Cisgender women living with HIV (WLWH) are disproportionately impacted by cervical cancer. Nevertheless, disparities in uptake and implementation of cervical cancer services persist in sub-Saharan Africa, where population-level estimates of screening coverage remain scarce.
Methods
We pooled data from nationally representative Population-based HIV Impact Assessment (PHIA) surveys conducted in Ethiopia, Malawi, Rwanda, Tanzania, Zambia, and Zimbabwe (2015–2019). After estimating the prevalence of self-reported lifetime cervical cancer screening (overall and by country), survey-weighted multivariable log-binomial regression identified socio-demographic and clinical correlates of screening uptake among WLWH aged 25–64 years.
Results
Overall, 6933 WLWH (mean age: 39.6 years) were included in the multi-country sample. The pooled prevalence of lifetime cervical cancer screening was 18.5% (range: 8.5% [Rwanda] to 25.3% [Zambia]). Screening uptake varied by HIV clinical status, with serostatus-aware (21.3% vs 9.0%), antiretroviral therapy-experienced (22.0% vs 10.5%), and virally suppressed (22.1% vs 11.6%) WLWH, respectively, reporting significantly (p < 0.001) higher screening rates. Screening was especially low among WLWH aged <35 years (14.7%), with no formal education (12.1%), in the poorest households (7.9%), and residing in rural areas (14.0%).
Conclusions
Fewer than one-fifth of WLWH had ever screened for cervical cancer, suggesting expanded availability and access to tailored, integrated services are critically needed.
BrayFFerlayJSoerjomataramI, et al.Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin2018; 68(6): 394–424.
2.
HullRMbeleMMakhafolaT, et al.Cervical cancer in low and middle-income countries. Oncol Lett2020; 20(3): 2058–2074.
3.
BlackERichmondR. Prevention of cervical cancer in sub-Saharan Africa: the advantages and challenges of HPV vaccination. Vaccines2018; 6(3): 61.
4.
StelzleDTanakaLFLeeKK, et al.Estimates of the global burden of cervical cancer associated with HIV. Lancet Global Health2021; 9(2): e161–e169.
5.
World Health Organization. WHO guidelines for screening and treatment of precancerous lesions for cervical cancer prevention. Geneva, Switzerland: World Health Organization, 2021.
6.
Practice Bulletin No. 157. Cervical cancer screening and prevention. Obstet Gynecol. 2016 Jan; 127(1): e1–e20. doi:10.1097/AOG.0000000000001263.
7.
RamírezATVallsJBaenaA, et al.Performance of cervical cytology and HPV testing for primary cervical cancer screening in Latin America: an analysis within the ESTAMPA study. Lancet Reg Health Am2023; 26: 100593.
8.
KungTPHGordonJRAbdullahiABarveAChaudhariVKosambiyaJK, et al.My husband says this: if you are alive, you can be someone…”: facilitators and barriers to cervical cancer screening among women living with HIV in India. Cancer Causes & Control2019; 30: 365–374.
9.
GuillaumeDChandlerRIgbinobaS. Barriers to cervical cancer screening among women living with HIV in low-and middle-income countries: a systematic review. J Assoc Nurses AIDS Care2020; 31(5): 497–516.
10.
AdedimejiAAjehRPierzA, et al.Challenges and opportunities associated with cervical cancer screening programs in a low income, high HIV prevalence context. BMC Wom Health2021; 21: 74.
11.
Anaman-TorgborJAngmorterhSKDordunooD, et al.Cervical cancer screening behaviours and challenges: a sub-Saharan Africa perspective. Pan Afr Med J2020; 36: 97.
12.
DzinamariraTMoyoEDzoboM, et al.Cervical cancer in sub-Saharan Africa: an urgent call for improving accessibility and use of preventive services. Int J Gynecol Cancer2023; 33(4): 592–597.
13.
SchnabelLGlassmanA. Gavi from the country perspective: assessing ke y challenges to effective partnership. Washington, DC: Center for Globa l Development, 2019.
14.
