Uptake and correlates of cervical cancer screening among women attending a community-based multi-disease health campaign in Kenya

Abstract

Introduction: Despite the increased risk of cervical cancer among HIV-positive women, many HIV-care programs do not offer integrated cervical cancer screening. Incorporating self-collected Human Papillomavirus (HPV) testing into HIV programs is a potential strategy to identify women at higher risk for cervical cancer while leveraging the staffing, infrastructure and referral systems for existing services. Community-based HIV and HPV testing has been effective and efficient when offered in single-disease settings.

Methods: This cross-sectional study was conducted within a community outreach and multi-disease screening campaigns organized by the Family AIDS Care and Education Services in Kisumu County, Kenya. In addition to HIV testing, the campaigns provided screening for TB, malaria, hypertension, diabetes, and referrals for voluntary medical male circumcision. After these services, women aged 25-65 were offered self-collected HPV testing. Rates and predictors of cervical cancer screening uptake and of HPV positivity were analyzed using tabular analysis and Fisher's Exact Test. Logistic regression was performed to explore multivariate associations with screening uptake.

Results: Among the 2016 women of screening age who attended the outreach campaigns, 749 women (35.6%) were screened, and 134 women (18.7%) were HPV-positive. In bivariate analysis, women who had no children (p < 0.01), who were not pregnant (p < 0.01), who were using contraceptives (p < 0.01), who had sex without using condoms (p < 0.05), and who were encouraged by a family member other than their spouse (p < 0.01), were more likely to undergo screening. On multivariable analysis, characteristics associated with higher screening uptake included: women aged 45-54 (OR 1.62, 95% CI 1.05-2.52) compared to women aged 25-34; no children (OR 1.65, 95% CI 1.06-2.56); and family support other than their spouse (OR 1.53, 95% CI 1.09-2.16). Women who were pregnant were 0.44 times (95% CI 0.25-0.76) less likely to get screened. Bivariate analyses with participant characteristics and HPV positivity found that women who screened HPV-positive were more likely to be HIV-positive (p < 0.001) and single (p < 0.001).

Conclusions: The low screening uptake may be attributed to implementation challenges including long waiting times for service at the campaign and delays in procuring HPV test kits. However, given the potential benefits of integrating HPV testing into HIV outreach campaigns, these challenges should be examined to develop more effective multi-disease outreach interventions.

Fig. 1

Study population flowchart

Fig. 2

Flow diagram of the multi-disease health campaign. *At this station, group education on cervical cancer as well as HIV, diabetes, hypertension, tuberculosis, malaria, sexually transmitted infections screening, pregnancy testing, and voluntary medical male circumcision was provided to ensure participants are fully informed about the tests and services offered at the health campaign. The topics covered in cervical cancer education included: causes of cervical cancer, signs and symptoms of cervical cancer, prevention strategies, screening methods such as self-collection HPV testing, and information about follow up care with positive HPV test results. **Three study activities related to cervical cancer were conduced at this station: (1) additional group education about cervical cancer and cervical cancer screening (this education consisted of a short description of the anatomy of the cervix, symptoms of cervical cancer and pre-cancer, risk factors of cervical cancer such as positive HIV status, ways to decrease cervical cancer risk (such as having fewer sexual partners and having sex at an older age), prevention strategies, eligibility for cervical cancer screening, misconceptions about cervical cancer (such as association between cervical cancer risk and poor hygiene or infertility), treatment services in local health facilities, and instructions of self-collection HPV testing); (2) HPV self-sampling collection by participants; and (3) administration of survey