Abstract
Introduction:
The sustainability of donor-supported cervical cancer screening for HIV-positive women in underresourced setting is a concern. The authors aimed to determine the willingness of HIV-positive women for out-of-pocket payment for the cancer screening, if necessary.
Methods:
Questionnaires were administered to 400 HIV-positive women at the Adult HIV clinic, University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria.
Results:
In all 11 (2.8%) respondents were aware of Pap smear, but only 1 (9.1%) of them had used it. After cervical cancer screening counseling, 378 (94.5%) respondents were willing to pay for Pap smear, irrespective of the cost. This willingness showed no trend across marital or educational groups. Younger age of respondents was not associated with willingness to pay for Pap smear (odds ratio = 1.24; confidence interval 95%: 0.52, 2.94).
Conclusion:
Willingness to pay for Pap smear by HIV-positive women in Enugu, Nigeria, is high. This has implication for the program sustainability.
Introduction
HIV-positive women have higher risks of developing cervical cancer and its premalignant lesions. 1 Therefore, they require frequent cervical cancer screening usually by Pap smear. In the general population, cervical cancer screening at intervals of 2 to 5 years is recommended, depending on the operational guideline 2,3 ; but for the HIV-positive women, a more frequent screening is recommended thus; Pap smear at the diagnosis of the disease and a repeat screening after 6 months if negative, afterward the woman should continue on a yearly screening for life. 4 Furthermore, cervical cancer screening for this at risk group of women is more important in this era when HIV screening and care have improved remarkably in Nigeria such that many people living with HIV/AIDS access antiretroviral therapy with other support services and are expected to live longer and healthier lives. Likewise, women living with HIV/AIDS are expected to live long enough to develop the human papilloma virus–associated cervical neoplasm. Fortunately, cervical cancer usually takes some time to develop from its screenable premalignant lesions, and the available standard treatment options for the latter are effective in HIV-positive women though recurrence may be higher. 5,6 Therefore, caregivers have ample opportunity to monitor women living with HIV/AIDS so as to identify the cervical lesions early and refer for appropriate treatment. Furthermore, it has been suggested that because of the current improved care for HIV-positive women in our environment, future morbidity and mortality in this group of women may shift to cervical cancer–related diseases if routine cervical cancer screening is not incorporated into the HIV treatment services. To counter this possible negative trend, provider-initiated cervical cancer counseling and testing (PICCT) strategy has been recommended for all outpatient clinics including the adult HIV clinics. 7 In this strategy, all eligible women seeking health care should receive information on cervical cancer and its screening and should be offered (or referred for) cervical cancer screening with an option of opting out. 1
On the other hand, it has been observed that routine cervical cancer screening for HIV-positive women, existing in Nigeria, is captured within the donor-assisted HIV treatment that may end some day. The sustainability of this free program remains a concern; therefore, the need to determine the willingness of HIV-positive women for out-of-pocket payment for cervical cancer screening, if necessary. In addition, the study assessed the level of awareness and use of Pap smear by HIV-positive women in Enugu, southeastern, Nigeria.
Methods
This was a cross-sectional study of 400 HIV-positive women selected from the Adult HIV clinic, University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria, over 3 months’ duration of May to July 2007. Respondents’ selection was by probability sampling using the systematic sampling method. Pretested structured questionnaires were administered to selected respondents by trained medical interns after obtaining informed consents. All HIV-positive women accessing care at the study center were eligible for the study. Exclusion criterion was acute illness that could hamper questionnaire administration. The information sought for included respondents’ sociodemographic characteristics, awareness of cervical cancer and Pap smear, ever used and frequency of Pap smear. Afterward, respondents were informed about cervical cancer and Pap smear (and its cost in the hospital) as well as the protocol for Pap screening in general population and among HIV women. Then, her willingness for out-of-pocket payment for routine Pap smear was sought for.
Statistical Package for Social Sciences (SPSS) computer software version 15.0 for windows was used for data entry and analysis. Respondents’ variables were dichotomized and their associations with the outcome of interest (willingness to pay for Pap smear) were compared using cross tabulation at 95% confidence level. Results were presented using simple percentages, tables, odd ratios (ODs), and confidence intervals (CI).
The sample size (n) was calculated using the formula (n =
The UNTH Enugu, Nigeria, is a teaching hospital owned by the Federal government of Nigeria. It offers primary and specialized health care to residents of Enugu state of Nigeria and its environ. It was one of the few tertiary health centers where organized HIV care started in Nigeria. As at the time of the study, the Adult HIV treatment site of the hospital was supported by Federal government of Nigeria and was the only organized HIV treatment center in the state. In the year preceding the study (2006), the clinic attended to a total of 6,158 HIV-positive women. It held a weekly outpatient clinic where free anti-retroviral drugs were accessed. On the contrary, the cost of Pap smear screening as at the time of the study was 1950 naira only (about US$13).
Enugu state of Nigeria is 1 of the 5 states of the Igbo-speaking south-eastern region of Nigeria. Majority of its 17 local government areas are rural and most residents live below poverty line. 9 As at the time of the study, the population was about 3.6 million with an annual growth rate of 2.28%, 10 and HIV sero-prevalence of 6.5%. 11 The later has reduced to 5.1% according to the 2010 national sentinel survey. 12
For this study, a respondent was adjudged as being aware of Pap smear when she knew that it was used for the prevention of cervical cancer. 7
Results
The mean age of respondents was 35.6 ± 9.7 years (range 16-65). All respondents were diagnosed HIV positive within 9 years prior to the study. Most (76.8%) respondents belong to 21- to 40-year age group. One hundred and six (36.5%) respondents were single. The modal educational and parity groups were secondary education and nulliparity, respectively. Details of respondents’ sociodemographic characteristics are shown in Table 1.
