providers for successful vaccine communication.

BACKGROUND: While many healthcare providers (HCPs) have navigated patients' vaccine concerns and questions prior to the rollout of the COVID-19 vaccines, sentiments surrounding the COVID-19 vaccines have presented new and distinct challenges. OBJECTIVE: To understand the provider experience of counseling patients about COVID-19 vaccinations, aspects of the pandemic environment that impacted vaccine trust, and communication strategies providers found supportive of patient vaccine education. METHODS: 7 focus groups of healthcare providers were conducted and recorded during December 2021 and January 2022, at the height of the Omicron wave in the United States. Recordings were transcribed, and iterative coding and analysis was applied. RESULTS: 44 focus group participants representing 24 US states with the majority (80%) fully vaccinated at the time of data collection. Most participants were doctors (34%) or physician's assistants and nurse practitioners (34%). The negative impact of COVID-19 misinformation on patient-provider communication at both intrapersonal and interpersonal levels as well as barriers and facilitators to patient vaccine uptake are reported. People or sources that play a role in health communication ("messengers") and persuasive messages that impact behavior or attitudes towards vaccination ("messages") are described. Providers expressed frustration in the need to continuously address vaccine misinformation in clinical appointments among patients who remained unvaccinated. Many providers found value in resources that provided up-to-date and evidence-based information as COVID-19 guidelines continued to change. Additionally, providers indicated that patient-facing materials designed to support vaccination education were not frequently available, but they were the most valuable to providers in a changing information environment. CONCLUSIONS: While vaccine decision-making is complex and hinges on diverse factors such as health care access (i.e., convenience, expense) and individual knowledge, providers can play a major role in navigating these factors with their patients. But to strengthen provider vaccine communication and promote vaccine uptake, a comprehensive communication infrastructure must be sustained to support the patient-provider dyad. The findings provide recommendations to maintain an environment that facilitates effective provider-patient communication at the community, organizational and policy levels. There is a need for a unified multisectoral response to reinforce the recommendations in patient settings.

A Pilot Study of Human Papillomavirus Detection in Urine Using a Novel Nucleic Acid Amplification Test.

INTRODUCTION: Human papillomavirus (HPV) testing is the standard-of-care for cervical cancer screening globally. Urine is a promising alternative to collecting a cervical specimen during a pelvic exam for HPV testing. There are no studies to date of HPV testing of urine using the Xpert HPV test. METHODS: We conducted a pilot study of 40 women; 30 women undergoing colposcopy because of a previous abnormality and 10 undergoing routine screening, to evaluate HPV detection in urine by the Xpert HPV test on the GeneXpert platform. Xpert HPV testing of urine was done according to the manufacturer's instructions for testing cervical specimens. These results were compared to a reference of combined results of 2 research HPV genotyping tests conducted on cervical specimens and to repeat Xpert HPV testing of urine. RESULTS: Analytic sensitivity and specificity of Xpert testing of urine for any high-risk HPV versus the cervical sample, categorized as HPV positive if at least 1 test was positive, were 64.3% (95% confidence interval [95%CI] = 42.1-76.1%) and 100% (97.5%CI = 71.5-100%), respectively. Analytic sensitivity and specificity of Xpert testing of urine for any high-risk HPV versus the cervical sample, categorized as positive if both tests were positive, were 66.7% (95%CI = 44.7-84.4%) and 86.7% (95%CI = 59.5-98.3%), respectively. Kappa values for first vs. second and first vs. third testing of urine by Xpert were 0.89 (95%CI = 0.79-1.00) and 0.90 (95%CI = 0.81-1.00), respectively. DISCUSSION: Given the call for global elimination of cervical cancer and widespread availability of GeneXpert, optimizing Xpert HPV testing of urine may be warranted.

A scoping review: Facilitators and barriers of cervical cancer screening and early diagnosis of breast cancer in Sub-Saharan African health settings.

