Browsing by Author "Parham GP"

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Advancing cervical cancer prevention initiatives in resource-constrained settings: insights from the Cervical Cancer Prevention Program in Zambia.
(2011-May) Mwanahamuntu MH; Sahasrabuddhe VV; Kapambwe S; Pfaendler KS; Chibwesha C; Mkumba G; Mudenda V; Hicks ML; Vermund SH; Stringer JS; Parham GP; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Groesbeck Parham and colleagues describe their Cervical Cancer Prevention Program in Zambia, which has provided services to over 58,000 women over the past five years, and share lessons learned from the program's implementation and integration with existing HIV/AIDS programs.
Clinical performance of digital cervicography and cytology for cervical cancer screening in HIV-infected women in Lusaka, Zambia.
(2014-Oct-01) Bateman AC; Parham GP; Sahasrabuddhe VV; Mwanahamuntu MH; Kapambwe S; Katundu K; Nkole T; Mulundika J; Pfaendler KS; Hicks ML; Shibemba A; Vermund SH; Stringer JS; Chibwesha CJ; *Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; †University of North Carolina at Chapel Hill, Chapel Hill, NC; ‡University Teaching Hospital, Lusaka, Zambia; §Vanderbilt University, Nashville, TN; ‖University of Cincinnati, Cincinnati, OH; and ¶Michigan Cancer Institute, Pontiac, MI.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Although there is a growing literature on the clinical performance of visual inspection with acetic acid in HIV-infected women, to the best of our knowledge, none have studied visual inspection with acetic acid enhanced by digital cervicography. We estimated clinical performance of cervicography and cytology to detect cervical intraepithelial neoplasia grade 2 or worse. Sensitivity and specificity of cervicography were 84% [95% confidence interval (CI): 72 to 91) and 58% (95% CI: 52 to 64). At the high-grade squamous intraepithelial lesion or worse cutoff for cytology, sensitivity and specificity were 61% (95% CI: 48 to 72) and 58% (95% CI: 52 to 64). In our study, cervicography seems to be as good as cytology in HIV-infected women.
eC3--a modern telecommunications matrix for cervical cancer prevention in Zambia.
(2010-Jul) Parham GP; Mwanahamuntu MH; Pfaendler KS; Sahasrabuddhe VV; Myung D; Mkumba G; Kapambwe S; Mwanza B; Chibwesha C; Hicks ML; Stringer JS; Center for Infectious Disease Research in Zambia, Lusaka, Zambia. groesbeck.parham@cidrz.org; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
OBJECTIVES: Low physician density, undercapacitated laboratory infrastructures, and limited resources are major limitations to the development and implementation of widely accessible cervical cancer prevention programs in sub-Saharan Africa. MATERIALS AND METHODS: We developed a system operated by nonphysician health providers that used widely available and affordable communication technology to create locally adaptable and sustainable public sector cervical cancer prevention program in Zambia, one of the world's poorest countries. RESULTS: Nurses were trained to perform visual inspection with acetic acid aided by digital cervicography using predefined criteria. Electronic digital images (cervigrams) were reviewed with patients, and distance consultation was sought as necessary. Same-visit cryotherapy or referral for further evaluation by a gynecologist was offered. The Zambian system of "electronic cervical cancer control" bypasses many of the historic barriers to the delivery of preventive health care to women in low-resource environments while facilitating monitoring, evaluation, and continued education of primary health care providers, patient education, and medical records documentation. CONCLUSIONS: The electronic cervical cancer control system uses appropriate technology to bridge the gap between screening and diagnosis, thereby facilitating the conduct of "screen-and-treat" programs. The inherent flexibility of the system lends itself to the integration with future infrastructures using rapid molecular human papillomavirus-based screening approaches and wireless telemedicine communications.
Identification of human papillomaviruses from formalin-fixed, paraffin-embedded pre-cancer and invasive cervical cancer specimens in Zambia: a cross-sectional study.