World Health Organization. Regional Office for South-East Asia. Accelerating the elimination of cervical cancer as a public health problem: towards achieving 90–70–90 targets by 2030. World Health Organization. Regional Office for South-East Asia. 2022. https://iris.who.int/handle/10665/361138.
15.
JustmanJEMugurungiOEl-SadrWM. HIV population surveys—bringing precision to the global response. N Engl J Med2018; 378(20): 1859–1861.
16.
World Health Organization. Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach. Geneva, Switzerland: World Health Organization, 2021.
Saasa-ModiseMLMusondaJMSikwese-MusondaJ, et al.Cervical cancer screening in women living with HIV attending primary care clinics in a health district, South Africa: a descriptive cross-sectional study. Pan Afr Med J2022; 43(1): 32.
19.
TchoungaBBoniSPKoffiJJ, et al.Cervical cancer screening uptake and correlates among HIV-infected women: a cross-sectional survey in Côte d’Ivoire, West Africa. BMJ Open2019; 9(8): e029882.
20.
MusondaJSSodoPPAyo-YusufO, et al.Cervical cancer screening in a population of black South African women with high HIV prevalence: a cross-sectional study. PLOS Glob Public Health2022; 2(11): e0001249.
21.
YangLBoilyMRönnMM, et al.Regional and country-level trends in cervical cancer screening coverage in sub-Saharan Africa: a systematic analysis of population-based surveys (2000–2020). PLoS Med2023; 20(1): e1004143.
22.
AcharyaKBhattaraiNDahalR, et al.Examining the availability and readiness of health facilities to provide cervical cancer screening services in Nepal: a cross-sectional study using data from the Nepal health facility survey. BMJ Open2024; 14(7): e077537.
23.
KiconcoAKabandaRRonaldA, et al.Correlates of intention to screen for cervical cancer among adult women in Kyotera District, Central Uganda: a community based cross-sectional study. BMC Wom Health2024; 24(1): 296.
24.
RahmanMMRahmanMSIslamMR, et al.Regional variations and inequalities in testing for early detection of breast and cervical cancer: evidence from a nationally representative survey in India. J Epidemiol. 2024; 37(1): JE20240065.
25.
NkurunzizaCGhebreRMagriplesU, et al.Healthcare provider challenges to early detection of cervical cancer at primary healthcare level in Rwanda. Gynecol Oncol Rep2021; 37: 100810.
26.
Asangbeh-KermanSLDavidovićMTaghaviK, et al.Cervical cancer prevention in countries with the highest HIV prevalence: a review of policies. BMC Publ Health2022; 22(1): 1530.
27.
ChinRJSangmaneeDPiergalliniL. PEPFAR funding and reduction in HIV infection rates in 12 focus sub-Saharan African countries: a quantitative analysis. Int J MCH AIDS2015; 3(2): 150–158.
28.
ChipantaDKapambweSNyondo-MipandoAL, et al.Socioeconomic inequalities in cervical precancer screening among women in Ethiopia, Malawi, Rwanda, Tanzania, Zambia and Zimbabwe: analysis of population-based HIV impact assessment surveys. BMJ Open2023; 13(6): e067948.
29.
TaghaviKMandiririAShamuT, et al.Cervical cancer screening cascade for women living with HIV: a cohort study from Zimbabwe. PLOS Glob Public Health2022; 2(2): e0000156.
30.
ChirwaGC. Explaining socioeconomic inequality in cervical cancer screening uptake in Malawi. BMC Publ Health2022; 22(1): 1376.
31.
BrobergGWangJÖstbergA, et al.Socio-economic and demographic determinants affecting participation in the Swedish cervical screening program: a population-based case-control study. PLoS One2018; 13(1): e0190171.
32.
GroverSBhatiaRFriebel-KlingnerTM, et al.Cervical cancer screening in HIV-endemic countries: an urgent call for guideline change. Cancer Treat Res Commun2023; 34: 100682.
33.
Asangbeh‐KermanSLDavidovićMTaghaviK, et al.Cervical cancer prevention and care in HIV clinics across sub‐Saharan Africa: results of a facility‐based survey. J Int AIDS Soc2024; 27(7): e26303.
