Uptake of cervical screening and prevalence of abnormal cervical lesions among HIV infected women in an urban HIV care setting in Uganda
Background: Cervical cancer is the second commonest cancer in women worldwide and the commonest cancer among women in Uganda. Annual cervical screening is recommended for women living with HIV for early detection of abnormal cervical changes. Mildmay Uganda integrated free cervical screening into routine HIV care in July of 2009; Visual Inspection under acetic acid (VIA) is used. However, uptake, factors associated with uptake of cervical screening and disease detection among the screened has not been widely investigated among HIV infected women in HIV care in Uganda. This study aimed at assessing uptake, factors associated with cervical screening uptake as well as prevalence of abnormal cervical lesions among HIV infected women at Mildmay Uganda. Methods: A retrospective review of all health care records of women aged ≥25 years receiving HIV care services at Mildmay Uganda between July 2009 and December 2012 was done. Correlates of cervical screening uptake were determined using logistic regression to obtain ORs as measures of association with their 95% confidence intervals. Eighteen (18) in-depth interviews and 6 Key informant interviews were conducted to assess client and service provider/facility factors that affect cervical screening uptake. All qualitative data were analyzed using content analysis method. Results: By December 2012, 3183/6823 (46.7%) had screened at least once. Of all those that were eligible for repeat screening, 620/1538 (40%) had had at least one repeat screening and 439/620(71%) had their repeat screening in 2012. Adherence to annual screening schedules was low with 9%, 1.3% and 0.5% being on schedule for the 1st 2nd and 3rd repeat screening. Of all the women who screened for the first time, 14.7% had abnormal lesions; cervicitis was the commonest at 6.2% followed by uncomplicated lesions at 4.7% and then complicated/extensive lesions at 2.4%. Seven percent (7.2%) of all the VIAs were positive and 35% of all positive VIAs were complicated lesions. The likelihood to take up cervical screening increased with receipt of general prevention education including cervical screening (Adjusted OR 2.86, 95% CI 1.85-4.41, p value < 0.0001) and duration in care of more than 4 years compared to those who had been in care for less than a year (Adjusted OR 1.71, 95% CI 1.30-2.24, p value <0.0001). However, absence of individualized counseling by a counselor was associated with reduced likelihood of cervical screening (Adjusted OR 0.69, 95% CI 0.55-0.87, p value 0.002). The following factors negatively impacted on uptake of cervical screening: Myths and misconceptions, fear of pain associated with cervical screening, fear of undressing and the need for women to preserve their privacy, low perceived cervical cancer risk stemming mostly from inadequate health education, shortage of health workers to routinely provide cervical cancer education and screening, and competing priorities for both provider time and patient time. Motivators of cervical cancer screening included the need for comprehensive assessment and management of all ailments to ensure good health, fear of consequences associated with cervical cancer, suspicion of being at risk and the desire to maintain a good relationship with health care workers Conclusion: Despite integration of free cervical screening, overall cervical screening and especially adherence to annual cervical screening among HIV infected women at Mildmay Uganda remains low. Yet, the prevalence of abnormal cervical lesions among those screened is high. These findings highlight the need for a proactive client-centered counseling and support to overcome fears and misconceptions, and to innovatively address the human resource barriers to uptake of cervical cancer screening.