Utilization of opportunistic cervical cancer screening in Nigeria.

BACKGROUND: While various interventions have been conducted to decrease cervical cancer's burden in Nigeria, no study has examined the trends in cervical cancer screening uptake over time. The present study sought to fill this gap in knowledge using data collected at Jos University Teaching Hospital (JUTH) in Nigeria. METHODS: Data collected continuously between 2006 and 2016 were analyzed to identify trends in screening uptake, changes in risk factors for cervical cancer, and to identify factors for women screened at Jos University Teaching Hospital (JUTH) in Jos, Nigeria. Categorical analyses and logistic regression models were used to describe patient characteristics by year, and to identify factors associated with repeated screening uptake. RESULTS: A total of 14,088 women who were screened between 2006 and 2016 were included in the database; 2,800 women had more than one screening visit. Overall, screening uptake differed significantly by year. On average women were first screened at age 38. About 2% of women screened were women living with HIV. Most women (86%) had normal pap smear at first screening, with the greatest decreased risk of abnormalities observed between 2011 and 2014. Odds of a follow-up screening after a normal result decreased significantly between 2008 and 2016 compared to women screened in 2006 and 2007. Finally, women living with HIV had increased odds of follow-up screening after having a normal pap smear. CONCLUSIONS: These findings contribute to our understanding of the potential social and health system barriers to cervical cancer control in Nigeria. The findings may assist policy makers to design interventions to increase access and compliance to recommended screening schedules in this vulnerable population.

The impact of the COVID-19 pandemic on routine HIV care and cervical cancer screening in North-Central Nigeria.

INTRODUCTION: Cervical cancer is the fourth most diagnosed cancer among women globally, with much of the burden being carried by women in limited-resource settings often worsened by the high prevalence of HIV. Furthermore, the COVID-19 pandemic disrupted organized screening efforts and HIV management regimens worldwide, and the impact of these disruptions have not been examined in these settings. The purpose of this paper is to describe whether uptake of cervical cancer screening and HIV management changed before, during, and since the COVID-19 pandemic in North-Central Nigeria. METHODS: Longitudinal healthcare administration data for women who obtained care between January 2018 and December 2021 were abstracted from the AIDS Prevention Initiative Nigeria (APIN) clinic at Jos University Teaching Hospital. Patient demographics, pap smear outcomes, and HIV management indicators such as viral load and treatment regimen were abstracted and assessed using descriptive and regression analyses. All analyses were conducted comparing two years prior to the COVID-19 pandemic, the four quarters in 2020, and the year following COVID-19 restrictions. RESULTS: We included 2304 women in the study, most of whom were between 44 and 47 years of age, were married, and had completed secondary education. About 85% of women were treated with first line highly active retroviral therapy (HAART). Additionally, 84% of women screened using pap smear had normal results. The average age of women who sought care at APIN was significantly lower in Quarter 3, 2020 (p = 0.015) compared to the other periods examined in this study. Conversely, the average viral load for women who sought care during that period was significantly higher in adjusted models (p < 0.0001). Finally, we determined that the average viral load at each clinic visit was significantly associated with the period in which women sought care. CONCLUSIONS: Overall, we found that COVID-19 pandemic mitigation efforts significantly influenced women's ability to obtain cervical cancer screening and routine HIV management at APIN clinic. This study buttresses the challenges in accessing routine and preventive care during the COVID-19 pandemic, especially in low-resource settings. Further research is needed to determine how these disruptions to care may influence long-term health in this and similar at-risk populations.

HIV and development of epithelial cell abnormalities in women with prior normal cervical cytology in Nigeria.

