TANZANIANS AND AMERICANS IN PARTNERSHIP TO FIGHT HIV/AIDS

Lower CD4 Counts and Higher Risk of Pre-Cervical Cancer Lesions: Correlation among HIV-Infected Women in Tanzania
by: Giulia Besana1; Mary Rose Giattas1; Marya Plotkin1; Robert Kamala2, Mainza Lukobo-Durrell1; Christina Lulu Makene1; Sharon Kibwana1 and Maryjane Lacoste1 1 Jhpiego, 2 Tanzania Ministry of Health and Social Welfare

Background: Cervical Cancer and HIV

HIV-positive women are at greater risk of cervical cancer
(CaCx) morbidity and mortality, with: Higher incidence and longer persistence of human papillomavirus (HPV) infection More rapid progression to invasive cervical cancer Increased risk of pre-cancerous lesions among HIVinfected women (Branca 2003, DeVuyst 2008, Parham 2006)

CECAP Screening
April 2010March 2012
HIV+ status known by PITC HIV+ status known on arrival

Results
Eligible Women Ever Enrolled in CTC* Eligible Women Enrolled in CTC Who Have Been Screened, from the Start of the Program N Morogoro Regional Hospital Ngerengere Health Centre Kibaoni Health Centre St. Francis District Hospital Mahenge Hospital Kilosa Hospital St. Kizito District Hospital Turiani Hospital 5,132 319 240 3,511 559 2,154 730 934 5,495 6,087 179 131 111 363 19 162 65 177 218 176 % 3% 41% 46% 10% 3% 8% 9% 19% 4% 3%

Health Facility

1,600 1,400 1,200 1,000 800 600 400 200 0

AprilJune 2010 JulySept 2010 OctDec 2010 JanMarch 2011 AprilJune 2011

HIV-/unknown

With a rate of 50 new cases and 38 deaths per 100,000

women in 2008, Tanzania has one of the highest CaCx burdens worldwide (GLOBOCAN 2008; http://globocan. iarc.fr)

MAISHA Support to MoHSW

Jhpiego, through the MAISHA program, supports the
Ministry of Health and Social Welfare (MoHSW) and partners to roll out cervical cancer prevention (CECAP) services, using visual inspection with acetic acid (VIA) and cryotherapy treatment for those with pre-cancerous lesions.

JulySept 2011

OctDec 2011

JanMarch 2012

Iringa Regional Hospital Mafinga Hospital

*Deaths not removed

Results are presented for new clients only:

22% (n=1,629) of screened, HIV-infected clients referred

from CTC

MAISHA supports CECAP service provision in 15 facilities

in Morogoro and Iringa Regions: CECAP services provided in reproductive and child health clinics to all women regardless of HIV status; HIV-infected women referred from Care and Treatment Centres (CTCs) Provider-initiated testing and counseling (PITC) offered on an opt-out basis as part of the service Single visit approach used (clients can receive all services in a single visit)

2% (n=157) of HIV-infected clients diagnosed through

PITC

A chi-square analysis showed a statistically significant association between CD4 count and VIA status (p=0.003). Regression analysis indicated that as ranges of CD4 count decreased, the risk of becoming VIA-positive increased by 20% from lowest strata to highest (coefficient -.00015, 95% CI -.00023 to -.000061).

Methods
Before delivering CECAP services, providers inquire
about each clients HIV status. If a client has an unknown or self-reported HIV-negative status, PITC is offered. For those who report being HIV-infected, the clients HIV CTC card is requested for verification.

Coverage of CECAP Services for CTC Clients

Range of months of service delivery between 11 and 23
months

CD4 counts recorded on clients CTC enrollment card are

entered into the CECAP clients record.

CECAP and HIV Care and Treatment Services

CECAP

CECAP client records are entered into a client-level

database stripped of identifiers.

Mean service delivery of 15 months Extremely low coverage of CECAP screening for CTCenrolled women: Ranged from 3%46% of eligible CTC clients screened, with an average of 6% eligible clients screened

7,410 new clients screened for cervical cancer from April

2010 to March 2012 in 11 health facilities; 1,786 of these clients were HIV-infected.

