HPV self‐sampling acceptability and preferences among women living with HIV in Botswana

Objective: To assess the acceptability and preferences of HPV screening with self- sampling and mobile phone results delivery among women living with HIV (WLWH) in Botswana, as an alternative to traditional speculum screening.Methods: WLWH aged 25 years or older attending an infectious disease clinic in Gaborone were enrolled in a cross- sectional study between March and April 2017.Women self- sampled with a flocked swab, had a speculum exam, and completed an interviewer- administered questionnaire about screening acceptability, experiences,and preferences.Results: Of the 104 WLWH recruited, 98 (94%) had a history of traditional screening. Over 90% agreed self- sampling was easy and comfortable. Ninety- five percent were willing to self- sample again; however, only 19% preferred self- sampling over speculumexam for future screening. Preferences differed by education and residence with self- sampling being considered more convenient, easier, less embarrassing, and less painful. Speculum exams were preferred because of trust in providers’ skills and women's low self- efficacy to sample correctly. Almost half (47%) preferred to receive results via mobile phone call. Knowledge of cervical cancer did not affect preferences.Conclusion: HPV self- sampling is acceptable among WLWH in Botswana; however, preferences vary. Although self- sampling is an important alternative to traditional speculum screening, education and support will be critical to address women's low self- efficacy to self- sample correctly

Performance of vaginal self-sampling for human papillomavirus testing among women living with HIV in Botswana

In Botswana, where human immunodeficiency virus (HIV) prevalence remains high, cervical cancer is the leading cause of cancer deaths in women. Multiple organizations recommend high-risk human papillomavirus (hr-HPV) testing as a screening tool; however, high coverage may not be feasible with provider-collected samples. We conducted the first assessment of self- versus provider-collected samples for hr-HPV testing in HIV-positive women in Botswana and report prevalence of hr-HPV and histological outcomes. We recruited HIV-positive women ≥25 years attending an HIV clinic in Gaborone. Self- and provider-collected samples from participants were tested for hr-HPV using Cepheid GeneXpert. Women testing positive for any hr-HPV returned for colposcopy. We used unweighted κ statistics to determine hr-HPV agreement. We report that 31 (30%) of 103 women tested positive for any hr-HPV. The most common genotypes were HPV 31/33/35/52/58. Overall agreement between self- and provider-collected samples for any hr-HPV was 92% with a κ of 0.80. Ten of the 30 hr-HPV-positive women attending colposcopy had CIN2+ (33%). In conclusion, in this HIV-positive population, there was excellent agreement between self and provider samples, and self-sampling may play an important role in screening programs in high HIV burden settings with limited resources like Botswana

Cervical cancer screening in HIV-endemic countries: An urgent call for guideline change

Women living with HIV (WLWH) are at an increased risk of developing HPV-related high grade cervical dysplasia and cervical cancer. Prior World Health Organization (WHO) screening guidelines recommended starting screening at age 30. We assessed characteristics of women diagnosed with cervical cancer to further inform and refine screening guidelines. We prospectively enrolled women diagnosed with cervical cancer from January 2015 to March 2020 at two tertiary hospitals in Gaborone, Botswana. We performed chi-square and ANOVA analyses to evaluate the association between age upon diagnosis and HIV status, CD4 count, viral load, and other sociodemographic and clinical factors. Data were available for 1130 women who were diagnosed with cervical cancer and 69.3% were WLWH. The median age overall was 47.9 (IQR 41.2–59.1), 44.6 IQR: 39.8 – 50.9) among WLWH, and 61.2 (IQR 48.6–69.3) among women living without HIV. There were 1.3% of women aged <30 years old, 19.1% were 30–39 and 37.2% were 40–49. Overall, 20.4% (n = 231) of cancers were in women <40 years. Age of cervical cancer diagnosis is younger in countries with higher HIV prevalence, like Botswana. Approximately 20% of the patients presented with cancer at <40 years of age and would have likely benefited from screening 10 years prior to cancer diagnosis to provide an opportunity for detection and treatment of pre-invasive disease

Vulvar cancer in Botswana in women with and without HIV infection: patterns of treatment and survival outcomes