BACKGROUND: HIV-associated cellular immune dysfunction has been linked to higher risk of cervical dysplasia and cancer in HIV infected women. We sought to understand the relationship between HIV and development of epithelial cell abnormalities (ECA) at follow-up in women with prior normal cervical cytology (NCC). METHODS: Retrospective cohort analysis of women who received a Pap test at the Operation Stop Cervical Cancer Unit in Jos, Nigeria over a 10-year period (2006-2016). We analyzed the data of women with NCC at first Pap who had at least one follow-up cytology result for time-to-detection of ECA. We determined follow-up time in years from date of first NCC to date of first ECA report or date of last NCC follow up report with censoring at last follow-up date or December 31st, 2016 whichever came first. The primary outcome was development of any ECA as defined by the Bethesda 2001 reporting system. We identified demographic and clinical factors associated with incident ECA using multivariable Cox regression. RESULTS: A total of 1599 women were eligible for this analysis. Overall, 3.7% (57/1556) of women reported being HIV infected. The median age at first Pap was 39 years (IQR; 33-45). The HIV infected women were younger (36.3 ± 8.1) compared to those uninfected (39.3 ± 6.6), p = 0.005. After an accrued follow-up time of 3809 person-years (PYs), 243 women (15%) had an ECA with an event rate of 6.38 per 100 PYs. Women ≥35 years at first Pap were more likely to have an ECA compared to those < 35 years (7.5 per 100 PYs vs 3.8 per 100 PYs, HR = 1.96; 95% CI: 1.4, 2.8). HIV status was not significantly associated with developing ECA in either unadjusted (7.4 per 100 PYs vs 6.4 per 100 PYs, HR = 1.17; 95% CI: 0.53, 2.3) or adjusted analyses (aHR = 1.78; 95% CI: 0.87, 3.65). CONCLUSION: Women living with HIV and on successful antiretroviral treatment may not have a differential hazard in the development of ECA during follow up after a prior normal Pap. Offering a repeat CCS to women who are 35 years or older irrespective of HIV status is likely an effective strategy in resource limited settings.

HIV status, age at cervical Cancer screening and cervical cytology outcomes in an opportunistic screening setting in Nigeria: a 10-year Cross sectional data analysis.

BACKGROUND: Invasive cervical cancer (ICC) is more prevalent in HIV infected women and occurs at younger median age than in HIV negative women. Organized cervical cancer screening (CCS) is presently lacking in Nigeria, and the age at CCS is not known in this population. We sought to examine the age at CCS, the cytology outcomes and whether outcomes differ by HIV infection status in an opportunistic screening setting. METHODS: Cross-sectional analysis of data on a sample of women who had received a CCS in an opportunistic screening service in Jos, Nigeria over a 10-year time period (2006-2016). We used logistic regression models to estimate the independent effect of patient-reported HIV and age at CCS and odds ratios for abnormal cytology outcomes adjusting for other covariates. We also assessed the correlation between median age at CCS and severity of abnormal cervical cytology outcomes. Statistical analyses were done on STATA version 14, College Station, Texas, USA. RESULTS: In a sample of 14,088, the median age at CCS was 37 years (IQR; 30-45). For HIV infected women vs. uninfected women, CCS occurred at earlier ages (35.0 ± 7.4 vs 38.2 ± 10.2 years, p < 0.001). All women, regardless of HIV status, who completed at least 7 or more years of education were 1.27 to 3.51 times more likely to have CCS before age 35 than women with less education. The predictors of an abnormal cervical cytology outcome at CCS were: age at CCS ≥ 35 (aOR = 3.57; 95% CI: 2.74, 4.64), multiparity ≥5 (aOR = 1.27; 95% CI: 1.03, 1.56), and provider-referral (aOR = 1.34; 95% CI: 1.09, 1.64). Irrespective of reported HIV status, we found a positive correlation between median age at CCS and severity of cytology outcome. DISCUSSION: The age at CCS in women who have utilized cervical cancer screening in the study population is relatively late compared to the recommended age by most guidelines from developed settings. Late age at CCS correlates positively with severity of abnormal cytology outcome irrespective of HIV status. More educated women are more likely to have CCS at early age and less likely to have underlying abnormal cytology outcomes.

Association between patient-reported HIV status and provider recommendation for screening in an opportunistic cervical Cancer screening setting in Jos, Nigeria.

