Julius Mwaiselage

Association Between the Test-and-Treat Strategy and the Severity of Cervical Dysplastic Lesions Among Women Living With HIV in Tanzania (2015-2023)

PURPOSE Cervical cancer remains a leading cause of morbidity and mortality in Tanzania where HIV exacerbates the risk of cancer and dysplasia. In 2017, Tanzania adopted the Test-and-Treat program for patients with HIV, which mandates immediate antiretroviral therapy for people living with HIV, regardless of CD4 count. This study examined the impact of this strategy on the severity of cervical dysplasia among women living with HIV (WLWH) at the Ocean Road Cancer Institute (ORCI). METHODS We used existing data of women who came to the ORCI cervical cancer early detection clinic between 2015 and 2023 for cervical cancer early detection. Of the 3,385 women screened, 1,686 were diagnosed with dysplastic lesions and included in the analysis. This subset consisted of 349 WLWH, 605 HIV-negative women, and 732 women with unknown HIV status. The remaining women either were visual inspection with acetic acid–negative or had suspected cervical cancer and were not included in the final analysis of dysplastic lesions. The year 2017 was chosen as a pivotal point for analysis because it marked the implementation of the Test-and-Treat strategy at the ORCI. The severity of dysplasia before and after 2017 was compared using trend and logistic regression analyses. RESULTS The Test-and-Treat strategy was associated with a significant increase in detecting small/moderate lesions ( P < .0001). The odds of being diagnosed with small/moderate lesions versus large lesions were approximately four times higher post-2017 (odds ratio, 3.972 [95% CI, 2.462 to 6.409]). CONCLUSION The Test-and-Treat strategy has significantly reduced the severity of cervical dysplasia among WLWH at the ORCI, highlighting the importance of integrating HIV treatment into cervical cancer prevention programs. Continuous research focusing on the long-term effects of the Test-and-Treat strategy and expansion of on-site pathology services, including timely histopathologic diagnosis, are essential to further reduce cervical cancer incidence, morbidity, and mortality among WLWH.

Barriers and facilitators for implementation of HPV-based cervical cancer screening in Tanzania: a qualitative study among healthcare providers, stakeholders, and Tanzanian women

Cervical cancer is the leading cause of cancer-related deaths in Tanzania and the most common form of cancer among Tanzanian women. Screening attendance remains among the lowest globally, necessitating improved attendance and screening methods. This study aims to assess the feasibility of implementing the World Health Organization's 2021 hPV-based screening guideline in Tanzania by identifying potential barriers and facilitators to HPV-based screening among screening clients, healthcare providers, and stakeholders. From October 2022 to February 2023, 25 semi-structured interviews were conducted with screening clients ( Barriers and facilitators emerged across all levels of the Social Ecological Model. At the individual level, clinic-based screening and a one-visit approach were barriers, while HPV-self-sampling was a facilitator. Interpersonal barriers included limited social support, while referrals served as facilitators. Community-level barriers included fear and misconceptions, countered by facilitators such as increased awareness and health education. Health system challenges included restrictive age limits and urbanization of human resources, with uptake through other health services acted as a facilitator. Political barriers highlighted the need for a steady local supply chain, while cost reduction could serve as a facilitator for guideline implementation. WHO's 2021 hPV-based screening guideline shows promise in Tanzania, but barriers such as clinic availability, fear, misconceptions, and supply chain issues must be addressed to ensure successful implementation.

Effectiveness of One-Way Text Messaging on Attendance to Follow-Up Cervical Cancer Screening Among Human Papillomavirus–Positive Tanzanian Women (Connected2Care): Parallel-Group Randomized Controlled Trial

Background Rapid human papillomavirus (HPV) DNA testing is an emerging cervical cancer screening strategy in resource-limited countries, yet it requires follow-up of women who test HPV positive. Objective This study aimed to determine if one-way text messages improved attendance to a 14-month follow-up cervical cancer screening among HPV-positive women. Methods This multicenter, parallel-group randomized controlled trial was conducted at 3 hospitals in Tanzania. Eligible participants were aged between 25 and 60 years, had tested positive to a rapid HPV test during a patient-initiated screening, had been informed of their HPV result, and had a private mobile phone with a valid number. Participants were randomly assigned in a 1:1 ratio to the intervention or control group through an incorporated algorithm in the text message system. The intervention group received one-way text messages, and the control group received no text messages. The primary outcome was attendance at a 14-month health provider-initiated follow-up screening. Participants were not blinded, but outcome assessors were. The analysis was based on intention to treat. Results Between August 2015 and July 2017, 4080 women were screened for cervical cancer, of which 705 were included in this trial—358 women were allocated to the intervention group, and 347 women were allocated to the control group. Moreover, 16 women were excluded before the analysis because they developed cervical cancer or died (8 from each group). In the intervention group, 24.0% (84/350) women attended their follow-up screening, and in the control group, 23.8% (80/335) women attended their follow-up screening (risk ratio 1.02, 95% CI 0.79-1.33). Conclusions Attendance to a health provider-initiated follow-up cervical cancer screening among HPV-positive women was strikingly low, and one-way text messages did not improve the attendance rate. Implementation of rapid HPV testing as a primary screening method at the clinic level entails the challenge of ensuring a proper follow-up of women. Trial Registration ClinicalTrials.gov NCT02509702; https://clinicaltrials.gov/ct2/show/NCT02509702. International Registered Report Identifier (IRRID) RR2-10.2196/10.2196/15863

