Cervical cancer and HIV in Zambian women
Authors: Anayawa Nyambe, Mwansa Ketty Lubeya
Journal: The Lancet Global Health (2021)

In 2018, Zambia had the third highest incidence of cervical cancer in the world with 66·4 new cases per 100 000 women,1WHOCosting the national strategic plan on prevention and control of cervical cancer: Zambia, 2019–2023. World Health Organization, Geneva2020https://cdn.who.int/media/docs/default-source/cervical-cancer/zambia-cxca-costing-report-20201112.pdf?sfvrsn=a433474c_4&download=trueDate accessed: April 21, 2021Google Scholar despite having established the Cervical Cancer Prevention Program in Zambia (CCPPZ) in 2006.2Parham GP Mwanahamuntu MH Kapambwe S et al.Population-level scale-up of cervical cancer prevention services in a low-resource setting: development, implementation, and evaluation of the cervical cancer prevention program in Zambia.PLoS One. 2015; 10e0122169Crossref PubMed Scopus (90) Google Scholar According to WHO, the high incidence of cervical cancer is linked to the heavy burden of HIV and AIDS.1WHOCosting the national strategic plan on prevention and control of cervical cancer: Zambia, 2019–2023. World Health Organization, Geneva2020https://cdn.who.int/media/docs/default-source/cervical-cancer/zambia-cxca-costing-report-20201112.pdf?sfvrsn=a433474c_4&download=trueDate accessed: April 21, 2021Google Scholar Considering that cervical cancer can be prevented by primary (human papillomavirus [HPV] vaccination), secondary (cervical screening and HPV DNA testing), and tertiary (cancer treatment and management) methods, it is plausible that other factors, such as HIV, have contributed to the increased disease burden. Zambia's goal is to have 65% screening coverage between 2019 and 2023, by targeting women with HIV aged 15–59 years, and women aged 25–59 years who are HIV-negative.1WHOCosting the national strategic plan on prevention and control of cervical cancer: Zambia, 2019–2023. World Health Organization, Geneva2020https://cdn.who.int/media/docs/default-source/cervical-cancer/zambia-cxca-costing-report-20201112.pdf?sfvrsn=a433474c_4&download=trueDate accessed: April 21, 2021Google Scholar The screening interval is every 3 years regardless of HIV status.1WHOCosting the national strategic plan on prevention and control of cervical cancer: Zambia, 2019–2023. World Health Organization, Geneva2020https://cdn.who.int/media/docs/default-source/cervical-cancer/zambia-cxca-costing-report-20201112.pdf?sfvrsn=a433474c_4&download=trueDate accessed: April 21, 2021Google Scholar Visual inspection with acetic acid and digital cervicography (VIAC) remains the primary mode of screening for 90% of women, while 10% receive HPV DNA testing.1WHOCosting the national strategic plan on prevention and control of cervical cancer: Zambia, 2019–2023. World Health Organization, Geneva2020https://cdn.who.int/media/docs/default-source/cervical-cancer/zambia-cxca-costing-report-20201112.pdf?sfvrsn=a433474c_4&download=trueDate accessed: April 21, 2021Google Scholar In The Lancet Global Health, Jake Pry and colleagues3Pry JM Manasyan A Kapambwe S et al.Cervical cancer screening outcomes in Zambia, 2010–19: a cohort study.Lancet Glob Health. 2021; 9: e832-e840Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar explore screening frequency, and examine predictors of screening results, treatment outcomes, and patterns of sensitisation strategies by age group and HIV status. The Article speaks to the effectiveness of the CCPPZ and reinforces the HIV and HPV infection relationship. Specifically, women with HIV have a higher chance of being VIAC-positive than women who are HIV-negative (adjusted odds ratio 3·60, 95% CI 2·14–6·08). The authors analysed data from 183 165 women who attended screening at any of the 11 government health facilities in Lusaka, Zambia, which provide screening services under the CCPPZ. Their results are therefore limited to screening outcomes only and rely on the test accuracy of the VIAC method to confirm if positivity is truly due to cervical intraepithelial neoplasia. The authors could not comment on histopathology nor on the association between being VIAC-positive and CD4 cell count, viral load, and duration on antiretroviral therapy, which might have given a better insight into the dynamics of HIV and HPV co-infection. Nevertheless, against the general consensus was the finding that younger women with HIV (≤29 years) were most likely to screen positive compared with older women (aged 30–49 years) with HIV.3Pry JM Manasyan A Kapambwe S et al.Cervical cancer screening outcomes in Zambia, 2010–19: a cohort study.Lancet Glob Health. 