Sociodemographic Characteristics of Respondents.
Sixty-nine (17.3%) women had knowledge of cervical cancer. A majority (82.6%) of this group was not aware of their risk of developing cervical cancer when compared to that of general population, 6 (8.7%) women felt their risks were increased, 1 (1.4%) felt it was reduced, while 5 (7.2%) thought it was the same.
Eleven (2.8%) respondents were aware of Pap smear, but only 1 (9.1%) of this aware group had used it (prescribed in a hospital). Out of this group, 5 respondents (45.5%) got their information on Pap smear from mass media, 4 (36.4%) from hospitals, and 1 (9.1%) respondent each from either seminar or friends.
After receiving information on cervical cancer in relation to HIV sero-positivity and Pap smear, 378 (94.5%) women were willing for out-of-pocket payment for routine Pap smear, irrespective of the cost. An analysis of linear-by-linear association showed that the willingness to pay for Pap smear by respondents showed no trend across age groups (
Relationships Between Respondents’ Variables and Willingness to Pay for Pap Smear.
aSingle, widowed, and divorced.
Seventeen (77.3%) respondents who were not eager to pay for Pap smear gave cost of the screening as their reason, 4 (18.2%) women had no reason, while the remaining 1 (4.5%) felt the government should take care of her health.
Discussion
This study found that most of the women living with HIV belong to 21 to 40 years age group, which is in keeping with the current epidemiology in Nigeria. 13 Also, the pattern of respondents’ educational status in this study, where the lowest prevalence of HIV sero-positivity was among women who had no formal education followed by those with tertiary education, conformed to the pattern reported in the recent antenatal survey. 12 It is also likely that fewer women with no formal education access hospital care in Enugu and Nigeria.
A few studies from the study area had identified low use of Pap smear by women 14 –17 ; so, the poor awareness and use of Pap smear in this study may not be surprising because respondents were members of the larger society and should share their health system, that is, the beliefs about illness causation and practices associated with health. 18 Nevertheless, the fact that over 80% of the respondents were not aware of their risks of developing cervical cancer exposes the level of cervical cancer awareness in our environment and supports the ongoing call to incorporate cervical cancer information and treatment in the management of every eligible woman that attends the outpatient clinics in Nigeria. 7 This call is obviously more important for the adult HIV clinics in our setting, which lacks organized screening program, because of the established association between HIV infection and cervical neoplasia. It may explain the progressively expanding incorporation of cervical cancer screening programs at HIV clinics in Nigeria as part of the comprehensive care of women living with HIV/AIDS. However, the cervical screening for HIV-positive women, where it exists, is captured under the donor-supported free HIV treatment. On the other hand, lack of sponsorship is a major deterrent to the scaling up of cervical cancer screening program in HIV treatment centers in Nigeria. This funding concern therefore raises the issue of program sustainability when the donor support is withdrawn in future.
This study has shown that most HIV-positive women are willing for out-of-pocket payment for cervical cancer screening, irrespective of the cost. However, there was a proviso identified by the study thus, the observed overwhelming willingness was expressed after individualized information on cervical cancer and its association with HIV. It is interesting that the expressed willingness to pay for Pap smear cuts across age, marital, parity, and educational groups. This may be linked to the fact that every woman who attends the HIV treatment center must have received post-HIV test counseling and therefore should be well motivated to live a quality life. This motivation is expected to cut across all sociodemographic groups; it may, therefore, not be surprising that in this study, the information on cervical cancer counseling had similar effect on all categories of study respondents as regard the willingness to pay for cervical cancer screening. An earlier report has suggested that HIV testing counselors be trained to initiate cervical cancer information during post-HIV test counseling. 19 It is hoped that this baseline information on cervical cancer during post-HIV test counseling would be built on by further PICCT at the adult HIV treatment clinics.
Furthermore, this study identified that a small proportion of respondents gave finance as a reason for their inability to pay for Pap smear, which brings to fore the problem of health financing in our environment. Most residents in the study area are poor, 9 so the unwillingness to pay for screening of the disease among a few respondents was expected. People prioritize expenditure based on the scale of preference; it is expected that provision of basic needs such as feeding and housing would be considered first before health screening. There is therefore the need to extend health insurance scheme to the community level so as to minimize the effect of lack of fund on health-seeking behavior. Nevertheless, it is our belief that repeated provider-initiated cervical cancer counseling of women might encourage those who were unwilling to pay for cervical cancer screening due to financial reasons to change their minds.
This study assumed that expressed willingness to pay equates to actual payment for cervical screening that may not be very correct. It will be interesting to test the assumption in HIV treatment centers that do not have funding for free Pap smear services. Nevertheless, the strength of the study lies in the fact that it highlighted the problem of sustainability of donor-funded HIV treatment programs in underresourced settings. It also showed that HIV-positive women are conscious of their health and would be willing to pay for health screening programs that would ensure sustained optimal health status.
In conclusion, the awareness and uptake of Pap smear among HIV-positive women in Enugu, Nigeria, was low and the current situation is not different. Future reduction of donor support for HIV care in Nigeria and the possible introduction of out-of-pocket payment for cervical cancer screening may not affect the uptake of the screening program by informed women. This underscores the need for the ongoing advocacy for provider-initiated counseling for cervical cancer screening.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.