Challenges in integrating cervical cancer screening in HIV care clinics in West Africa: a pilot study in Abidjan, Côte d’Ivoire

International audiencen.

Risk factors for cervical intraepithelial neoplasia in HIV-infected women on antiretroviral treatment in Côte d'Ivoire, West Africa.

Facing the dual burden of invasive cervical cancer and HIV in sub-Saharan Africa, the identification of preventable determinants of Cervical Intraepithelial Neoplasia (CIN) in HIV-infected women is of paramount importance.A cervical cancer screening based on visual inspection methods was proposed to HIV-infected women in care in Abidjan, Côte d'Ivoire. Positively screened women were referred for a colposcopy to a gynaecologist who performed directed biopsies.Of the 2,998 HIV-infected women enrolled, 132 (4.4%) CIN of any grade (CIN+) were identified. Women had been followed-up for a median duration of three years [IQR: 1-5] and 76% were on antiretroviral treatment (ART). Their median most recent CD4 count was 452 [IQR: 301-621] cells/mm3. In multivariate analysis, CIN+ was associated with a most recent CD4 count >350 cells/mm3 (OR: 0.3; 95% CI: 0.2-0.6) or ≥200-350 cells/mm3 (OR 0.6; 95% CI 0.4-1.0) (Ref: <200 cells/mm3 CD4) (p<10-4).The presence of CIN+ is less common among HIV-infected women with limited or no immune deficiency. Despite the potential impact of immunological recovery on the reduction of premalignant cervical lesions through the use of ART, cervical cancer prevention, including screening and vaccination remains a priority in West Africa while ART is rolled-out

Cervical cancer screening by visual inspection in Côte d'Ivoire, operational and clinical aspects according to HIV status

<p>Abstract</p> <p>Background</p> <p>Cervical cancer screening is not yet standard of care of women attending HIV care clinics in Africa and presents operational challenges that need to be addressed.</p> <p>Methods</p> <p>A cervical cancer screening program based on visual inspection methods was conducted in clinics providing antiretroviral treatment (ART) in Abidjan, Côte d'Ivoire. An itinerant team of midwives was in charge of proposing cervical cancer screening to all HIV-positive women enrolled in ART clinics as well as to HIV-negative women who were attending the Abidjan national blood donor clinic. Positively screened women were systematically referred to a colposcopic examination. A phone-based tracking procedure was implemented to reach positively screened women who did not attend the medical consultation. The association between HIV status and cervical cancer screening outcomes was estimated using a multivariate logistic model.</p> <p>Results</p> <p>The frequency of positive visual inspection was 9.0% (95% CI 8.0-10.0) in the 2,998 HIV-positive women and 3.9% (95% CI 2.7-5.1) in the 1,047 HIV-negative ones (<it>p </it>< 10^-4). In multivariate analysis, HIV infection was associated with a higher risk of positive visual inspection [OR = 2.28 (95% CI 1.61-3.23)] as well as more extensive lesions involving the endocervical canal [OR = 2.42 (95% CI 1.15-5.08)]. The use of a phone-based tracking procedure enabled a significant reduction of women not attending medical consultation after initial positive screening from 36.5% to 19.8% (<it>p </it>< 10^-4).</p> <p>Conclusion</p> <p>The higher frequency of positive visual inspection among HIV-positive women supports the need to extend cervical cancer screening program to all HIV clinics in West Africa. Women loss to follow-up after being positively screened is a major concern in cervical screening programs but yet, partly amenable to a phone tracking procedure.</p

Main characteristics of HIV-infected women screened for cervical malignancies according to the presence or absence of cervical intraepithelial neoplasia of any grade (CIN+) in Abidjan, Côte d'Ivoire.

<p>*Current or former use of smoked and/or chewed tobacco.</p>†<p>CD4 count (cells/mm3) measured during first clinical follow-up for HIV infection.</p>‡<p>Last known CD4 count (cells/mm3) measured prior or during the cervical cancer screening visit.</p><p>Abbreviations: CIN/ICC Cervical Intraepithelial Neoplasia/Invasive Cervical Cancer ART Antiretroviral Treatment.</p

Determinants of cervical intraepithelial neoplasia of any grade (n = 132) in 2,998 HIV-infected women in Abidjan, Côte d'Ivoire. The IeDEA West Africa collaboration.

∫<p>Comparison of CD4 count (cells/mm³) according to ART duration (median [interquartile range]): ≥1 years: 358 [212–532], ≥2–3 years: 477 [313–650], ≥ 4 years 512 [366–691] (p<10⁻⁴).</p><p>*CD4 count (cells/mm3) measured during first clinical follow-up for HIV infection.</p>†<p>Last known CD4 count (cells/mm3) measured prior or during the cervical cancer screening visit.</p