ObjectivesVulvar cancer is a rare gynecological malignancy. However, the incidence of human papillomavirus (HPV)-associated vulvar disease is increasing, particularly in low- and middle-income countries. HIV infection is associated with an increased risk of HPV-associated vulvar cancer. We evaluated treatment patterns and survival outcomes in a cohort of vulvar cancer patients in Botswana. The primary objective of this study was to determine overall survival and the impact of treatment modality, stage, and HIV status on overall survival.MethodsWomen with vulvar cancer who presented to oncology care in Botswana from January 2015 through August 2019 were prospectively enrolled in this observational cohort study. Demographics, clinical characteristics, treatment, and survival data were collected. Factors associated with survival including age, HIV status, stage, and treatment were evaluated.ResultsOur cohort included 120 women with vulvar cancer. Median age was 42 (IQR 38-47) years. The majority of patients were living with HIV (89%, n=107) that was well-controlled on antiretroviral treatment. Among women with HIV, 54.2% (n=58) were early stage (FIGO stage I/II). In those without HIV, 46.2% (n=6) were early stage (stage I/II). Of the 95 (79%) patients who received treatment, 20.8% (n=25) received surgery, 67.5% (n=81) received radiation therapy, and 24.2% (n=29) received chemotherapy, either alone or in combination. Median follow-up time of all patients was 24.7 (IQR 14.2-39.1) months and 2- year overall survival for all patients was 74%. Multivariate analysis demonstrated improved survival for those who received surgery (HR 0.26; 95% CI 0.08 to 0.86) and poor survival was associated with advanced stage (HR 2.56; 95% CI 1.30 to 5.02). Survival was not associated with HIV status.ConclusionsThe majority of women with vulvar cancer in Botswana are young and living with HIV infection. Just under half of patients present with advanced stage, which was associated with worse survival. Improved survival was seen for those who received surgery

Benchmarking of the Cervical Cancer Care Cascade and Survival Outcomes After Radiation Treatment in a Low- and Middle-Income Country Setting

Delays in care for patients with cervical cancer in Botswana can be benchmarked using a multidisciplinary clinic model

Stage and outcomes of invasive cervical cancer patients in Botswana: A prospective cohort study from 2013 to 2020

ObjectiveTo present the stage distribution, patterns of care, and outcomes of patients from Botswana with invasive cervical cancer, living with or without HIV.MethodsBetween 2013 and 2020, women with cervical cancer were prospectively enrolled in an observational cohort study.ResultsA total of 1,043 patients were enrolled; 69% were women living with HIV. The median age of the cohort was 47&nbsp;years (interquartile range [IQR] 40-58 years), with women living with HIV presenting at a younger age compared to women without HIV (44 versus 61 years, p&nbsp;&lt;&nbsp;0.001). Among women living with HIV, the median CD4 count at the time of cancer diagnosis was 429.5 cells/μL (IQR 240-619.5 cells/μL), 13% had a detectable viral load, and 95% were on antiretroviral therapy. In regard to treatment, 6% (n&nbsp;=&nbsp;58) underwent surgery, 33% (n&nbsp;=&nbsp;341) received radiation therapy, 51% (n&nbsp;=&nbsp;531) received chemoradiation, and 7% (n&nbsp;=&nbsp;76) did not receive treatment. Stage distribution in the cohort was as follows: I 17% (n&nbsp;=&nbsp;173), II 37% (n&nbsp;=&nbsp;388), III 35% (n&nbsp;=&nbsp;368), and IV 8% (n&nbsp;=&nbsp;88). For all patients, 2-year OS was 67%. In multivariable Cox regression, worse OS was associated with stage: II (HR 1.91, p&nbsp;=&nbsp;0.007), III (HR 3.99, p&nbsp;&lt;&nbsp;0.001), and IV (HR 5.06, p&nbsp;&lt;&nbsp;0.001) compared to stage I. Improved OS was associated with hemoglobin&nbsp;&gt;&nbsp;10&nbsp;g/dL (HR 0.51, p&nbsp;&lt;&nbsp;0.001) compared to Hb&nbsp;≤&nbsp;10&nbsp;g/dL.ConclusionsAmong women in Botswana with cervical cancer, most patients presented with stage II or III disease warranting radiation therapy or chemoradiation. While two-thirds of cervical cancer patients were women living with HIV, HIV did not impact OS