Title

Access to cervical cancer screening among women living with HIV in Malawi - analysis of Malawi population-based HIV impact assessment (MPHIA) 2020-21 and MPHIA 2015-16 surveys

Presenter

Laurence Gunde

Authors

L. Gunde¹, D. Payne¹, A. Wang¹, A. Kabaghe¹, A. Maida¹, D. Kayira¹, E. Rabold², S. Jonnalagadda², T. Dobbs², A.C. Voetsch², O. Kumwenda³, T. Phiri⁴, J. Kachingwe⁴, T. Jenda⁴, J. Chiwoko⁵, E. Mangulenje⁶, M. Farahani⁷, F. Kayigamba⁸, K. Mirkovic¹

Institutions

¹US. Centers for Disease Control and Prevention, Lilongwe, Malawi, ²US. Centers for Disease Control and Prevention, Atlanta, United States, ³USAID, Lilongwe, Malawi, ⁴Malawi Ministry of Health, Lilongwe, Malawi, ⁵Lighthouse Trust, Lilongwe, Malawi, ⁶EGPAF, Lilongwe, Malawi, ⁷ICAP at Columbia University, New York, United States, ⁸ICAP at Columbia University, Lilongwe, Malawi

BACKGROUND: Malawi has one of the highest cervical cancer (CxCa) burdens globally. CxCa screening and treatment of pre-cancer is an important intervention to eliminate CxCa. The Malawi Population-based HIV Impact Assessment (MPHIA) 2015-16 reported low coverage for CxCa screening among women living with HIV (WLHIV). Since October 2018, President's Emergency Plan for AIDS Relief (PEPFAR) Malawi has supported the provision of CxCa screen-and-treatment services for WLHIV in the highest-burden antiretroviral (ART) facilities in Malawi. We compared the MPHIA 2020-21 screening and treatment data to the MPHIA 2015-16 findings.
METHODS: The MPHIAs are nationally representative household surveys that include a questionnaire and HIV testing. Women aged 15-64 were asked about CxCa screening, results, and treatment. We analyzed self-reported CxCa screening data among WLHIV by demographic factors and reported 95% confidence intervals (CI). Results were weighted and accounted for survey design.
RESULTS: In 2015-16 and 2020-21, 1,507 and 1,616 WLHIV were interviewed, respectively. In 2015-16, 16.1% (95% CI: 13.5%-18.8%) reported CxCa screening, compared to 38.4% (95% CI: 35.3%-41.6%) in 2020-21. CxCa screening among WLHIV on ART increased from 17.0% (95% CI: 14.2%-20.2%) to 41.2% (95% CI: 38.0%-44.5%).
Although CxCa screening coverage improved across multiple demographic characteristics, the magnitude of improvement was highest in the lower education and wealth classes. There was an over 3-fold increase in WLHIV with no education (9.0%; 95% CI: 5.6%-14.2% to 30.4%; 95% CI: 24.1%-37.5%). For those in the lowest wealth quintile, screening was almost 7 times more in 2020-21 (3.8%; 95% CI: 1.6%-8.5% to 25.8%; 95% CI: 19.8%-32.9%).
There was greater improvement in CxCa screening coverage in rural settings; 11.7% (95% CI: 9.3%-14.7%) to 36.0% (95% CI: 32.3%-39.9%) compared to 27.5% (95% CI: 22.6%-33.0%) to 46.0% (95% CI: 40.9%-51.1%) in urban.
Same-day treatment for abnormal results was 52.4% (95% CI: 27.0%-76.7%) in 2015-16 and 74.6% (95% CI: 48.7%-90.1%) in 2020-21.
CONCLUSIONS: CxCa screening among WLHIV has markedly improved, especially for those on ART and in underserved communities. This suggests that PEPFAR investments and integration of CxCa screening in ART clinics have increased demand and access. However, this can be strengthened by ensuring CxCa screening services are available at all ART facilities.

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