Page 364 - HIVMED_v21_i1.indb

Page 2 of 8 Original Research

high risk for precancerous and cancerous lesions. 10,11 This management depending on the type and extent of the cervical
modality of screening has not been rolled out in the region lesion. Visual inspection with acetic acid and cryotherapy are
because of the prohibitive cost of the test. The diagnostic conducted by the nurses. The LEEP procedure is performed
landscape is changing, and as cost-effective point-of-care by a gynaecologist, and the excised tissue is sent to an
HPV DNA tests are becoming more accessible, countries external laboratory for histological examination.
have commenced HPV screening as the preferred primary
cervical cancer screening method. 12,13
Study procedure
The Zimbabwean government partnering with GAVI, the We invited women attending cervical cancer screening
Vaccine Alliance in 2018, rolled out a national HPV between 01 September 2017 and 21 November 2018 to
vaccination programme, as its cervical cancer primary participate in the study. Sexually active, HIV-positive
prevention method. The programme targeted the countries’ women above the age of 18 years who consented to
800 000 girls aged 10–14 using the bivalent vaccine, which participate in the study were recruited. Potential participants
14
confers protection to hrHPV subtypes 16/18/45. This, with a positive pregnancy test were excluded. Baseline
however, has raised questions on the cross protective effect of information including sexual history and demographic
other hrHPV subtypes, which have been reported to be information were collected and stored in a Microsoft Access
prevalent amongst women in Zimbabwe. 15,16 database.

Sub-Saharan African studies investigating HPV prevalence At the baseline visit, we screened participants using VIA, the
in WLHIV have shown a wide variability across different study nurses collected endocervical swabs for the HPV DNA
countries from 24% to 64%. 17,18,19,20,21,22 In 2017, a Zimbabwean tests. Women who screened positive by VIA were reviewed
study showed a hrHPV prevalence of 33% in a rural cohort six monthly, and those who screened negative, annually.
of 123 WLHIV. Types 35, 52 and 58 were found to be For the HPV DNA tests, we collected endocervical swabs
amongst the highly prevalent types, in addition to types 16 using the Cervexbrush25 and deposited the samples into
and 18. These geographical differences in HPV burden Preservcyt50 transport medium. We used Xpert® HPV kits
15
and type distribution highlight the need to assess the for testing on the GeneXpert machine located at the onsite
Zimbabwean urban context independently. In this cohort NC laboratory. The test detected 14 high-risk HPV with
study, we investigated the prevalence of hrHPV, the callouts for HPV 16, HPV 18/45 and ‘other hrHPV’. Amongst
associated risk factors and VIA outcomes during 2 years of the ‘other hrHPV’ subtypes are HPV 31, 33, 35, 39, 51, 52, 56,
follow-up.
58, 59, 66 and 68. The 14 HPV types are detected in five
Methods fluorescent channels, each with individual parameters for
target detection and validity; channel 1: HPV16, channel 2:
Study design and setting HPV18/45, channel 3: HPV31/33/35/52/58, channel 4:
This analytic cohort study was conducted amongst WLHIV at HPV51/59, channel 5: HPV 39/56/66/68. For channels in
®
Newlands Clinic (NC), in Harare, Zimbabwe. The NC was which more than one type is detected, the Xpert HPV test
24
established in 2004 in partnership with the Ministry of Health does not distinguish between types. Positive hrHPV results
and Child Care (MoHCC) and provides comprehensive HIV during the study period did not alter VIA follow-up intervals
care to approximately 6500 men, women and children. Sexual which were determined by VIA results only. We followed up
23
reproductive health services form an integral component of participants with VIA screening for a median of 26 months
HIV care at NC and include cervical cancer screening, (interquartile range [IQR]: 24–28), which was up to April
diagnosis and treatment of sexually transmitted infections 2020. Participants with incident HPV-related disease as high-
(STIs), and the provision of short- and long-acting reversible grade vulva intraepithelial neoplasia (VIN3) were censored
contraceptive methods. An HPV vaccination programme was from further follow-up.
also introduced at the clinic in 2015. In this year alone, 517
adolescents and youth 12–22 years old (312 females and 205 We collected additional patient data including antiretroviral
males) were vaccinated using the quadrivalent HPV vaccine. therapy (ART) medication history, VIA screening results and
The vaccination of children, adolescents and young adults still laboratory results from the clinic’s electronic database. None
continues to date at the clinic as part of the clinic’s effort to of the women in the study cohort had an HPV vaccination
prevent a potential burden of HPV-related cancers in these history.
young people as they mature.
Statistical analysis
Women registered in care at NC attend routine annual
cervical cancer screening where the VIA method is used We used Stata 13.1 (College Station, Texas) for data cleaning
as guided by the Zimbabwean Ministry of Health. The and analysis. We used proportions and medians for
procedure is performed by a team of three nurses who have descriptive statistics, logistic regression and the associated
been trained in this technique. Women with a positive Wald test for measures of association between hrHPV
VIA screen are treated with either cryotherapy, loop test and potential risk factors, and Wilcoxon Rank-Sum
electrical excision procedure (LEEP) or referred for specialist (Mann Whitney) test differences between continuous

http://www.sajhivmed.org.za 356 Open Access