Determinants of cervical cancer screening uptake among women living with HIV and receiving treatment from public health facilities

Abstract

Background: Cervical cancer disproportionately affects women living with HIV, given that they experience relatively more severe disease sequelae, and poor prognosis. That is in addition to the fact that they are more likely to experience cervical cancer treatment failure, have a higher risk of adverse events and recurrence following treatment. That makes them have a 10-fold mortality risk, making them a significant target group for cervical cancer prevention. Being mainly above the eligible age for vaccination, they can mostly benefit from cervical cancer screening (CCS), that they ought to do annually. Few of them are however doing so, globally, in Africa, in Uganda, and in Mbarara district, particularly Mbarara municipality. The purpose of this study was to investigate the level of cervical cancer screening uptake and its determinants among women living with HIV in Mbarara Municipality. Method: An analytical cross-sectional survey was used; stratified and simple random sampling was used to sample the health facilities, while simple random sampling was used to sample the women who were engaged in structured interviews, with their clinical data collected using medical record abstraction. The data collected has been analyzed using descriptive and inferential statistics (robust Poisson), in SPSS version 25. Results: Less than a quarter of the women living with HIV 22% (33/153) had sought and received cervical cancer screening annually between the years 2017 and 2019. At an individual level, CCS was associated with non-affordability of annual CCS (aPR = 1.153, CI = 1.042 - 1.275), attendance of community outreaches for health (aPR = 1.124, CI = 1.012- 1.247), perceptions of non-embarrassment of screening (aPR = 1.186, CI = 1.018 - 1.382), knowledge of the cause of cervical cancer (aPR = 0.810, CI = 0.702 - 0.934), knowledge that a virus causes cervical cancer (aPR = 0.744, CI = 0.660 - 0.839), perception that screening can lead to enlargement of private parts (cPR = 0.886, CI = 0.795 - 0.988), being currently sexually active (aPR = 0.834, CI = 0.746 - 0.931), perceived benefit of screening (aPR = 1.253, CI = 1.050 - 1.495), being para 1 (aPR = 0.664, CI = 0.484 - 0.911), being married (aPR = 0.899, CI = 0.821 - 0.984), and the born again (aPR = 0.836, CI = 0.743 - 0.941, P = 0.003), formal education (aPR = 0.911, CI = 0.850 - 0.977, P = 0.009) and primary education (aPR = 1.458, CI = 1.203 - 1.767). At a clinical level, CCS was associated with four-year duration on ART (aPR = 1.111, CI = 1.040 - 1.180), duration since diagnosis (aPR = 0.705, CI = 0.580 - 0.857, functional status (aPR = 0.903, CI = 0.834 - 0.979), viral load less than 1000 (aPR = 0.895, CI = 0.820 - 0.977). At an institutional level screening is associated with education about the need for CCS (cPR = 0.893, CI = 0.832 - 0.958), education about CCS along with partners (aPR = 1.124, CI = 1.036 - 1.218), and sufficient staffing at facility (aPR = 1.199, CI = 1.096 - 1.313). Conclusion: Cervical cancer screening uptake among women living with HIV in Mbarara municipality is low; whereas lifetime screening is fairly high among them, adherence to the screening protocol is low. Only 2 in 10 of them screen annually. Such a health seeking behavior is determined, by mainly their individual characteristics, and to an extent by clinical and health care service characteristics. Recommendations: There is a need to sensitize the HIV positive women that cervical cancer screening is free at public health facilities, couple health education is key, need to address all the misconceptions surrounding the screening among others