Grant Number:	1R21CA279942-01A1 Interpret this number
Primary Investigator:	Stanton, Amelia
Organization:	Boston University (Charles River Campus)
Project Title:	Identifying and Addressing Barriers in the Cervical Cancer Treatment Cascade Among Women with HIV in South Africa
Fiscal Year:	2024

PROJECT SUMMARY/ABSTRACT The vast majority of women who develop and die from cervical cancer live in low- and middle-income countries.1 In sub-Saharan Africa, geographic inequities in rates of cervical cancer are fueled by high HIV incidence and prevalence among women with HIV (WWH). South Africa (SA) bears the greatest HIV burden in the world2 and has the highest cervical cancer incidence rate globally;3 in SA, 53% of all cervical cancer cases are attributable to HIV.4 With increased attention paid to the importance of cervical cancer screening (which, in SA, is typically cytology-based via Pap smears),5 Pap smear screening rates have risen; as of 2018, 52% of women had been screened,6 up from 18-25% in earlier studies.7 However, cervical cancer can only be prevented if patients are retained in care and subsequently treated. Alarmingly, only 26% of WWH who received high-risk abnormal Pap results completed medically-required follow-up and management within 18 months.8 To increase retention of WWH in the cervical cancer treatment cascade, it is imperative that we investigate the specific factors that negatively affect follow-up appointment attendance and engagement with necessary treatment. Without a nuanced understanding of barriers to retention and treatment across multiple levels, WWH will continue to be at disproportionate risk for cervical cancer. A multi-level retention care intervention that is tailored to the unique needs of WWH who have recently received high-risk abnormal Pap results has strong potential to mitigate massive cervical cancer disparities. We now propose to conduct the formative work that is necessary to develop the novel intervention, which, in line with PAR-21-341, will modify the complex, intersecting factors that contribute to cervical cancer development among WWH. In qualitative interviews with (1) WWH (n<10) who had a high-risk abnormal Pap smear in the past six months and have not yet attended a follow-up visit and (2) WWH (n<10) who had a high-risk abnormal Pap smear in the past six months and have attended at least one follow-up visit, we will explore the individual, interpersonal, clinic-level, and structural barriers and facilitators to follow-up appointment attendance and subsequent treatment. Intervention preferences will also be probed. In separate interviews with providers (n<8), we will explore their perspectives on barriers to delivery of care and barriers to retention of patients in care post- abnormal Pap smear. The qualitative data will inform the specification of the multi-level intervention, which will be tested in a pilot randomized controlled trial (n=60). Feasibility and acceptability will be the primary study outcomes, which will be assessed among both patients and providers. We will also assess for signals of clinically meaningful differences in (1) the proportion of women who attend a follow-up appointment (and, of those, the proportion who complete the next phase of treatment, which will be exploratory), and (2) self-efficacy to attend a follow-up and/or other cervical cancer-related appointments. If deemed to be feasible and acceptable, with preliminary signals of efficacy, the intervention will be ready for an R01-level hybrid efficacy/effectiveness trial.





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