Prevalence and predictors of cervical cancer screening among HIV-positive women in rural western Uganda: insights from the health-belief model
Authors: Vigneshwaran Easwaran , Goruntla Narayana , Bommireddy Bhavana Reddy , Mantargi Mohammad Jaffar Sadiq , Mopuri Bhavani , Thammisetty Durga Prasad , Veerabhadrappa Kasturi Vishwanathasetty , Bukke Sarad Pawar Naik 
Published: December 2023

Abstract
Background
Women living with HIV are at increased risk of developing cervical cancer (CC). Screening for cancer is an important preventive strategy for the early detection of precancerous lesions and its management. There has been inadequate evidence on cervical cancer screening (CCS) practices among HIV-positive women in rural western Uganda. This study aimed to assess the prevalence and predictors of CCS among HIV-positive women, as well as knowledge and practices regarding cervical cancer screening.

Methods
A cross-sectional, analytical study was conducted among HIV-positive women attending HIV care facilities located in rural settings of western Uganda. A validated and interview-based data collection form was used to capture statistics regarding demographics, HIV care, obstetric profile, health belief constructs, and knowledge and history of CCS from the participants. Bivariate and multivariate logistic regression analyses were used to correlate women’s characteristics and health beliefs toward CCS practices.

Results
The prevalence of CCS among HIV-positive women was found to be 39.1% (95%CI: 14.0–71.7). A multivariate logistic regression analysis showed that post-secondary education attainment (AOR = 3.21; 95%CI = 2.12–7.28), four years or more lapsing after being diagnosed as HIV-positive (AOR = 2.87; 95%CI = 1.34–6.13), having more than one child (AOR = 1.87; 95%CI = 1.04–3.35), antenatal care attendance (AOR = 1.74; 95%CI = 1.02–3.43), post-natal care attendance (AOR = 3.75; 95%CI = 1.68–5.89), and having good knowledge regarding CC (AOR = 1.26; 95%CI = 1.98–3.02) were positively associated with adherence to CCS among HIV-positive women in western Uganda. Health Belief Model (HBM) constructs like the perceived risk of developing CC (AOR = 1.82; 95%CI = 1.16–2.01), worries about developing CC (AOR = 5.01; 95%CI = 4.26–8.32), believing that CC leads to death (AOR = 2.56; 95%CI = 1.64–3.56), that screening assists in early identification (AOR = 2.12; 95%CI = 1.84–3.74) and treatment (AOR = 4.63; 95%CI = 2.78–6.43) of precancerous lesions, reducing the risk of mortality (AOR = 1.84; 95%CI = 1.12–2.75), and the reassurance provided by negative test results (AOR = 2.08; 95%CI = 1.33–4.22) were positively associated with adhering to CCS. A female doctor performing the screening (AOR = 2.02; 95%CI = 1.57–3.98) as well as offering a free screening service (AOR = 3.23; 95%CI = 1.99–4.38) were significantly associated with CCS. Meanwhile, screening being painful (AOR = 0.28; 95%CI = 0.12–0.45), expensive (AOR = 0.36; 95%CI = 0.24–0.53), time-consuming (AOR = 0.30; 95%CI = 0.19–0.41), embarrassing (AOR = 0.02; 95%CI = 0.01–0.06), and the fear of positive results (AOR = 0.04; 95%CI = 0.02–0.10) were found to have a significant negative association with adhering to CCS.

Conclusions
Only one-third of HIV-positive women had undergone CCS. Variables including secondary education attainment, four years or more lapsing after being diagnosed as HIV-positive, having more than one child, antenatal care attendance, post-natal care attendance, and knowledge about CC were positively associated with CCS adherence. Educational programs should be geared towards the risk of CC, severity of cases, benefits of screening, and reducing barriers associated with screening, which can significantly improve cervical CCS among HIV-positive women. The study proposes the incorporation of free screening services and the inclusion of trained female staff in CC prevention policies to improve CCS.