HIV status, age at cervical Cancer screening and cervical cytology outcomes in an opportunistic screening setting in Nigeria: a 10-year Cross sectional data analysis

Abstract

BackgroundInvasive cervical cancer (ICC) is more prevalent in HIV infected women and occurs at younger median age than in HIV negative women. Organized cervical cancer screening (CCS) is presently lacking in Nigeria, and the age at CCS is not known in this population. We sought to examine the age at CCS, the cytology outcomes and whether outcomes differ by HIV infection status in an opportunistic screening setting.MethodsCross-sectional analysis of data on a sample of women who had received a CCS in an opportunistic screening service in Jos, Nigeria over a 10-year time period (2006–2016). We used logistic regression models to estimate the independent effect of patient-reported HIV and age at CCS and odds ratios for abnormal cytology outcomes adjusting for other covariates. We also assessed the correlation between median age at CCS and severity of abnormal cervical cytology outcomes. Statistical analyses were done on STATA version 14, College Station, Texas, USA.ResultsIn a sample of 14,088, the median age at CCS was 37 years (IQR; 30–45). For HIV infected women vs. uninfected women, CCS occurred at earlier ages (35.0 ± 7.4 vs 38.2 ± 10.2 years, p < 0.001). All women, regardless of HIV status, who completed at least 7 or more years of education were 1.27 to 3.51 times more likely to have CCS before age 35 than women with less education. The predictors of an abnormal cervical cytology outcome at CCS were: age at CCS ≥ 35 (aOR = 3.57; 95% CI: 2.74, 4.64), multiparity ≥5 (aOR = 1.27; 95% CI: 1.03, 1.56), and provider-referral (aOR = 1.34; 95% CI: 1.09, 1.64). Irrespective of reported HIV status, we found a positive correlation between median age at CCS and severity of cytology outcome.DiscussionThe age at CCS in women who have utilized cervical cancer screening in the study population is relatively late compared to the recommended age by most guidelines from developed settings. Late age at CCS correlates positively with severity of abnormal cytology outcome irrespective of HIV status. More educated women are more likely to have CCS at early age and less likely to have underlying abnormal cytology outcomes.

HIV and Development of Epithelial Cell Abnormalities in women with prior normal cervical cytology in Nigeria

“…Similarly, women with higher parity ≥3 at rst Pap test with normal cytology were 1.65 times more likely to develop an ECA at follow-up Pap test compared to women with a lower parity. We have previously documented in the same screening population in Jos that cervical cancer screening at age 35 or more, and in women with high parity was associated with higher odd for an underlying abnormal cervical cytology outcome irrespective of HIV status [16]. The ndings of the effect of multiparity on the development of an ECA on subsequent follow up Pap test is corroborated by reports on the cofactors in cervical pre-cancer and progression to invasive cervical cancer that women of parity 3 or more were signi cantly more likely to have pre-cancer compared to nulliparous women.…”

“…The possible explanation for the observed convergence could be related to the documented higher risk of development of ECA with advancing age with longer follow up Pap test. [16] Also, our analysis focused on the age at rst CCS rather than adjusting for change in age at the time of outcome assessment. In future research, data on the age at outcome assessment should be collected and modelled as a time-varying covariate to have a better understanding of the effect of age on development of ECA.…”

“…Since these infections were neither con rmed microbiologically nor classi ed as Bacterial vaginosis, Trichomonas, or Candida, it is likely that reporting bias was not controlled leading to misclassi cation. However, since women with vaginal infection are more likely to have had cervical cancer screening at an early age [16] the odds for an abnormal cervical cytology could be lower at rst Pap test and at follow up Pap particularly if the interval was shorter.…”

“…Also, a cross-sectional analysis of the larger primary sample from which this follow up cohort was derived has been published [16] Fig. 1.…”

Prevalence and Predictors of Cervical Cytological (Pap Smear) Abnormalities Among HIV-infected Women at the HIV Treatment Center of Jos University Teaching Hospital Jos, Nigeria.

“…[2,3] Proven and cost-effective measures for eliminating cervical cancer such as avoidance of risk factors, HPV vaccination, papanicolaou screening( pap smear) and treatment of precancerous lesions exist, but to date have not been widely implemented in regions of the world where the disease burden is highest. [2][3][4][5][6] In Nigeria as in other sub-Saharan African countries there is no organized screening program, and the few services available are only opportunistic with little or no impact. [7][8][9][10][11][12] Development of cervical cancer screening policy and institution of organized screening program targeted at covering ≥ 80% of population at risk is fundamental.…”