(2015-Jan-16) Bateman AC; Katundu K; Polepole P; Shibemba A; Mwanahamuntu M; Dittmer DP; Parham GP; Chibwesha CJ; Centre for Infectious Disease Research in Zambia, Plot 5032 Great North Road, Lusaka, Zambia. bateman.allen@gmail.com.; Centre for Infectious Disease Research in Zambia, Plot 5032 Great North Road, Lusaka, Zambia. professorparham@gmail.com.; University of Zambia Teaching Hospital, Lusaka, Zambia. mulindim@gmail.com.; Centre for Infectious Disease Research in Zambia, Plot 5032 Great North Road, Lusaka, Zambia. mulindim@gmail.com.; Department of Obstetrics and Gynecology, UNC School of Medicine, UNC, Chapel Hill, North Carolina, USA. Carla.Chibwesha@cidrz.org.; Department of Obstetrics and Gynecology, UNC School of Medicine, UNC, Chapel Hill, North Carolina, USA. professorparham@gmail.com.; Department of Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. bateman.allen@gmail.com.; Centre for Infectious Disease Research in Zambia, Plot 5032 Great North Road, Lusaka, Zambia. Carla.Chibwesha@cidrz.org.; Centre for Infectious Disease Research in Zambia, Plot 5032 Great North Road, Lusaka, Zambia. Katundu.Katundu@cidrz.org.; University of Zambia Teaching Hospital, Lusaka, Zambia. poleman1981@gmail.com.; University of Zambia Teaching Hospital, Lusaka, Zambia. professorparham@gmail.com.; University of Zambia Teaching Hospital, Lusaka, Zambia. shibemba@yahoo.com.; Program in Global Oncology, UNC Lineberger Comprehensive Cancer Center and School of Medicine, UNC, Chapel Hill, North Carolina, USA. dirk_dittmer@med.unc.edu.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: The most common human papillomavirus (HPV) genotypes isolated from cervical cancer in select African countries are HPV-16, HPV-18, HPV-35, and HPV-45, but the most common genotypes in Zambia are unknown. The overall objective of this study was to assess the potential impact of current HPV vaccines in preventing cervical cancer in Zambia, by determining the combined prevalence of HPV-16 and/or HPV-18 in invasive cervical cancer (ICC) and high-grade pre-cancer [cervical intraepithelial neoplasia 2 or 3 (CIN2/3)] cases. FINDINGS: We compared DNA extraction techniques to determine which assay performs well in the Zambian context, where unbuffered formalin is used to fix specimens. We then tested specimens with the Abbott RealTime High-Risk HPV test to estimate the prevalence of HPV-16/18 in formalin-fixed, paraffin-embedded ICC and CIN2/3 specimens. DNA extraction using heat (without xylene) was more successful than xylene-based extraction. Over 80% of specimens tested using heat extraction and the Abbott RealTime HPV test were positive for HPV. HPV-16 and/or HPV-18 were identified in 65/93 (69.9%) ICC specimens positive for HPV and in 38/65 (58.5%) CIN2/3 specimens positive for HPV. CONCLUSIONS: To our knowledge this is the first report to identify HPV genotypes in cervical cancers in Zambia. A combined HPV-16/18 prevalence of 69.9% in ICC specimens suggests that current vaccines will be highly protective against cervical cancer in Zambia.
Implementation and Operational Research: Age Distribution and Determinants of Invasive Cervical Cancer in a "Screen-and-Treat" Program Integrated With HIV/AIDS Care in Zambia.