To address gaps in access to cervical cancer screening and early diagnosis of breast cancer services in Sub-Saharan African (SSA), this scoping review was conducted to explore facilitators and barriers that exist on the patient-, provider-, and system-level. An extensive literature search was conducted in accordance with scoping review methodology and the Cochrane guidelines. Our search criteria were limited to original research studies conducted in community or clinical settings in SSA within the last 10 years (2010-2020). Themes found from this review included patient knowledge and provider education, access to screening services, trust, health-related behaviors, attitudes, values, and practices, community and social values, health infrastructure, resource allocation, and political will. Identified barriers included lack of knowledge about cervical and breast cancer among patients, gaps in education and training among providers, and lack of resources and health infrastructure at the facility level and within the overall health system. Facilitators included perceived risk of cancer, support and encouragement of the provider, and utilization of novel approaches in low-resource settings by health systems. To better address individual-, provider-, and health system and facility-based facilitators and barriers to care, there is a need for political and financial investment and further research on the health service delivery in specific national health systems, especially in the context of the global campaign to eliminate cervical cancer as a public health problem.

A comparison of screening tests for detection of high-grade cervical abnormalities in women living with HIV from Cameroon.

BACKGROUND: Women living with human immunodeficiency virus (WLWH), especially those living in low- and middle-income countries (LMIC), are at increased risk of cervical cancer. The optimal cervical-cancer screening strategy for WLWH has not been determined. We therefore conducted a pilot study of screening methods in WLWH living in Limbe, Cameroon. METHODS: Five-hundred sixty-six WLWH, aged 25-59 years, were enrolled. After self-collecting a cervicovaginal specimen, they underwent a pelvic exam, during which a provider also collected a cervical specimen and visual inspection after acetic acid (VIA) was performed. Both self- and provider-collected specimens were tested for high-risk HPV by the Xpert HPV Test (Cepheid, Sunnyvale, CA, USA), with the residual of the latter used for liquid-based cytology. Women testing HPV positive on either specimen and/or VIA positive were referred to colposcopy and biopsies. However, because of poor attendence for follow-up colposcopy for the screen positives due to civil strife and technical issues with biopsies, high-grade cytology and/or clinical diagnosis of cancer was used as the primary high-grade cervical abnormality endpoint. Clinical performances for high-grade cervical abnormality of HPV testing and VIA for screening WLWH, and the most carcinogenic HPV genotypes and/or VIA to triage high-risk HPV-positive WLWH, were evaluated. RESULTS: Four-hundred eighty-seven (86.0%) WLWH had results for HPV testing on both specimen, VIA, and cytology and were included in the analysis. Forty-nine (10.1%) had a high-grade cervical abnormality. HPV testing on provider- and self-collected specimens was more sensitive than VIA (95.9 and 91.8% vs. 43.8%, respectively, p < 0.01 for both comparisons) for identifying women with high-grade cervical abnormalities. HPV testing on provider- and self-collected specimens was less specific than VIA (57.5 and 51.6% vs. 89.7%, respectively, p < 0.01 for both comparisons) for identifying women with high-grade cervical abnormalities; HPV testing on provider-collected specimens was more specific than on self-collected specimens (p < 0.01). Among HPV-positive women, HPV16/18/45 detection or VIA positivity had a sensitivity and positive predictive value of 73.5 and 29.0%, respectively, for provider-collected specimens and 68.8 and 22.9%, respectively, for self-collected specimens for high-grade cervical abnormalities. CONCLUSIONS: HPV testing was more sensitive but less specific than VIA for detection of high-grade cervical abnormality in WLWH. Improved triage methods for HPV-positive WLWH are needed. TRIAL REGISTRATION: NCT04401670 (clinicaltrials.gov); retrospectively registered on May 26, 2020.

A Pooled Analysis to Compare the Clinical Characteristics of Human Papillomavirus-positive and -Negative Cervical Precancers.

