Introduction

Recommendations for cervical cancer screening initiation in HIV-positive women varies internationally with little published data available. In March 2018, the Namibian Ministry of Health and Social Services finalized cervical cancer prevention guidelines setting first screening for HIV-positive women at age 20 years because of high HIV prevalence (15.7%) and average age of 16 years at sexual debut. Analysis of program data compared visual inspection with ascetic acid (VIA)-positivity at age of first screening by HIV status to inform and strengthen screening practices.

Methods

Program data from the first 8 months (October 2018–June 2019) of VIA and cryotherapy implementation in Namibia’s Khomas region compared rates of VIA-positivity by age at self-reported first ever screening, lesion severity, and HIV status. Chi-square tests examined the significance of differences in VIA-positivity and lesion severity percentages by HIV status, and compilation of age-stratified cryotherapy treatment and large loop excision of the transformation zone (LLETZ) referral data compared percentages by HIV status.

Results

Of 1,102 women screened, 287 (26%) were HIV-positive. Overall, 161 (15%) had pre-cancer lesions, 52 of whom were HIV-positive (18% VIA-positivity). [Table 1]. VIA-positivity in ages 20-24 years was 40% in HIV-positive compared to 15% in HIV-negative women. The proportion of HIV-positives with VIA-positivity was significantly higher (18% and 13%, p=0.04) and the proportion of HIV-positives with large lesions ineligible for cryotherapy was higher, although not significant (31% and 21%, p=0.08). [Tables 1, 3]. Completion of cryotherapy treatment was 80%. [Table 2].

Conclusions

Young HIV-positive women in Namibia had high VIA-positivity. Age stratified cancer incidence data could distinguish Human Papillomavirus infections likely to self-clear from true pre-cancer lesions in young women. Additionally, cost-benefit analysis of potential overtreatment and cancer cases averted in young women could guide resource allocation. Treatment completion rates are high in Namibia despite inadequate human resources and carbon dioxide supply chain challenges.

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Introduction

Women in Namibia experience geographic and other barriers in accessing cervical cancer screening and treatment services. In 2018, the Ministry of Health and Social Services introduced a screen and treat approach with visual inspection with acetic acid and cryotherapy (VIAC). Namibia has high HIV prevalence (15.7% among women aged 15–64 years) and increasing cervical cancer mortality rates. A review of the literature found no studies in Namibia, or generally, comparing treatment rates in women with cervical pre-cancer lesions stratified by HIV status. To address this gap, we compared cryotherapy completion rates in HIV-positive and HIV-negative women who screen VIA-positive in Namibia.

Methods

Routine program data from the first 8 months (October 2018-June 2019) of Namibia’s VIAC implementation in the Khomas region at CDC-funded facilities were used to analyze cryotherapy completion rates and large loop excision of the transformation zone (LLETZ) referral between HIV-positive and HIV-negative women. A chi-square test was performed to examine whether the difference in the cryotherapy completion percentages between HIV-positive and HIV-negative women was significant.

Results

More HIV-positive women (86%) completed cryotherapy than HIV-negative women (75%) across age groups (Table 1), however the relationship was not statistically significant (p=.0581) (Table 2). All women screened ineligible for cryotherapy were referred for LLETZ treatment, however, LLETZ completion data are not available at this time.

Conclusions

HIV-positive women with cervical pre-cancer lesions in Namibia were not significantly more likely to complete cryotherapy treatment. Further analyses with a larger and more diverse samples from other regions in Namibia are needed to confirm these findings. Additional data are needed to identify strategies to improve cryotherapy treatment completion rates among all eligible women. Specific areas for further exploration include comparing women’s comfort level with healthcare system interactions, readiness to accept medical diagnoses, and healthcare worker engagement and prioritization of HIV-positive women.