(2015-Sep-01) Kapambwe S; Sahasrabuddhe VV; Blevins M; Mwanahamuntu MH; Mudenda V; Shepherd BE; Chibwesha CJ; Pfaendler KS; Hicks ML; Vermund SH; Stringer JS; Parham GP; *Center for Infectious Disease Research in Zambia, Lusaka, Zambia; †University of Zambia, Lusaka, Zambia; ‡Vanderbilt University, Nashville, TN; §University of North Carolina at Chapel Hill, Chapel Hill, NC; ‖University of Cincinnati, Cincinnati, OH; ¶Michigan Cancer Institute, Pontiac, MI.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: Cervical cancer screening efforts linked to HIV/AIDS care programs are being expanded across sub-Saharan Africa. Evidence on the age distribution and determinants of invasive cervical cancer (ICC) cases detected in such programs is limited. METHODS: We analyzed program operations data from the Cervical Cancer Prevention Program in Zambia, the largest public sector programs of its kind in sub-Saharan Africa. We examined age distribution patterns by HIV serostatus of histologically confirmed ICC cases and used multivariable logistic regression to evaluate independent risk factors for ICC among younger (≤35 years) and older (>35 years) women. RESULTS: Between January 2006 and April 2010, of 48,626 women undergoing screening, 571 (1.2%) were diagnosed with ICC, including 262 (46%) HIV seropositive (median age: 35 years), 131 (23%) HIV seronegative (median age: 40 years), and 178 (31%) of unknown HIV serostatus (median age: 38 years). Among younger (≤35 years) women, being HIV seropositive was associated with a 4-fold higher risk of ICC [adjusted odds ratio = 4.1 (95% confidence interval: 2.8, 5.9)] than being HIV seronegative. The risk of ICC increased with increasing age among HIV-seronegative women and women with unknown HIV serostatus, but among HIV-seropositive women, the risk peaked around age 35 and nonsignificantly declined with increasing ages. Other factors related to ICC included being married (vs. being unmarried/widowed) in both younger and older women, and with having 2+ (vs. ≤1) lifetime sexual partners among younger women. CONCLUSIONS: HIV infection seems to have increased the risk of cervical cancer among younger women in Zambia, pointing to the urgent need for expanding targeted screening interventions.
Implementation of 'see-and-treat' cervical cancer prevention services linked to HIV care in Zambia.
(2009-Mar-27) Mwanahamuntu MH; Sahasrabuddhe VV; Pfaendler KS; Mudenda V; Hicks ML; Vermund SH; Stringer JS; Parham GP; University Teaching Hospital, Ministry of Health, Lusaka, Zambia. mulindi.mwanahamuntu@cidrz.org; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Implementation of cervical cancer prevention services for HIV-infected women in Zambia: measuring program effectiveness.
(2010) Parham GP; Mwanahamuntu MH; Sahasrabuddhe VV; Westfall AO; King KE; Chibwesha C; Pfaendler KS; Mkumba G; Mudenda V; Kapambwe S; Vermund SH; Hicks ML; Stringer JS; Chi BH; University of Cincinnati, OH, USA.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia ; University Teaching Hospital, Lusaka, Zambia.; University of Alabama at Birmingham, AL, USA ; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia ; University Teaching Hospital, Lusaka, Zambia.; Vanderbilt University, TN, USA.; Michigan Cancer Institute, MI, USA.; University of Michigan, MI, USA.; University Teaching Hospital, Lusaka, Zambia.; University of Alabama at Birmingham, AL, USA ; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Vanderbilt University, TN, USA ; National Cancer Institute, MD, USA.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: Cervical cancer kills more women in low-income nations than any other malignancy. A variety of research and demonstration efforts have proven the efficacy and effectiveness of low-cost cervical cancer prevention methods but none in routine program implementation settings of the developing world, particularly in HIV-infected women. METHODS: In our public sector cervical cancer prevention program in Zambia, nurses conduct screening using visual inspection with acetic acid aided by digital cervicography. Women with visible lesions are offered same-visit cryotherapy or referred for histologic evaluation and clinical management. We analyzed clinical outcomes and modeled program effectiveness among HIV-infected women by estimating the total number of cervical cancer deaths prevented through screening and treatment. RESULTS: Between 2006 and 2008, 6572 HIV-infected women were screened, 53.6% (3523) had visible lesions, 58.5% (2062) were eligible for cryotherapy and 41.5% (1461) were referred for histologic evaluation. A total