Early cervical lesions detected by visual inspection : viral factors, management and follow-up

Abstract

Currently 80% of cervical cancer cases worldwide arise in low income countries. In Uganda, the age standardized incidence rate of cervical cancer is estimated at 40.7 per 100,000 women. Public health policies, logistical, socio-political-cultural factors and other inequities limit the delivery of services for cervical cancer prevention. This thesis presents data on biological factors and service delivery issues that may affect cervical cancer control.

Article I: A qualitative study using focus group discussions (FGDs) explored factors that influence the usage of reproductive health care services with an emphasis on cervical cancer. Barriers identified included: a lack of knowledge and misconceptions about cervical cancer, cultural constructs about the illness, economic factors, patriarchal domestic gender power relations, alternative authoritative sources of reproductive health knowledge, and unfriendly health care services.

Article II: An open interventional study with 2 arms, to evaluate the efficacy of male partner involvement in reducing the loss to follow-up among women referred for colposcopy after a positive cervical cancer-screening test. A total of 5,094 women were screened in two family planning/postnatal clinics at Mulago Hospital, Kampala, Uganda. 824 screened positive and were referred for colposcopy, half were allocated to the intervention group and half to the control group. In the intervention group, information about the screening findings and a request to assist their partner in attending the next examination were sent to the male partners. In the control group, a standard service was provided, which did not include a letter to the male partner. Women in the intervention group were more than twice as likely to return for colposcopy (odds ratio, OR 2.8, 95% confidence interval, CI 1.9 3.9).

Article III: We estimated the prevalence of cervical abnormalities detectable by visual inspection and cervical lesions diagnosed by colposcopy according to Human Immunodeficiency Virus (HIV) serostatus and described the outcomes of cryotherapy treatment. In a "see and treat" cervical prevention strategy, trained nurses screened women for cervical cancer using visual inspection with acetic acid (VIA) and visual inspection with Lugol's iodine (VILI). Women with abnormal visual inspection findings were referred for colposcopic evaluation and HIV testing. Women with premalignant cervical lesions detected at colposcopy were treated mainly by cryotherapy, and were evaluated for treatment outcome after 3 months by a second colposcopy. The colposcopy diagnosed abnormal cervical lesions in 27% of women who returned.HIV seropositivity was associated with a higher likelihood of cervical lesions especially inflammation (Risk Ratio, RR=1.7, 95% CI 1.2-2.4) and low grade squamous intraepithelial lesions (LGSIL) (RR= 2.6, 95% CI 1.0-6.7).

Article IV: From 625 women who underwent colposcopic evaluation, information on social demographic characteristics was collected. They were tested for HIV testing and HPV typing was performed using SPF10/LiPA. The overall prevalence of HPV infection was 39.4 %. The most common HPV types in decreasing order of frequency were: HPV16, HPV52, HPV35, and HPV18. An age of less than 40 years, low income status and infection with HIV were statistically significant risk factors for any HPV infection.

Conclusions: The work in this thesis identified potential barriers for the successful implementation of cervical cancer programs in Uganda, proposed some practical solutions that may improve cervical cancer screening uptake and added to the body of knowledge about the distribution of HPV types that may be relevant to the development of second generation HPV vaccines.