Regional and country-level trends in cervical cancer screening coverage in sub-Saharan Africa: A systematic analysis of population-based surveys (2000–2020)

Abstract

Background Sub-Saharan Africa (SSA) has the highest cervical cancer (CC) burden globally—worsened by its HIV epidemics. In 2020, the World Health Organization (WHO) introduced a CC elimination strategy with goals for vaccination, screening, and treatment. To benchmark progress, we examined temporal trends in screening coverage, percent screened at least twice by the age of 45, screening coverage among women living with HIV (WLHIV), and pre-cancer treatment coverage in SSA. Methods and findings We conducted a systematic analysis of cross-sectional population-based surveys. It included 52 surveys from 28 countries (2000 to 2020) with information on CC screening among women aged 25 to 49 years (N = 151,338 women). We estimated lifetime and past 3-year screening coverage by age, year, country, and HIV serostatus using a Bayesian multilevel model. Post-stratification and imputations were done to obtain aggregate national, regional, and SSA-level estimates. To measure re-screening by age 45, a life table model was developed. Finally, self-reported pre-cancer treatment coverage was pooled across surveys using a Bayesian meta-analysis. Overall, an estimated 14% (95% credible intervals [95% CrI]: 11% to 21%) of women aged 30 to 49 years had ever been screened for CC in 2020, with important regional and country-level differences. In Eastern and Western/Central Africa, regional screening coverages remained constant from 2000 to 2020 and WLHIV had greater odds of being screened compared to women without HIV. In Southern Africa, however, screening coverages increased and WLHIV had equal odds of screening. Notably this region was found to have higher screening coverage in comparison to other African regions. Rescreening rates were high among women who have already been screened; however, it was estimated that only 12% (95% CrI: 10% to 18%) of women had been screened twice or more by age 45 in 2020. Finally, treatment coverage among 4 countries with data was 84% (95% CrI: 70% to 95%). Limitations of our analyses include the paucity of data on screening modality and the few countries that had multiple surveys. Conclusion Overall, CC screening coverage remains sub-optimal and did not improve much over the last 2 decades, outside of Southern Africa. Action is needed to increase screening coverage if CC elimination is to be achieved.

Prevalence of Human Papillomavirus in Different Mucous Membranes in HIV Concordant Couples in Rwanda

“…To note, in our included cohort of WLWH in 2021, 58% had undergone a pap smear test, which is an increase compared to the 27% who had undergone a pap smear in our previously studied cohort at the HIV clinic in 2015 [11]. The current percentage of women living with HIV who had been screened is higher than the one estimated for Rwanda in previous reports [37]. It is currently unknown whether the increase in cervical cancer screening in Rwanda also includes other women than risk patients for cervical cancer.…”

“…The likelihood of being cervical cancer screened is higher in WLWH than in HIVnegative women in East Africa [37]. To note, in our included cohort of WLWH in 2021, 58% had undergone a pap smear test, which is an increase compared to the 27% who had undergone a pap smear in our previously studied cohort at the HIV clinic in 2015 [11].…”

Cervical precancer and cancer incidence among insured women with and without HIV in South Africa

“…As more frequent cervical cancer screening is recommended for WLWH, 27,28 detection bias might have contributed to the higher cervical precancer and cancer rates we found among WLWH compared to women without HIV. We lacked comprehensive data on cervical cancer screening to assess this hypothesis in our study, but a systematic study of population‐based surveys found that the odds of cervical cancer screening were similar in WLWH and women without HIV in Southern Africa 29 …”

Inferring the natural history of HPV from global cancer registries: insights from a multi-country calibration

“…The proportion of women aged 30-49 in Sub-Saharan Africa who had ever received a cervical screen has been estimated at 3-5% (20), although among countries for which survey or other reported data were available, coverage was estimated to be higher, at around 14% (21,22). Across the four countries that had published survey data on precancer treatment, coverage was estimated at around 80% (21). Substantial variation in both the coverage levels and the quality of screening programs has been reported.…”