of 75% (1095 out of 1462) of patients who were referred for evaluation complied. Pathology results from 65% (715 out of 1095) of women revealed benign abnormalities in 21% (151), cervical intraepithelial neoplasia (CIN) I in 30% (214), CIN 2/3 in 33% (235) and invasive cervical cancer in 16.1% (115, of which 69% were early stage). Using a conditional probability model, we estimated that our program prevented 142 cervical cancer deaths (high/low range: 238-96) among the 6572 HIV-infected women screened, or one cervical cancer death prevented per 46 (corresponding range: 28-68) HIV-infected women screened. CONCLUSION: Our prevention efforts using setting-appropriate human resources and technology have reduced morbidity and mortality from cervical cancer among HIV-infected women in Zambia. Financial support for implementing cervical cancer prevention programs integrated within HIV/AIDS care programs is warranted. Our prevention model can serve as the implementation platform for future low-cost HPV-based screening methods, and our results may provide the basis for comparison of programmatic effectiveness of future prevention efforts.
Minimizing verification bias in cervical cancer screening of HIV-infected women.
(2015-Mar) Bateman AC; Chibwesha CJ; Parham GP; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Department of Obstetrics and Gynecology, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Department of Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. Electronic address: bateman.allen@gmail.com.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Department of Obstetrics and Gynecology, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; University Teaching Hospital, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Approximately one-third of cervical intraepithelial neoplasia 2 and above can be missed by only biopsying quadrants of the cervix with visible lesions by digital cervicography.
Monitoring the performance of "screen-and-treat" cervical cancer prevention programs.
(2014-Jul) Mwanahamuntu MH; Sahasrabuddhe VV; Blevins M; Kapambwe S; Shepherd BE; Chibwesha C; Pfaendler KS; Mkumba G; Vwalika B; Hicks ML; Vermund SH; Stringer JSA; Parham GP; Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, USA.; Center for Infectious Disease Research in Zambia, Lusaka, Zambia.; Michigan Cancer Institute, Pontiac, USA.; Department of Obstetrics and Gynecology, University Teaching Hospital, Lusaka, Zambia.; Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, USA.; Department of Medicine, Vanderbilt University School of Medicine, Nashville, USA.; Department of Obstetrics and Gynecology, University of Cincinnati, Cincinnati, USA.; Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, USA.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Partnering with traditional Chiefs to expand access to cervical cancer prevention services in rural Zambia.
(2019-Mar) Kapambwe S; Mwanahamuntu M; Pinder LF; Chisele S; Chirwa SC; Parham GP; Ministry of Health, Republic of Zambia, Lusaka, Zambia.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Department of Obstetrics and Gynecology, Women and Newborn Hospital, Lusaka, Zambia.; Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
OBJECTIVE: To evaluate how the influence of traditional Chiefs can be leveraged to promote access to cervical cancer prevention services in rural Zambia. METHODS: A retrospective review of outcome data was conducted for all screening outreach events that occurred in Zambian Chiefdoms between October 4, 2015, and October 3, 2016. Members of the health promotion team of the Cervical Cancer Prevention Program in Zambia visited local Chiefs to inform them of the importance of cervical cancer prevention. The local Chiefs then summoned adults living within their Chiefdoms to assemble for cervical cancer prevention health talks. Screen-and-treat services were implemented within each of the Chiefdoms over a 1-week period. RESULTS: VIA-enhanced digital imaging of the cervix (digital cervicography) was offered to 8399 women in ten Chiefdoms as part of a village-based screening (VBS) program. In all, 419 (4.9%) women had positive screening test results. Of these women, 276 (65.8%) were treated immediately with thermocoagulation and 143 (34.1%) were referred to provincial government hospitals to undergo either the loop electrosurgical excision procedure/large loop excision of the transformation zone (n=109, 26.0%) or punch biopsy (n=34, 8.1%). CONCLUSION: The influence of traditional Chiefs was leveraged to facilitate access to cervical cancer prevention services in rural Zambia.
