High prevalence of cervical squamous intraepithelial lesions in women on antiretroviral therapy in Cameroon: Is targeted screening feasible?

Abstract

Background: Cervical cancer is the most common cancer in women in low-income countries. Although cervical cancer incidence and mortality is higher in HIV-positive women, resource limitations restrict the implementation of systematic screening programs in these women. We explored the potential for targeted screening by assessing the prevalence, severity and predictors of cervical squamous intra-epithelial lesions (SILs) in HIV-positive women in Cameroon.

Methods and findings: We conducted a cross-sectional study of women on antiretroviral therapy in Cameroon. Socio-demographic, behavioral, and clinical information was obtained from eligible women. Cervical exfoliated cells were then collected, a conventional cytology performed and epithelial lesions classified according to the Bethesda 2001 system. A total of 282 women, aged 19-68 years, were enrolled in this study. The median CD4 count was 179 cells/microliter (interquartile range: 100-271). SILs were detected in 43.5% of the 276 women with satisfactory samples: including atypical squamous cells of unknown significance (ASCUS) 0.7%, low-grade SIL (LSIL) 25.0%, atypical squamous cells, cannot exclude high grade lesions (ASC-H) 14.5%, and high-grade SIL (HSIL) 3.3%. None of the demographic or clinical characteristics considered significantly predicted the presence of any SILs or the presence of severe lesions requiring colposcopy.

Conclusion: The prevalence of SIL in women on antiretroviral therapy in Cameroon was high underscoring the need for screening and care in this population. In the absence of any accurate demographic or clinical predictor of SIL, targeted screening does not seem feasible. Alternative affordable screening options need to be explored.

Figure 1

Total weighted errors associated with screening for any precancerous lesion by the relative ‘cost’ of ‘false negative’ errors compared to ‘false positive’ errors. (A–C: Screening based on risk score with a cut-off targeting 25%, 50% and 75% of women for A, B and C respectively; D: Universal screening; E: No screening). Note that ‘cost’ is used as a generic term, not just limited to monetary value, while ‘false positive’ and ‘false negative’ respectively refer to screening a patient with no lesion and not screening a patient with lesions.

Figure 2

Total weighted errors associated with screening for ASC-H/HSIL by the relative ‘cost’ of ‘false negative’ errors compared to ‘false positive’ errors. (A–C: Screening based on risk score with a cut-off targeting 25%, 50% and 75% of women for A, B and C respectively; D: Universal screening; E: No screening). Note that ‘cost’ is used as a generic term, not just limited to monetary value, while ‘false positive’ and ‘false negative’ respectively refer to screening a patient with no severe lesion and not screening a patient with severe lesions.