Given that high-risk human papillomavirus (HPV) is the necessary cause of virtually all cervical cancer, the clinical meaning of HPV-negative cervical precancer is unknown. We, therefore, conducted a literature search in Ovid MEDLINE, PubMed Central, and Google Scholar to identify English-language studies in which (i) HPV-negative and -positive, histologically confirmed cervical intraepithelial neoplasia grade 2 or more severe diagnoses (CIN2+) were detected and (ii) summarized statistics or deidentified individual data were available to summarize proportions of biomarkers indicating risk of cancer. Nineteen studies including 3,089 (91.0%) HPV-positive and 307 (9.0%) HPV-negative CIN2+ were analyzed. HPV-positive CIN2+ (vs. HPV-negative CIN2+) was more likely to test positive for biomarkers linked to cancer risk: a study diagnosis of CIN3+ (vs. CIN2; 18 studies; 0.56 vs. 0.24; P < 0.001) preceding high-grade squamous intraepithelial lesion cytology (15 studies; 0.54 vs. 0.10; P < 0.001); and high-grade colposcopic impression (13 studies; 0.30 vs. 0.18; P = 0.03). HPV-negative CIN2+ was more likely to test positive for low-risk HPV genotypes than HPV-positive CIN2+ (P < 0.001). HPV-negative CIN2+ appears to have lower cancer risk than HPV-positive CIN2+. Clinical studies of human high-risk HPV testing for screening to prevent cervical cancer may refer samples of HPV test-negative women for disease ascertainment to correct verification bias in the estimates of clinical performance. However, verification bias adjustment of the clinical performance of HPV testing may overcorrect/underestimate its clinical performance to detect truly precancerous abnormalities.

Cervical human papillomavirus DNA detection in women living with HIV and HIV-uninfected women living in Limbe, Cameroon.

BACKGROUND: There are limited data on cervical HPV prevalence in Cameroon and none from its Anglophone region. We investigated cervical HPV prevalence in HIV-uninfected (HIV[-]) and HIV-infected (WLWH) women living in the region. METHODS: A convenience sample of consecutively recruited HIV[-] women (n = 295) and women living with HIV (WLWH) (n = 560) attending the Limbé Regional Hospital were enrolled into a cervical screening study. Women underwent screening that included HPV testing of self-collected and provider-collected specimens. We calculated the HPV prevalence by HIV status, overall and stratified by age, and among WLWH, stratified by CD4 counts. We compared the concordance for the detection of HPV between self- and provider-collected specimens. RESULTS: Crude HPV prevalence was 21.69 % (95 % confidence interval [95 %CI] = 17.21-26.48 %) for HIV[-] women and 46.43 % (95 %CI = 42.24-50.66 %) for WLWH (p < 0.001). Among WLWH, older age (ptrend = 0.01) and higher CD4 counts (ptrend = 0.007) were associated with lower HPV prevalence. There was a good-to-excellent agreement for HPV detection between specimens, and self-collected were more likely than provider-collected specimens to test HPV positive, for all women and stratified by HIV status. CONCLUSIONS: HIV-related immunosuppression was a risk factor for HPV prevalence in this population. HPV testing of self-collected specimens appeared to be less specific than HPV testing of provider-collected specimens.

Acceptability of Self-Sampling for Cervical Cancer Screening Among Women Living With HIV and HIV-Negative Women in Limbé, Cameroon.

Introduction: Like many countries in Sub-Saharan Africa, Cameroon has a high burden of cervical cancer and low availability and uptake of screening. Self-collection has the potential to increase the uptake of cervical cancer screening among Cameroon women. This paper explores patient and community insights surrounding self-collection among women living with HIV and HIV[-] women as well as the barriers and facilitators to obtaining and utilizing self-collected specimens in cervical cancer screening programs. Materials and methods: We utilized an exploratory qualitative approach to obtain data through focus group discussions and in-depth interviews during data collection that took place from May to August 2018. A two-stage sampling strategy was used to select 80 women who participated in six focus group discussions and eight in-depth interviews. We utilized the socio-ecological framework to guide data analysis. Results: All participants indicated that self-sampling was an acceptable method of specimen collection and should be offered as an option for cervical cancer screening in Cameroon. Whereas, most women, regardless of HIV status, preferred the option for self-collection, barriers were identified, such as lack of education about self-collection procedure, being uncomfortable, embarrassed or in pain from the procedure, fear of consequences, perceived competence about ability to self-collect and privacy and confidentiality. We also found that HIV-related stigma was a major concern for HIV[-] women that could prevent them from accessing cervical cancer screening integrated within HIV treatment settings. Conclusions: To promote self-collection for cervical cancer screening, educational interventions with both patients and providers are necessary to increase knowledge of and overall willingness to utilize self-collection. Further research is recommended to examine the role of stigma for HIV[-] women in screening locations associated with HIV treatment.