Invasive cervical cancer and HIV – young women need access to screening

Implementation and operational research: age distribution and determinants of invasive cervical cancer in a "screen-and-treat" program integrated with HIV/AIDS care in Zambia.

Kapambwe S, Sahasrabuddhe VV, Blevins M, Mwanahamuntu MH, Mudenda V, Shepherd BE, Chibwesha CJ, Pfaendler KS, Hicks ML, Vermund SH, Stringer JS, Parham GP. J Acquir Immune Defic Syndr. 2015 Sep 1;70(1):e20-6. doi: 10.1097/QAI.0000000000000685.

Background: Cervical cancer screening efforts linked to HIV/AIDS care programs are being expanded across sub-Saharan Africa. Evidence on the age distribution and determinants of invasive cervical cancer (ICC) cases detected in such programs is limited.

Methods: We analyzed program operations data from the Cervical Cancer Prevention Program in Zambia, the largest public sector programs of its kind in sub-Saharan Africa. We examined age distribution patterns by HIV serostatus of histologically confirmed ICC cases and used multivariable logistic regression to evaluate independent risk factors for ICC among younger (≤35 years) and older (>35 years) women.

Results: Between January 2006 and April 2010, of 48 626 women undergoing screening, 571 (1.2%) were diagnosed with ICC, including 262 (46%) HIV seropositive (median age: 35 years), 131 (23%) HIV seronegative (median age: 40 years), and 178 (31%) of unknown HIV serostatus (median age: 38 years). Among younger (≤35 years) women, being HIV seropositive was associated with a 4-fold higher risk of ICC [adjusted odds ratio = 4.1 (95% confidence interval: 2.8, 5.9)] than being HIV seronegative. The risk of ICC increased with increasing age among HIV-seronegative women and women with unknown HIV serostatus, but among HIV-seropositive women, the risk peaked around age 35 and nonsignificantly declined with increasing ages. Other factors related to ICC included being married (vs. being unmarried/widowed) in both younger and older women, and with having 2+ (vs. ≤1) lifetime sexual partners among younger women.

Conclusions: HIV infection seems to have increased the risk of cervical cancer among younger women in Zambia, pointing to the urgent need for expanding targeted screening interventions.

Abstract access [1] 

Editor’s notes: Increasingly, HIV care services (includes AIDS) are providing platforms for introduction of cervical cancer screening programmes in sub-Saharan Africa. Screening is often also available for HIV-negative women. This analysis of data from a large routine programme gives a useful indication of the rates of identification of invasive cervical cancer (ICC), and describes the burden and distribution of disease; information relevant to future service provision. The association described of ICC with HIV and sexual behaviour is well-known. The findings highlight the importance of ensuring that younger women (especially if known to be HIV-positive) have access to routine screening. A significant part of the burden is borne by older women. HIV status may not always be known or revealed. Important questions remain concerning the cost-benefit of providing screening services and the effect of ART on risk of ICC. In addition, the potential role of human papilloma virus vaccine, which GAVI is currently implementing in demonstration projects in the region, in influencing the risk of ICC in younger women remains to be determined. 

Avoid TB deaths [3]
Cancers [4], HIV [5]
Africa [6]
Zambia [7]
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