Awareness, perceived risk and practices related to cervical cancer and pap smear screening among HIV-positive women in an urban HIV clinic in Johannesburg, South Africa
Background and objectives: Cervical cancer is a major cause of cancer-related deaths in many developing countries yet it is a preventable and treatable in early disease. Recent research has seen increasing morbidity and mortality due to cancer of the cervix attributed to the advent of the human immunodeficiency virus (HIV) epidemic worldwide. Papanicolaou smears (Pap smears) to detect cervical abnormalities are currently the best known form of early detection and prevention of invasive cervical cancer (ICC). Knowledge and awareness about cervical cancer and associated risk factors, and cervical screening is very important in determining appropriate health seeking behaviours with the aim to reduce morbidity and mortality. This study examines awareness, perceived risk and practices related to cervical cancer screening among HIV-positive women in an urban HIV clinic in Johannesburg, South Africa. This will be useful in making recommendations with regards to designing and planning of screening programmes, and addressing cervical cancer education and awareness. Materials and methods: This study analysed secondary data collected from an ongoing cervical cancer study undertaken by Right to Care in partnership with the Clinical HIV Research Unit (CHRU) among HIV-positive adult (18 years and older), female patients enrolled in the Themba Lethu Clinic HIV care and treatment programme in Johannesburg, South Africa from November 2009 to December 2012. Clinical data for all respondents was extracted from TherapyEdge-HIVTM, the electronic medical database system used for patient management at the facility. Descriptive statistics were used to summarise baseline characteristics. Models using logistic regression were developed to estimate odds ratios (OR) to further identify baseline sociodemographic factors and clinical characteristics associated with behaviours studied (awareness, perceived risk and practice related to cervical cancer and Pap smear testing) and to identify the association between these factors and the prevalence and severity of cervical disease. Awareness of the Pap smear test and the human papillomavirus (HPV) was assessed based on whether the women report knowing what a Pap smear test is, and whether they have ever heard about HPV. Perceived risk about getting cervical cancer was assessed based on how worried the study participants were about getting cervical cancer. Previous Pap screening practice was assessed using reported screening history of the study participants. In addition to this, a subanalysis was conducted to see how these responses compare to 1) the recommended practice according to the South African national cervical cancer screening guidelines based on the age of participants, and 2) the latest HIV treatment guidelines based on year of HIV diagnosis. Analysis of attrition of study participants at 12 months of study participation was conducted using different time to event analysis techniques including Kaplan Meier, Log-rank test and Cox proportional hazards model. Cox proportional hazards models were fitted to investigate associations between baseline covariate and attrition. A sub-analysis was also carried out using descriptive statistics and chi-square tests to compare the cohort of patients that were included in the study (the VICAR1 cohort) and the rest of the larger Themba Lethu Clinic (TLC) population that was not included in the study to see if there were any significant differences noted between the two groups. In addition, a sensitivity analysis of the of 12 month follow up study visit was conducted using descriptive statistics and chi-square tests to determine if there were any significant differences between study participants that came for their 12 month study visit and those that did not come for their 12 month study visit. Results: Eight hundred and fifty seven (71.30%) participants reported to be aware of Pap smear screening, with only 18.15% reporting to be aware of HPV. Of the 1192 participant who had data to ascertain perceived risk regarding cervical cancer disease, 662 (55.54%) of the women were very worried, 250 (20.97%) were somewhat worried, 280 (23.49%) were not worried about getting cervical cancer. A total of 381 (36.46%) women had adequate practice according to the national cervical cancer screening guidelines. While 304 (28.57%) had adequate practice according to the national HIV treatment guidelines. Factors associated with Pap smear screening awareness were being in the 50+ age group (aOR=4.70, 95% CI 1.63-13.55) as compared to the 18-29 age group, being of non-South African nationality (aOR=0.41, 95% CI 0.20-0.83), having a grade 10 to matric level education (aOR=2.12, 95%CI 1.28-3.52), and a tertiary level education (aOR=2.62, 95%CI 1.07-6.41) as compared to having a less than a grade 10 level education. None of the factors assessed were found to be significantly associated with awareness regarding HPV. Factors associated with perceived risk regarding cervical cancer disease were having a tertiary education (aOR=3.74, 95%CI 1.13-12.38) as compared to having less than a grade 10 level, taking snuff (aOR=0.55, 95%CI 0.33-0.92) and drinking alcohol (aOR=2.53, 95% CI 1.24- 5.17). Being in the 30-39 age group (aOR=12.23, 95%CI 4.00-37.35) as compared to being in 18-29 age group, cohabiting with a partner (aOR=0.36, 95%CI 0.17-0.75) as compared to being single, being self-employed (aOR=2.95, 95%CI 0.82-10.66) as compared to those in full time employment, and being initiated on highly active antiretroviral therapy (aOR=0.17, 95%CI 0.06-0.55) were associated with Pap smear screening practices according to the national cervical cancer guidelines. None of the factors proved to be significantly associated with the practice according to the national HIV treatment guidelines, this is mainly because the HIV treatment guidelines have stricter screening requirements for HIV positive women. Those that had a moderate to severe baseline study Pap smear at enrolment into the study were 92% less likely to have disease progression at their 12 month Pap smear screening (aOR=0.08, 95%CI 0.05-0.13) compared to those that had a negative baseline Pap smear at study enrolment. This is mostly because they would have had a treatment intervention based on their baseline study Pap screening result therefore they would mostly likely not have disease progression at a follow up screening. Only seven women enrolled in the study died of non-cervical cancer related causes during the study period. In the analysis on all-cause attrition (deceased or lost to follow up) those that are initiated on highly active antiretroviral therapy were 92% less likely to be deceased or lost to follow up than those that were not initiated on highly active antiretroviral therapy (aOR=0.08, 95% CI 0.05-0.13). The global test for the overall model showed that the proportional hazard assumption had not been violated, p=0.684. Conclusions: Results for our study showed high levels of Pap smear screening awareness amongst the study participants. However, low levels of Pap screening uptake was observed for study participants. These results and results shown in previous studies show that awareness is only the first hurdle in the challenges related to cervical cancer prevention and treatment. Adequate practice is the factor that will have the most positive influence on the disease morbidity and mortality. Rates of screening practices have been found to be worse in populations with less than 70% Pap smear screening awareness. Findings from this study and similar findings from other studies highlight that more research needs to be done into effective health education programmes to address the gaps in adequate screening practice. These efforts should not only target the clients but also the health providers as they also have an important role to play in improving awareness, knowledge and practices related to cervical cancer and Pap smear screening amongst their clients.
Wits School of Public Health May 2015