Population-level scale-up of cervical cancer prevention services in a low-resource setting: development, implementation, and evaluation of the cervical cancer prevention program in Zambia.
(2015) Parham GP; Mwanahamuntu MH; Kapambwe S; Muwonge R; Bateman AC; Blevins M; Chibwesha CJ; Pfaendler KS; Mudenda V; Shibemba AL; Chisele S; Mkumba G; Vwalika B; Hicks ML; Vermund SH; Chi BH; Stringer JS; Sankaranarayanan R; Sahasrabuddhe VV; Center for Infectious Disease Research in Zambia, Lusaka, Zambia; University of California, Irvine, Irvine, California, United States of America.; Center for Infectious Disease Research in Zambia, Lusaka, Zambia; University of Zambia, Lusaka, Zambia.; International Agency for Research on Cancer, Lyon, France.; Vanderbilt University, Nashville, Tennessee, United States of America; National Cancer Institute, Bethesda, Maryland, United States of America.; Center for Infectious Disease Research in Zambia, Lusaka, Zambia; University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.; Michigan Cancer Institute, Pontiac, Michigan, United States of America.; University of Zambia, Lusaka, Zambia.; Vanderbilt University, Nashville, Tennessee, United States of America.; Center for Infectious Disease Research in Zambia, Lusaka, Zambia; University of Zambia, Lusaka, Zambia; University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America; International Agency for Research on Cancer, Lyon, France.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: Very few efforts have been undertaken to scale-up low-cost approaches to cervical cancer prevention in low-resource countries. METHODS: In a public sector cervical cancer prevention program in Zambia, nurses provided visual-inspection with acetic acid (VIA) and cryotherapy in clinics co-housed with HIV/AIDS programs, and referred women with complex lesions for histopathologic evaluation. Low-cost technological adaptations were deployed for improving VIA detection, facilitating expert physician opinion, and ensuring quality assurance. Key process and outcome indicators were derived by analyzing electronic medical records to evaluate program expansion efforts. FINDINGS: Between 2006-2013, screening services were expanded from 2 to 12 clinics in Lusaka, the most-populous province in Zambia, through which 102,942 women were screened. The majority (71.7%) were in the target age-range of 25-49 years; 28% were HIV-positive. Out of 101,867 with evaluable data, 20,419 (20%) were VIA positive, of whom 11,508 (56.4%) were treated with cryotherapy, and 8,911 (43.6%) were referred for histopathologic evaluation. Most women (87%, 86,301 of 98,961 evaluable) received same-day services (including 5% undergoing same-visit cryotherapy and 82% screening VIA-negative). The proportion of women with cervical intraepithelial neoplasia grade 2 and worse (CIN2+) among those referred for histopathologic evaluation was 44.1% (1,735/3,938 with histopathology results). Detection rates for CIN2+ and invasive cervical cancer were 17 and 7 per 1,000 women screened, respectively. Women with HIV were more likely to screen positive, to be referred for histopathologic evaluation, and to have cervical precancer and cancer than HIV-negative women. INTERPRETATION: We creatively disrupted the 'no screening' status quo prevailing in Zambia and addressed the heavy burden of cervical disease among previously unscreened women by establishing and scaling-up public-sector screening and treatment services at a population level. Key determinants for successful expansion included leveraging HIV/AIDS program investments, and context-specific information technology applications for quality assurance and filling human resource gaps.
Strategies for achieving healthy energy balance among African Americans in the Mississippi Delta.