Acceptability of text messages and knowledge change for cervical cancer screening: a Tanzanian mixed methods study

ObjectivesTo investigate the acceptability of a text message intervention and evaluate if text messages could increase knowledge of cervical cancer and screening.DesignThis study was a substudy of a randomised controlled trial that used a mixed methods research design combining a quantitative questionnaire dataset and qualitative interview data. A before and after assessment was made of questionnaire responses. Acceptability was measured on a 6-point Likert scale and knowledge was measured through 16 binary true/false knowledge questions concerning cervical cancer and screening. Qualitative data were coded using a combined inductive–deductive approach.SettingOcean Road Cancer Institute in Dar es Salaam as well as Kilimanjaro Christian Medical Center and Mawenzi Regional hospital in the Kilimanjaro Region in Tanzania.ParticipantsHuman papillomavirus (HPV) positive women who had been randomised to the intervention group and received educative and reminder messages. Qualitative interviews were conducted with a subgroup of women in the intervention group.Interventions15 one-way educative and reminder text messages.ResultsA total of 115 women in the intervention group responded to both the baseline and follow-up questionnaire. Overall, women found it highly acceptable to receive text messages, and there was a trend towards acceptability rising between baseline and follow-up (mean: 0.22; 95% CI 0.00 to 0.44; p=0.05; t-statics=1.96). A significant increase in acceptability was found among the lowest educated and those who had not previously been screened. The qualitative interviews showed that the underlying reasons for the high acceptability rate were that the women felt someone cared for them and that the text messages were for their own benefits. The text messages did not improve the women’s knowledge on cervical cancer and screening.ConclusionsEducative and reminder text messages are highly acceptable among HPV-positive Tanzanian women; however, they do not increase the women’s knowledge of cervical cancer and screening.Trial registration numberclingov (NCT02509702).

HIV and Early Treatment Outcomes Among Women With Cervical Cancer Treated With Concurrent Chemoradiation in Tanzania

PURPOSE Cervical cancer (CC) is the leading malignancy in Tanzania. Low-income countries are faced with double epidemics of HIV and CC. This study aimed to investigate how HIV and cancer stage at diagnosis affect early treatment outcomes among women with CC treated with concurrent chemoradiation in Tanzania in the highly active antiretroviral therapy era. MATERIALS AND METHODS This was a prospective cohort study of patients newly diagnosed with CC at the Ocean Road Cancer Institute from November 2019 to January 2020. The tumor response was assessed using RECIST 3 months post-treatment. The tumor response was categorized as a complete or partial response according to the ultrasound and pelvic examination findings. The univariate and multivariate logistic regression explained the relationship between several covariates (age, stage, HIV status, equivalent dose in 2 Gy fractions, chemotherapy cycles, and treatment time) and treatment response. RESULTS A total of 102 patients with CC were included in this study at baseline. After adjusting for other covariates, only completion of treatment within 56 days (odds ratio [OR], 9.23; 95% CI, 1.53 to 55.85; P = .016) and receiving at least three cycles of cisplatin (OR, 5.6; 95% CI, 1.47 to 21.34; P = .012) were significantly associated with complete tumor response. HIV status was not significantly associated with complete tumor response (OR, 1.534; 95% CI, 0.424 to 5.545; P = .5144). CONCLUSION Early treatment response was independent of HIV status. With wide coverage of anitretroviral therapy, patients with HIV can receive radical treatment and have the same early outcomes as their HIV-negative counterparts.

Use of SMSs to Improve Attendance to Cervical Cancer Follow-up Screening

This study evaluates the effect of the SMS intervention 'Connected2Care' on the attendance rate to cervical cancer screening follow-up appointments.