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Barriers to Cervical Cancer Screening Among HIV-Infected Women in Tanzania

A Conversation With Pauline E. Jolly, PhD, MPH


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Population screening programs and the advent of human papillomavirus (HPV) vaccination have made cervical cancer largely a preventable disease. Despite these advances, ­cervical cancer remains a leading cause of cancer death for ­women in low- and middle-income countries.

A recent study identified barriers to cervical cancer screening, diagnosis, and treatment among HIV-infected women and explored the acceptability of patient navigators in Tanzania.1 The ASCO Post recently spoke with the study’s lead author, Pauline E. Jolly, PhD, MPH, of the University of Alabama at Birmingham.

Pauline E. Jolly, PhD, MPH

Pauline E. Jolly, PhD, MPH

Research Interests

Please tell readers of The ASCO Post about your current position and work.

I am a Professor in the Department of Epidemiology at the School of Public Health at the University of Alabama at Birmingham. I teach courses in infectious disease epidemiology and HIV/AIDS/sexually transmitted diseases, conduct research, and perform services for the institution and other organizations. My area of expertise is immunology and infectious diseases, and I conduct laboratory research on HIV-immune pathogenesis, particularly in the area of immune responses to infection and on aflatoxin ingestion and health impacts in the Ashanti Region of Ghana, especially among people infected with HIV.

My research has been funded by grants from the American Foundation for AIDS Research, the National Institutes of Health, the U.S. Agency for International Development, and the Centers for Disease Control and Prevention. I also conduct epidemiologic and behavioral research on HIV/AIDS/sexually transmitted infections and other infectious and chronic diseases in countries in Africa, Latin America, and the Caribbean (Ghana, Kenya, Tanzania, Swaziland, Peru, Guatemala, Trinidad and Tobago, and Jamaica).

Tanzania Study Details

In a nutshell, please describe the methodology and goal(s) of your study in Tanzania.

Our study on the acceptability of peer navigators for patients with cervical cancer in Tanzania had both quantitative and qualitative components. We conducted a cross-sectional study among 400 women with HIV infection aged at least 19 years attending 12 Management and Development for Health public sector HIV Care and Treatment Clinics in and around Dar es Salaam, Tanzania, from May 1 to August 31, 2012. Management and Development for Health physicians and nurses informed eligible women about the study and invited them to participate.

Women who expressed an interest were introduced to the study staff. A trained research assistant fluent in Kiswahili and English explained the study and the informed consent process. All participants provided signed informed consent. The institutional review boards of the University of Alabama at Birmingham and the National Institute for Medical Research in Dar es Salaam, Tanzania, reviewed and approved the study protocol before its implementation. Consenting eligible women were administered a questionnaire (in English or Kiswahili) that collected information on sociodemographic characteristics, barriers to cervical cancer screening and treatment, knowledge and attitude toward cervical cancer screening, and perceptions and attitudes toward peer navigators.

We conducted 4 focus group discussion sessions: 2 with HIV-positive women between the ages of 24 and 57 years who had been screened for cervical cancer and 2 with male and female clinicians and nurses who perform cervical cancer screening. The topics covered in the focus group sessions included barriers to cervical cancer screening and treatment, knowledge of and attitudes toward cervical screening, and perceptions of and attitudes toward patient navigation. Our objectives were to identify barriers to cervical cancer screening and treatment among the women and to determine acceptance of the women toward peer navigators to reduce barriers to screening and treatment.

Barriers to Cervical Screening

As you pointed out, Tanzania has one of the highest incidence rates of cervical cancer in Eastern Africa. What are the major obstacles to early screening? Is an HPV vaccine initiative or other preventive measure in place?

Some of the barriers to cervical screening identified in the study1 follow:

  • Lack of accurate knowledge and misconceptions regarding cervical cancer and the need for cervical screening
  • Unavailability of sufficient screening services—extra-long wait times at clinics—and lack of services in rural areas (75% of reproductive-age women in Tanzania live in rural communities without easy access to screening)
  • Women’s fear and misperceptions of cervical screening (eg, the feeling that diagnosis leads to death)
  • Lack of awareness that treatment of precancerous lesions is possible and available
  • Difficulty in navigating the complicated system from screening to diagnosis and treatment.

At the time of the study, women who screened positive for cervical lesions that were too large for treatment by cryotherapy in the clinics were referred to the Ocean Road Cancer Institute in Dar es Salaam. Travel to Ocean Road for treatment is cost-prohibitive for many families; consequently, many women did not follow through and receive appropriate diagnosis and treatment.

Additionally, many nurses did not feel they had the skill sets to provide screening and cryotherapy services and expressed the need for more training. Some thought that feedback from the Ocean Road Cancer Institute specialists regarding the findings on patients they referred there for further diagnostic screening and treatment may help to build confidence in their screening abilities.

“It is frustrating that a disease that is so highly preventable is still taking such a heavy toll on the lives of women across the globe.”
— Pauline E. Jolly, PhD, MPD

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Yes, there is an HPV vaccine initiative in Tanzania. The country launched the national vaccination drive in April 2018 and will receive 3.9 million vaccines in 2019 to vaccinate girls between the ages of 9 and 14 years.

Patient Navigation Programs

Patient navigation programs in the United States took time to gain traction in mainstream oncology. Please tell us about your experience in Tanzania with patient navigation.

Unfortunately, we have not been able to implement a peer navigation program in Tanzania due to a lack of grant funding. About 97% of the women in our quantitative study were highly receptive of having peer navigators and said they would like assistance with explanation of medical terms; 88% said they would like peer navigators to accompany them for cervical evaluation and/or treatment.

In our qualitative study, participants in both types of focus group sessions (women and clinicians) agreed that a patient navigation program would be an effective way to help women through the cancer continuum of care, including screening, diagnosis, follow-up care, and treatment. We included these preliminary data in a grant application, but it was not funded.

Government Support of Initiatives

Population-based initiatives are complex. Are the Tanzanian government health services supportive of initiatives to address the cervical cancer crisis?

Yes, the Tanzanian government health services are supportive of initiatives to address cervical cancer. We worked closely (and still communicate frequently) with the Cervical Cancer Focal Person in the Ministry of Health. I have been informed that there is a Ministry of Health initiative with partner support to establish and strengthen the Tanzania population cancer register.

Closing Thoughts

Please share some closing thoughts on this important work and how it might be generalizable for other nations in the developing world.

I have conducted cervical cancer–related studies in Jamaica, Swaziland, and Tanzania. Regardless of whether the screening method of choice is a Pap smear or visual inspection with acetic acid, the problems with timely screening, diagnosis, and treatment among women are similar. They include a need for clear understanding of cervical cancer and the importance of cervical screening among women; sociocultural misconceptions about the disease; lack of sufficient free or low-cost screening services; lack of trained personnel to conduct screening and treatment of precancerous lesions; and a complex system related to screening, diagnosis, and treatment, which is difficult for women to navigate.

It is frustrating that a disease that is so highly preventable is still taking such a heavy toll on the lives of women across the globe and that a highly acceptable method that would greatly help to alleviate this health burden, such as peer navigation, is not being implemented.

DISCLOSURE: Dr. Jolly reported no conflicts of interest.

REFERENCE

1. Bateman LB, Blakemore S, Koneru A, et al: Barriers and facilitators to cervical cancer screening, diagnosis, follow-up care and treatment: Perspectives of human immunodeficiency virus-positive women and health care practitioners in Tanzania. Oncologist 24:69-75, 2019.


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