(2007-Oct) Parham GP; Scarinci IC; Department of Medicine Room 126, Bevill Research Bldg, University of Alabama at Birmingham, Birmingham, AL 35294, USA. gparham@cidrz.org; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
INTRODUCTION: Low-income African Americans who live in rural areas of the Deep South are particularly vulnerable to diseases associated with unhealthy energy imbalance. The Centers for Disease Control and Prevention (CDC) has suggested various physical activity strategies to achieve healthy energy balance. Our objective was to conduct formal, open-ended discussions with low-income African Americans in the Mississippi Delta to determine 1) their dietary habits and physical activity levels, 2) their attitudes toward CDC's suggested physical activity strategies, and 3) their suggestions on how to achieve CDC's strategies within their own environment. METHODS: A qualitative method (focus groups) was used to conduct the study during 2005. Prestudy meetings were held with African American lay health workers to formulate a focus group topic guide, establish inclusion criteria for focus group participants, select meeting sites and times, and determine group segmentation guidelines. Focus groups were divided into two phases. RESULTS: All discussions and focus group meetings were held in community centers within African American neighborhoods in the Mississippi Delta and were led by trained African American moderators. Phase I focus groups identified the following themes: overeating, low self-esteem, low income, lack of physical exercise, unhealthy methods of food preparation, a poor working definition of healthy energy balance, and superficial knowledge of strategies for achieving healthy energy balance. Phase 2 focus groups identified a preference for social support-based strategies for increasing physical activity levels. CONCLUSION: Energy balance strategies targeting low-income, rural African Americans in the Deep South may be more effective if they emphasize social interaction at the community and family levels and incorporate the concept of community volunteerism.
The burden of cervical pre-cancer and cancer in HIV positive women in Zambia: a modeling study.
(2015-Jul-24) Bateman AC; Katundu K; Mwanahamuntu MH; Kapambwe S; Sahasrabuddhe VV; Hicks ML; Chi BH; Stringer JS; Parham GP; Chibwesha CJ; University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. professorparham@gmail.com.; Michigan Cancer Institute, Pontiac, MI, USA. mrhicks2@comcast.net.; University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. Benjamin.Chi@cidrz.org.; University of Zambia, Lusaka, Zambia. mulindim@gmail.com.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. mulindim@gmail.com.; University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. Jeffrey_Stringer@med.unc.edu.; Vanderbilt University, Nashville, Tennessee, USA. vikrant.sahasrabuddhe@vanderbilt.edu.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. Katundu.Katundu@cidrz.org.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. sharon.kapambwe@cidrz.org.; University of Zambia, Lusaka, Zambia. professorparham@gmail.com.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. Carla.Chibwesha@cidrz.org.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. Benjamin.Chi@cidrz.org.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. bateman.allen@gmail.com.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. professorparham@gmail.com.; University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. bateman.allen@gmail.com.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: HIV infection is associated with a higher incidence of precancerous cervical lesions and their progression to invasive cervical cancer (ICC). Zambia is a global epicenter of HIV and ICC, yet the overall burden of cervical pre-cancer [cervical intraepithelial neoplasia 3 (CIN3)] and ICC among its HIV positive adult female population is unknown. The objective of this study was to determine the burden of cervical disease among HIV positive women in Zambia by estimating the number with CIN3 and ICC. METHODS: We conducted a cross-sectional study among 309 HIV positive women attending screening in Lusaka (Zambia's most populated province) to measure the cervical disease burden by visual inspection with acetic acid enhanced by digital cervicography (DC), cytology, and histology. We then used estimates of the prevalence of CIN3 and ICC from the cross-sectional study and Spectrum model-based estimates for HIV infection among Zambian women to estimate the burden of CIN3 and ICC among HIV positive women nationally. RESULTS: Over half (52 %) of the study participants screened positive by DC, while 45 % had cytologic evidence of high grade squamous intraepithelial lesions (SIL) or worse. Histopathologic evaluation revealed that 20 % of women had evidence of CIN2 or worse, 11 % had CIN3 or worse, and 2 % had ICC. Using the Spectrum model, we therefore estimate that 34,051 HIV positive women in Zambia have CIN3 and 7,297 have ICC. CONCLUSIONS: The DC, cytology, and histology results revealed a large cervical disease burden in this previously unscreened HIV positive population. This very large burden indicates that continued scale-up of cervical cancer screening and treatment is urgently needed.