BACKGROUND: Cervical cancer screening (CCS) is an important health service intervention for prevention of morbidity and mortality from invasive cervical cancer. The role of provider recommendation and referral is critical in utilization of this services particularly in settings where screening is largely opportunistic. We sought to understand how patient-reported human immunodeficiency virus (HIV) infection status is associated with provider referral in an opportunistic screening setting. METHODS: We performed a cross-sectional analysis of data on a sample of women who had received a CCS at the "Operation Stop" cervical cancer (OSCC) screening service in Jos, Nigeria over a 10-year time period (2006-2016). We used the de-identified records of women who had their first CCS to analyze the association between patient-reported HIV and likelihood of provider-referral at first CCS. We performed descriptive statistics with relevant test of association using Student t-test (t-test) for continuous variables and Pearson chi square or Fisher exact test where applicable for categorical variables. We also used a bivariable and multivariable logistic regression models to estimate the independent association of patient-reported HIV on provider referral. All statistical tests were performed using STATA version 14.1, College Station, Texas, USA. Level of statistical significance was set at 0.05. RESULTS: During the 10-year period, 14,088 women had their first CCS. The reported HIV prevalence in the population was 5.0%; 95% CI: 4.6, 5.4 (703/14,088). The median age of women who were screened was 37 years (IQR; 30-45). Women who were HIV infected received more referrals from providers compared to women who were HIV uninfected (68.7% versus 49.2%), p-value < 0.001. Similarly, we found an independent effect of patient-reported HIV infection on the likelihood for provider-referral in the screened sample (aOR = 2.35; 95% CI: 1.95, 2.82). CONCLUSION: Our analysis supports the design of health systems that facilitates providers' engagement and provision of necessary counseling for CCS in the course of routine clinical care. The practice of offering recommendation and referrals for CCS to women at high risk of cervical cancer, such as HIV infected women should be supported.

Obstetric predictors of hypertension: A cross-sectional study of women attending the postnatal clinic of Jos University Teaching Hospital.

BACKGROUND: Hypertensive disease in pregnancy (HDP) accounts for high mother and child morbi-mortality and predict future cardiometabolic diseases. This study aimed to identify obstetric predictors of HDP needing preventive action to reduce its consequences; when women present to antenatal clinic (ANC). MATERIALS AND METHODS: Cross-sectional descriptive this was an Interviewer-administered semi-structured questionnaire-based study of the anthropometric, and blood pressure measurementsin attendees at the postnatal clinic (PNC) of Jos University with ANC records. SETTING: Six weeks postnatal clinic (PNC) of Jos University Teaching Hospital (JUTH). RESULTS: The following indices proved predictive of HDP and subsequent hypertension: weight (P = 0.009), hip circumference (P = 0.018), parity (P = 0.043), waist circumference (P = 0.00), abdominal height (P = 0.040), waist/height (P = 0.020), history of developing hypertension in previous pregnancy (P = 0.000), birth weight of baby (P = 0.02), and mode of delivery (P = 0.05). CONCLUSION: To initiate preventive action on ANC registration in mitigating effects of or outrightly preventing HDP, careful check on anthropometry as well as history of hypertension or operative/preterm delivery in a previous pregnancy is necessary.

Cervical cancer survival in a resource-limited setting-North Central Nigeria.

BACKGROUND: Organized cervical cancer screening services are presently lacking in Nigeria contributing to late presentation and diagnosis of invasive cervical cancer cases (ICCs) at advanced stages in most gynecologic units in Nigeria. We evaluated outcomes of ICCs diagnosed at Jos University Teaching Hospital (JUTH) to better understand factors associated with cervical cancer survival in similar resource limited settings. METHODS: We performed a retrospective cohort study with a prospective follow up data to estimate time from diagnosis to mortality among women diagnosed with ICCs at JUTH. Women who were diagnosed with ICCs between January 2011 and May 2013 were followed up after initial evaluation at JUTH and subsequent referral for specialized treatment in one of the national oncology treatment centers in Nigeria. The main outcome measured was all-cause mortality rate and overall survival (OS) after diagnosis of ICC. The follow up data were updated and observations were censored March 31, 2015. The overall death rate was estimated using the total number of death events and the cumulative follow-up time from diagnosis to death. We conducted Cox proportional hazard regression to assess factors associated with death. RESULTS: A total of 65 histologically confirmed ICCs were followed up. The median age of the cohort was 50 years with a median parity of 7. The HIV prevalence in the cohort was 8.2 % and the majority (72.3 %) were diagnosed at advanced stages (AD) of ICC. Simple total abdominal hysterectomy (TAH) was performed in 38.9 % of patients who were diagnosed at early stage disease (ED). After a cumulative follow up of 526.17 months, 35 deaths occurred with an overall death rate of 79.8 per 100 women-years. We also found a significantly higher hazard of death in women with AD (HR = 3.3) and baseline anemia (HR = 3.0). In the subgroup of women with ED, the OS was significantly higher for those who had TAH compared to those who did not (26.5 versus 11.6 months respectively). CONCLUSION: Advanced stage disease and baseline anemia were independently associated with higher death rate. Cervical cancer patients diagnosed at early stages by non-oncologic specialist in settings lacking the standard of care may benefit from improve survival with simple hysterectomy.