2021; 9: e832-e840Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar A meta-analysis by Kelly and colleagues4Kelly H Weiss HA Benavente Y et al.Association of antiretroviral therapy with high-risk human papillomavirus, cervical intraepithelial neoplasia, and invasive cervical cancer in women living with HIV: a systematic review and meta-analysis.Lancet HIV. 2018; 5: e45-e58Summary Full Text Full Text PDF PubMed Scopus (111) Google Scholar found that women with HIV who had higher CD4 cell counts had a 36–70% reduction in the risk for high-risk HPV and a 36–80% reduction in the risk for cervical intraepithelial neoplasia of grade 2 or worse. It could be assumed that older women with HIV have been on antiretroviral therapy longer and adhere to usage, and therefore have good levels of viral suppression. These actions could have contributed to lowering the prevalence of high-risk HPV infection and significantly lowering the risk of cervical cancer.4Kelly H Weiss HA Benavente Y et al.Association of antiretroviral therapy with high-risk human papillomavirus, cervical intraepithelial neoplasia, and invasive cervical cancer in women living with HIV: a systematic review and meta-analysis.Lancet HIV. 2018; 5: e45-e58Summary Full Text Full Text PDF PubMed Scopus (111) Google Scholar It might also be possible that young women with HIV who are diagnosed with HIV infection at a very young age can lower their risk if placed on antiretroviral therapy early enough, but more evidence is required. Other than being younger than 20 years, the exact age of the youngest participants in the study was not stated, but screening of girls and women with HIV was required at first sexual intercourse regardless of age.3Pry JM Manasyan A Kapambwe S et al.Cervical cancer screening outcomes in Zambia, 2010–19: a cohort study.Lancet Glob Health. 2021; 9: e832-e840Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar According to the Zambian Demographic Health Survey,5Zambia Statistics AgencyMinistry of Health ZambiaICFZambia Demographic and Health Survey 2018: 2019; Lusaka, Zambia, and Rockville, Maryland, USA.https://dhsprogram.com/pubs/pdf/FR361/FR361.pdfDate accessed: April 26, 2021Google Scholar the median age at which Zambian girls and women first have sexual intercourse is 16·6 years. Mosicki and colleagues6Moscicki AB Ellenberg JH Farhat S Xu J Persistence of human papillomavirus infection in HIV-infected and -uninfected adolescent girls: risk factors and differences, by phylogenetic type.J Infect Dis. 2004; 190: 37-45Crossref PubMed Scopus (175) Google Scholar found that it took a mean time of 689 days for adolescent girls who were HIV-positive aged 13–18 years to clear an initial HPV infection compared with their HIV-negative counterparts who took a mean of 403 days. This result solidifies the need to initiate screening at 15 years for adolescent girls who are HIV-positive. However, young women (<20 years) who were HIV-negative were also screened and reasons behind the decision to screen them were not stated. Screening adolescent individuals is debatable due to the transient nature of HPV infection and very low prevalence of both high-grade squamous intraepithelial lesions and cervical cancer in this age group.7Campaner AB Fernandes GL Cervical cancer screening of adolescents and young women: further evidence shows a lack of clinical value.J Pediatr Adolesc Gynecol. 2021; 34: 6-11Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar Furthermore, the sensitivity and specificity of VIAC in adolescent girls is not completely understood and further tests might be required for a proper diagnosis—providing further support for screening women who are HIV-negative starting at the age of 25 years. Nonetheless, in a population in which not all women are aware of their HIV status, the question remains as to what is the ideal age to initiate screening in countries with a high burden of HIV. Despite the need to fully understand the relationship between HIV and cervical cancer in Zambia, the authors have shown that a robust, cost-effective cervical cancer screening programme is possible in a developing country. The CCPPZ has managed to increase screening coverage by 65·7% in less than a decade using various strategies.3Pry JM Manasyan A Kapambwe S et al.Cervical cancer screening outcomes in Zambia, 2010–19: a cohort study.Lancet Glob Health. 2021; 9: e832-e840Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar It is clearly a programme on its way to achieving both national and global goals to eliminate cervical cancer as a public health problem.8WHOGlobal strategy towards the elimination of cervical cancer as a public health problem. World Health Organization, Geneva2019https://www.who.int/publications/i/item/9789240014107Date accessed: April 21, 2021Google Scholar We declare no competing interests. Cervical cancer screening outcomes in Zambia, 2010–19: a cohort studyCCPPZ has effectively increased women's engagement in screening since its inception in 2006. Customised sensitisation strategies relevant to different age groups could increase uptake and adherence to screening. The high proportion of screen positivity in women younger than 20 years with HIV requires further consideration. Our data are not able to discern if women with HIV have earlier disease onset or whether this difference reflects misclassification of disease in an age group with a higher sexually transmitted infection prevalence. Full-Text PDF Open Access