Fellowship Site: Clinica de Familia, La Romana, Dominican Republic
US Institution: Florida International University
Project Title: Cervical Cancer Screening in HIV-Infected Women in La Romana, Dominican Republic
Cervical cancer is an AIDS-defining condition in HIV-infected women. The natural history of high-risk (oncogenic) human papillomavirus (HPV) infection in HIV-infected women is more aggressive than in uninfected women, consistent with the role of normal cell-mediated immunity in controlling oncogenic HPV subtype infection. Mortality due to cervical cancer is high in women in low and middle-income countries, including the Dominican Republic (DR), with the 2nd highest cervical cancer mortality in the Caribbean and even higher in HIV-infected women in those countries. Dramatic declines in incidence of and mortality related to cervical cancer (particularly when detected before metastatic disease) have accompanied the introduction of cytopathologic screening using Papanicolau (“pap”) testing and more recently, HPV subtype nucleic acid amplification testing has emerged as a promising strategy. Because of their higher risk of progression to persistent high-risk HPV subtype infection, cervical cancer and related mortality, guidelines for pap and HPV subtype testing in HIV-infected women are more aggressive than in HIV-uninfected counterparts. Access to and acceptance of pap screening are essential to controlling the morbidity and mortality of cervical cancer in HIV-infected women, and barriers to access to and acceptance of screening are of critical importance. However, it has been reported that HIV-infected women who have access to and have accepted cervical cancer screening, and whose results suggest that they require further testing (e.g. colposcopy) to determine whether they need treatment, may not actually adhere to referrals. In Clínica de Familia La Romana, one of the HIV clinics with the largest HIV+ populations in the DR, almost half of women referred for colposcopy did not attend it. The aims of this study are to:
1a) Conduct a medical record review to identify HIV-infected women receiving combined antiretroviral therapy aged >18 years who have not been screened or are not up-to-date in screening for cervical cancer in Clínica de Familia La Romana and
1b) Offer liquid cytological (Thin Prep) and oncogenic HPV-subtype testing to those who have not been screened or are overdue for re-screening;
AIM 2: Estimate the proportion of women referred to or linked to colposcopy or other specialized care based on cervical cancer screening who attend attend at least once (attenders) and the proportion who did not attend (non-attenders or “cases” and compare attenders to non-attenders by demographic and other (including structural factors;
AIM 3: Conduct in-depth interviews (n=10-15) to qualitatively explore factors associated with attendance/non-attendance at scheduled appointments for specialized care/colposcopy.