High-risk human papilloma virus and cervical abnormalities in HIV-infected women with normal cervical cytology.

BACKGROUND: The prevalence of High-Risk Human papilloma virus (HR-HPV), a necessary cause of invasive cervical cancer (ICC) is relatively high in HIV infected women. Gaps exist in our knowledge of the optimal approaches for managing women who have HR-HPV with normal cervical cytology (NCC) particularly in settings of HIV infection. METHODS: Between May 2012 and June 2013 we conducted a colposcopic assessment of HIV-infected women with prior (NCC) and known HR-HPV status to compare cervical abnormalities in women with and without HR-HPV. Colposcopic examinations were done at the Operation Stop Cervical Cancer (OSCC) unit of the Jos University Teaching Hospital (JUTH), Jos, Nigeria. Abnormal colposcopic finding (ACF) was defined as areas of aceto-white epithelium involving the squamo-coulumnar junction, areas of punctation, mosaic pattern or atypical vessels. We compared proportions of ACF as well as histologic grades of cervical intra-epithelial neoplasia (CIN) in women with or without HR-HPV. Statistical analysis was done on STATA. RESULTS: We conducted colposcopic examinations in 78 out of 89 (86.5%) eligible women. The mean age of the cohort was 32.4 years (SD ±4.6) with a median 32 years (IQR 29-36). After a mean follow up time of 20.1 months from the initial cervical pap cytology and HR-HPV testing, we found 12 of 78 (15.4%) women with ACF. The odds for an ACF was statistically higher [OR = 4.0 (95% CI: 1.1-14.7)] in women with HR-HPV compared to those without. Of the twelve women with ACF, subsequent histologic examination of colposcopically directed cervical biopsies confirmed CIN 1 in 4 cases (33.3%), CIN 2 in 1 case (8.3%), CIN 3 in 2 cases (16.7%), carcinoma-in-situ (CIS) in 2 cases (16.7%), and normal cervix in 3 (25.0%). Overall, the proportion of women detected with any grade of CIN was 11.5% (9/78) and 6.4% (5/78) were CIN 2 or greater lesion (CIN2+). CONCLUSION: HIV-infected women with NCC and HR-HPV had a four-fold higher likelihood for an ACF. The practice of early colposcopic examination of HIV-infected women with prior NCC and HR-HPV may increase early detection of higher grade CIN and CIS cancer stages in our setting.

Declining rate of infection with maternal human immunodeficiency virus at delivery units in north-central Nigeria.

HIV testing during labour and delivery provides a critical opportunity for administering appropriate interventions to prevent mother-to-child-transmission (PMTCT). We studied current HIV rates and infection trend among women tested during delivery following scale-up of PMTCT and antiretroviral therapy (ART) programs in Jos, north central Nigeria. Between March 2010 and January 2012, provider-initiated HIV testing and counselling was offered in early labour. Women were recruited from a government tertiary health centre, a faith-based hospital, and a private health centre. Those who previously tested HIV negative during antenatal care (ANC) and those who presented at the labour ward with unknown HIV status were tested. A total of 944 subjects (727 re-tested for HIV infection and 217 with unknown HIV status) were enrolled and tested during labour. The HIV incidence and sero-conversion rates during pregnancy among women who repeated HIV testing at delivery was 1.7 per 100 person-years of observation (pyo) and 0.6% (4/727), respectively, while the rate among those who tested for the first time in labour was 1.8% (4/217). Women who accessed ANC were older and had achieved a higher educational status than those who did not access ANC. A 3- to 5-fold decline in HIV incidence and prevalence rates was detected among women tested at delivery when compared to data from a report in 2004. It is not certain whether the decline in maternal HIV infection is due to the major state-wide scale-up of PMTCT and HIV treatment programs. A broader and purposefully designed evaluation study would be required to verify observed occurrence.