The epidemiology and knowledge of cervical cancer in Zimbabwe

Abstract

Background: Chronic and persistent infection with human papillomavirus (HPV) is the most important factor associated with the development of cervical cancer. Cervical cancer deaths have been on the rise in recent years with 85% of about 270 000 annual deaths occurring in developing countries. The rise in cervical cancer trends in the past two decades has coincided with the human immunodeficiency virus (HIV) epidemic especially in the sub-Saharan African region. With the advent of HIV especially among young people in most of these developing countries, the incidence, morbidity and burden of cervical cancer are likely to continue increasing. Although cervical cancer prevention/screening and treatment is available in most developing countries, challenges and constraints still exist when it comes to HIV-positive women. Most developing countries, Zimbabwe included, do not have adequate infrastructure, funds, human resources, proper guidelines, and policies, which facilitate the adoption of effective prevention and treatment methods for cervical cancer among HIV-positive women. Therefore, the first part of this study involved two systematic reviews to weigh current evidence on screening and treatment of cervical cancer in HIV-seropositive women. In addition to the burden in HIVpositive women, the rise in HIV-incidence and risky sexual behaviour (multiple sexual partners, early sexual debut and use of contraceptives) among young people (15 to 24 years old), pose as barriers to successful establishment and implementation of cervical cancer control initiatives. In Zimbabwe, there is underutilisation of available cervical cancer services (although some are expensive) due to lack of knowledge and information about cervical cancer, a patriarchal and conservative society that views cervical cancer as a women’s issue. Adding to these issues, Zimbabwe does not have a cancer communication strategy that focuses on cancer risks factors as a cancer primary prevention. The National Cancer Prevention and Control Strategy for Zimbabwe (2014-2018) highlighted that underfunding has resulted in health education on cervical cancer to be unstructured. Therefore, as Zimbabwe sets out to strengthen cervical cancer prevention with the launch of the National Mass HPV Vaccination drive in May 2018, a number of questions still exists; how can a culturally patriarchal society aid and accept vaccination freely? How can young boys, men and the rest of the community be integrated within cervical cancer prevention programmes? Are there opportunities for HIV-positive women in these initiatives? How can the issue of health inequity which is associated with cervical cancer incidence be addressed? Aim: This PhD study weighed current evidence on screening and treatment of cervical cancer in HIV-seropositive women in developing countries through two systematic reviews; and assessed the knowledge, attitude and practices of young people towards cervical cancer, prevention/screening, HPV and vaccination. Methods: The research design was an integrative approach, which utilised a combination of two systematic reviews and a cross-sectional survey. The two systematic reviews explored cervical cancer prevention and treatment modalities for HIV-positive women, whilst the crosssectional survey assessed young people’s knowledge, attitude and practices concerning cervical cancer. Study participants for the cross-sectional survey were recruited through a three-stage cluster design from high schools and universities in Zimbabwe. Knowledge, attitudes and practices were assessed using questions based and adapted from the concepts of the Health Belief Model (HBM) and the Cervical Cancer Measuring tool kit-United Kingdom (UK). Results: The study found that HPV Deoxyribonucleic acid/Messenger RNA (DNA/mRNA) testing (n=16, 64.0%), visual inspection with acetic acid (VIA) (n=13, 52.0%) and Pap smear (n=11, 44.0%) are the mostly used cervical cancer screening methods. HPV testing has a better accuracy/efficiency than other methods with a sensitivity of between 80.0-97.0% and specificity of 51.0-78.0%. In addition, the study found that sequential screening using VIA or visual inspection with Lugol’s iodine (VILI) and HPV testing has shown better clinical performance in screening HIV-seropositive women. Whilst radiation, chemotherapy, chemoradiation, and surgery have shown the possibility of effectiveness among HIVseropositive women, cervical cancer stage, immunosuppressive level, and multisystem toxicities due to treatment are associated with treatment completion, prognosis and survival outcomes. Those infected with HIV are of a younger age and have more advanced cervical cancer as compared to those who are HIV-negative. The majority of young people, 87.47% (656/750), claimed to know what cervical cancer is. However, only 43.14% (324/751) had ever heard of cervical cancer prevention/screening and 53% (398/751) did not know about HPVhow it is transmitted or prevented. Misconceptions regarding cervical cancer causes exist, with some young people attributing cervical cancer to use of detergents, certain foodstuffs and having sex with an uncircumcised man. Conclusion and Recommendations: This research not only reports on the current screening and treatment modalities for cervical cancer among HIV-positive women, but it also offers a lens through which government can generate behavioural changes around cervical cancer among young people. Although cervical cancer screening exists in almost all developing countries, what is missing is both opportunistic and systematic organized population-based screening. Cervical cancer screening programmes need to be integrated into already existing HIV services, to enable early detection and treatment. The study suggests a need to offer opportunistic and coordinated screening programmes that are provider-initiated to young women (from 15 years), especially those who are HIV-infected, to promote early identification of cervical precancerous lesions. Opportunities to include young boys and HIV-positive middle-aged women in the recently launched mass HPV vaccination programmes exist and can be utilised. Ring-fencing budgets or introducing cancer levies and investing resources in evidence-based screen and treat strategies for precancerous lesions in HIV-seropositive women and young people will reduce morbidity and mortality due to cervical cancer. Developing a standard cervical cancer primary prevention tool that can be integrated into schools can be a step towards addressing health inequity. Research on cervical cancer management of HIVseropositive patients focusing on the quality of life of those treated, the effectiveness of the treatment method taking into account CD4+ count and ART is required.