The burden of human papillomavirus infections and related diseases in sub-saharan Africa.
(2013-Dec-29) De Vuyst H; Alemany L; Lacey C; Chibwesha CJ; Sahasrabuddhe V; Banura C; Denny L; Parham GP; Department of Obstetrics and Gynaecology and Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Groote Schuur Hospital, Observatory, Cape Town, South Africa.; Unit of Infections and Cancer (UNIC), Cancer Epidemiology Research Program (CERP), Institut Català d'Oncologia - Catalan Institute of Oncology (ICO), L'Hospitalet de Llobregat (Barcelona), Spain; CIBER en Epidemiología y Salud Pública (CIBERESP), Spain.; Department of Obstetrics and Gynecology, UNC Global Women's Health, University of North Carolina - Chapel Hill, North Carolina, USA. Electronic address: groesbeck.parham@cidrz.org.; Department of Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda.; Hormonal and Reproductive Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.; Infection and Cancer Epidemiology Group, International Agency for Research on Cancer (WHO-IARC), Lyon, France.; University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, U.S.A and Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Centre for Immunology and Infection, Hull York Medical School, University of York, York, UK.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Despite the scarcity of high quality cancer registries and lack of reliable mortality data, it is clear that human papillomavirus (HPV)-associated diseases, particularly cervical cancer, are major causes of morbidity and mortality in sub-Saharan Africa (SSA). Cervical cancer incidence rates in SSA are the highest in the world and the disease is the most common cause of cancer death among women in the region. The high incidence of cervical cancer is a consequence of the inability of most countries to either initiate or sustain cervical cancer prevention services. In addition, it appears that the prevalence of HPV in women with normal cytology is higher than in more developed areas of the world, at an average of 24%. There is, however, significant regional variation in SSA, with the highest incidence of HPV infection and cervical cancer found in Eastern and Western Africa. It is expected that, due to aging and growth of the population, but also to lack of access to appropriate prevention services and the concomitant human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) epidemic, cervical cancer incidence and mortality rates in SSA will rise over the next 20 years. HPV16 and 18 are the most common genotypes in cervical cancer in SSA, although other carcinogenic HPV types, such as HPV45 and 35, are also relatively more frequent compared with other world regions. Data on other HPV-related anogenital cancers including those of the vulva, vagina, anus, and penis, are limited. Genital warts are common and associated with HPV types 6 and 11. HIV infection increases incidence and prevalence of all HPV-associated diseases. Sociocultural determinants of HPV-related disease, as well as the impact of forces that result in social destabilization, demand further study. Strategies to reduce the excessive burden of HPV-related diseases in SSA include age-appropriate prophylactic HPV vaccination, cervical cancer prevention services for women of the reproductive ages, and control of HIV/AIDS. This article forms part of a regional report entitled "Comprehensive Control of HPV Infections and Related Diseases in the Sub-Saharan Africa Region" Vaccine Volume 31, Supplement 5, 2013. Updates of the progress in the field are presented in a separate monograph entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.
The use of thermal ablation in diverse cervical cancer "screen-and-treat" service platforms in Zambia.
