The Impact of an Educational Program on Cervical Cancer Knowledge Among HIV-Positive Women in Bali, Indonesia

Abstract

Desak Putu Oki Lestari,1 Ania Imani Wellere,2 Ilene K Brill,2 Ni Luh Putu Eka Kartika Sari,3 Pauline E Jolly,2 Chandrika J Piyathilake4 1Department of Anatomical Pathology, Faculty of Medicine and Health Sciences, University of Warmadewa, Bali, Indonesia; 2Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA; 3Department of Biomolecular, Faculty of Medicine and Health Sciences, University of Warmadewa, Bali, Indonesia; 4Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL, USACorrespondence: Chandrika J Piyathilake, Emeritus Professor of the Department of Nutrition Sciences, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, USA, Tel [phone], Email [email protected]: The burden of Human papillomavirus (HPV)-related cancers is expected to rise in Indonesia as there has been an increase in the availability of medication that prolongs the survival of women infected with the human immunodeficiency virus (HIV+). There is an urgent need for cervical cancer (CC) screening to address this concern.Objective: The objectives of the current study were to determine the burden of HPV infections and cervical pre-cancer lesions and evaluate the effectiveness of an education program to improve HPV and CC knowledge among women attending HIV clinics in Bali, Indonesia.Methods: A questionnaire focused on HPV and CC was administered to 200 HIV+ women before (pre-education) and after the education program (post-education). Cervical cells were used to perform the Papanicolaou (Pap) and test for 13 high-risk (HR) HPV genotypes. Women diagnosed with Pap diagnoses of greater than atypical squamous cells of undetermined significance (≥ASCUS+) were identified as abnormal Pap.Results: Fifty-four percent of women were diagnosed with ASCUS+ and 81% of those women were positive for any one of the 13 HR-HPV genotypes while 71% were positive for any HPV genotype included in the 9-valent (9V) HPV vaccine. The percentages of women who answered questions correctly at the pre-education interview was 3– 25% while 97– 100% gave the correct answers to the same questions at the post-education interview (P< 0.0001).Conclusion: Our study for the first-time documented that a significant proportion of women who attend HIV clinics in Bali are diagnosed with ASCUS+ and HR-HPVs which put them at high risk for developing CC. It would have been possible to prevent the development of ASCUS+ in at least 70% of those women if 9V HPV vaccine was given to these women. Since all 200 women educated by our program consented for screening, we clearly demonstrated that HIV+ women attending HIV clinics can be successfully educated to participate in CC screening.Plain Language Summary: When women infected with the human immunodeficiency virus (HIV) live longer because of the availability of HIV medications, more women are likely to develop cervical cancer (CC) caused by another virus called the human papillomavirus (HPV), a common infection in HIV infected women. Therefore, there is an urgent need for CC screening to address this concern. Participation in CC screening is low in developing countries like Indonesia. Since several studies have shown the need for education programs to improve cancer screening rates of women at high risk for developing CC in such countries, we conducted a study to test the burden of HPV infections and cervical pre-cancer lesions and evaluate the effectiveness of an education program to improve HPV and CC knowledge among women attending HIV clinics in Bali, Indonesia. We observed that more than 50% of women have cervical pre-cancer lesions and 81% of those women are also infected with cancer causing HPVs. We also observed that the percentages of women who answered questions correctly at the pre-education interview was 3– 25% while 97– 100% gave the correct answers to the same questions at the post-education interview. Since all 200 women educated by our program consented for screening, we clearly demonstrated that women attending HIV clinics can be successfully educated to participate in CC screening, an important step to lower the risk of developing CC in HIV infected women.Keywords: cervical cancer, screening, education

Keywords

• cervical cancer
• screening
• education