Data from 11 sites are presented. As a quality assurance measure, in May 2012, 13% of all
client records (n=218) were matched with CTC records, with good matching of information.

Of the 7,410 cases:

A total of 532 (7%) tested positive for VIA.

National guidelines state that all HIV-infected women

should be screened when diagnosed with HIV, regardless of age, once sexually exposed, and screened annually regardless of CaCx result: National target for the next 5 years states that at least 50% of HIV-infected women should be screened.

the 1,786 HIV-infected clients: Of

A total of 236 (13%) tested positive for VIA. Overall, 92% (n=415) of VIA-positive clients were

Results
Program Overview, April 2010March 2012
Clients screened 7,410

treated with cryotherapy on the same day.

HIV prevalence among women (1549 years)
HIV+ through PITC 157 (2%)

Limitations
HIV+ from CTC 1,629 (22%) HIV-/unknown 5,624 (76%)

The relationship between CD4 and VIA status controlled

or modified by ART was not examined because of limited information on treatment duration, start of ARV treatment, type of drugs and adherence to drugs.

ART may be a confounder.

VIA+ 25 (16%)
Morogoro 7% Iringa 19%

VIA121 (77%)

VIA+ 211 (13%)

VIA1,400 (86%)

VIA+ 296 (5%)

VIA5,179 (92%)

Challenges
Of the 1,786 HIV-infected clients screened, 1,289 had
documentation on a recent CD4 count.

The low coverage of CECAP screening among CTCenrolled women related to systems issues around linkages and referrals: Severe shortage of health care staff at all levels Overburden and frequent shuffling of health staff Limited knowledge of clients about the availability and importance of the service

VIA Positivity and ART among HIV-Positive Clients

CD4 Count Patients with CD4 Count 92 150 217 263 205 362 1,289 VIA+ ART % of People in This CD4 Count on ART 88% 95% 89% 75% 75% 66% 78%

HIV Care and Treatment

Estimated number and proportion of HIV-infected women

15+ years enrolled in HIV CTCs: Morogoro Regionestimated 60,768 HIV-positive, 18% enrolled in care Iringa Regionestimated 173,923 HIV-positive, 27% enrolled in care
0199 100199 200299 300399 400499 500+ TOTAL

N 19 25 32 38 14 32 160

% 21% 17% 15% 14% 7% 9% 12%

On ART 81 143 193 198 147 240 1,002

Not on ART 7 6 18 56 51 108 246

Missing Info 4 6 6 9 7 14 41

Conclusions and Recommendations

The findings underscore the importance of offering CaCx
screening in a high HIV setting: With earlier and more frequent screening based on the size of the lesion and CD4 count

Service delivery models that reinforce linkages between

CTC and CaCx services are key to protecting HIVinfected women.

HIV-infected women should be made more aware of their

increased risk and the availability of screening services.

We thank the Tanzanian Ministry of Health and Social Welfare for their support and collaboration. This work has been supported by the Presidents Emergency Plan for AIDS Relief (PEPFAR) under the terms of grant No. N00244-09-1-0050. This poster is made possible by the generous support of the American people through the United States Agency for International Development (USAID) Cooperative Agreement No. 621-A-00-08-00023-00. The contents are the responsibility of the Mothers and Infants, Safe Healthy Alive (MAISHA) program and do not necessarily reflect the views of USAID or the United States Government.

Tanzania guidelines start ART at 350

Further studies are needed to:

There was increasing VIA positivity as CD4 counts declined. positive compared with CD4 >400/mm3.
Identify when to start screening and how often vis--

CD4 counts <99 were three times as likely to be VIA VIA positivity among women with higher CD4 counts
similar to those of HIV-negative women.

vis CD4 count. Investigate the relationship among CD4, ARV and VIA status. Gather patients and providers perspectives and attitudes on CaCx screening to find out how to increase awareness among the community and improve access to services, and how to improve linkages and referrals within the health system.