(2022-Apr) Mwanahamuntu M; Kapambwe S; Pinder LF; Matambo J; Chirwa S; Chisele S; Basu P; Prendiville W; Sankaranarayanan R; Parham GP; Zambia Ministry of Health, Cancer Control, Lusaka, Zambia.; Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA.; International Agency for Research on Cancer, WHO Screening Group, Early Detection and Prevention Section, Lyon, France.; Center for Infectious Disease Research in Zambia, Cervical Cancer Prevention Program, Lusaka, Zambia.; Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.; Department of Obstetrics and Gynecology, Women and Newborn Hospital, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
OBJECTIVE: Thermal ablation (TA) was implemented in public sector cervical cancer prevention services in Zambia in 2012. Initially introduced as a treatment modality in primary healthcare clinics, it was later included in mobile outreach campaigns and clinical research trials. We report the feasibility, acceptability, safety, and provider uptake of TA in diverse clinical contexts. METHODS: Screening services based on visual inspection with acetic acid were offered by trained nurses to non-pregnant women aged 25-59 years. Women with a type 1 transformation zone (TZ) were treated with same-visit TA. Those with a type 2 or 3 TZ, or suspicious for cancer, were managed with same-visit electrosurgical excision or punch biopsy, respectively. A provider survey was conducted. RESULTS: Between 2012 and 2020, 2123 women were treated with TA: primary healthcare clinics, n = 746; mobile outreach clinics, n = 1127; research clinics, n = 250. Of the 996 women treated in primary healthcare and research clinics, 359 (48%) were HIV positive. Mild cramping during treatment was the most common adverse effect. No treatment interruptions occurred. No major complications were reported in the early (6 weeks) follow-up period. Providers expressed an overwhelming preference for TA over cryotherapy. CONCLUSION: TA was feasible, safe, and acceptable in diverse clinical contexts. It was the preferred ablation method of providers when compared with cryotherapy.
Utilization of cervical cancer screening services and trends in screening positivity rates in a 'screen-and-treat' program integrated with HIV/AIDS care in Zambia.
(2013) Mwanahamuntu MH; Sahasrabuddhe VV; Blevins M; Kapambwe S; Shepherd BE; Chibwesha C; Pfaendler KS; Mkumba G; Vwalika B; Hicks ML; Vermund SH; Stringer JS; Parham GP; Center for Infectious Disease Research in Zambia, Lusaka, Zambia ; University Teaching Hospital, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: In the absence of stand-alone infrastructures for delivering cervical cancer screening services, efforts are underway in sub-Saharan Africa to dovetail screening with ongoing vertical health initiatives like HIV/AIDS care programs. Yet, evidence demonstrating the utilization of cervical cancer prevention services in such integrated programs by women of the general population is lacking. METHODS: We analyzed program operations data from the Cervical Cancer Prevention Program in Zambia (CCPPZ), the largest public sector programs of its kind in sub-Saharan Africa. We evaluated patterns of utilization of screening services by HIV serostatus, examined contemporaneous trends in screening outcomes, and used multivariable modeling to identify factors associated with screening test positivity. RESULTS: Between January 2006 and April 2011, CCPPZ services were utilized by 56,247 women who underwent cervical cancer screening with visual inspection with acetic acid (VIA), aided by digital cervicography. The proportion of women accessing these services who were HIV-seropositive declined from 54% to 23% between 2006-2010, which coincided with increasing proportions of HIV-seronegative women (from 22% to 38%) and women whose HIV serostatus was unknown (from 24% to 39%) (all p-for trend<0.001). The rates of VIA screening positivity declined from 47% to 17% during the same period (p-for trend <0.001), and this decline was consistent across all HIV serostatus categories. After adjusting for demographic and sexual/reproductive factors, HIV-seropositive women were more than twice as likely (Odds ratio 2.62, 95% CI 2.49, 2.76) to screen VIA-positive than HIV-seronegative women. CONCLUSIONS: This is the first 'real world' demonstration in a public sector implementation program in a sub-Saharan African setting that with successful program scale-up efforts, nurse-led cervical cancer screening programs targeting women with HIV can expand and serve all women, regardless of HIV serostatus. Screening program performance can improve with adequate emphasis on training, quality control, and telemedicine-support for nurse-providers in clinical decision making.