Cervical Cancer Screening in Botswana: An Urgent Call for Guideline Change.

PURPOSE/OBJECTIVE(S) Women living with HIV are at an increased risk of acquiring HPV-related cervical atypia that can progress to cervical cancer. In sub-Saharan Africa, cervical cancer makes up the largest proportion of years of life lost due to cancer, largely due to women diagnosed at younger ages, typically between 35 and 50 years. Botswana has the second highest prevalence of HIV in the world. Current World Health Organization guidelines for cervical cancer recommend screening between ages of 30-49 years; however, data suggest that women with HIV who get cervical cancer are diagnosed at a younger age. We assessed characteristics of women diagnosed with cervical cancer to further inform and refine screening guidelines. MATERIALS/METHODS We prospectively enrolled women diagnosed with cervical cancer from January 2015 to March 2020 at two tertiary hospitals in Gaborone, Botswana. We performed chi-square and ANOVA analyses to evaluate the association between categorical age at diagnosis and HIV status, CD4 count, viral load and other sociodemographic and clinical factors. RESULTS Data were available for 1,130 women who were diagnosed with cervical cancer, 69.3% were women living with HIV (WLWH). Of the total 1130 women (median age 47.9 (IQR 41.2-59.1), 1.3 % were < 30 years of age, 19.1 % were 30-39 and 37.2% were 40-49. Overall, 20.4% (n = 231) of cancers were in women < 40 years. When analyzed by age, 86.7% of patients < 30 years of age were WLWH (mean CD4 371.6 cells/µL), 86.1% in patients 30-39 years (mean CD4 671.8 cells/µL). Overall, 86.1% of women who were < 40 years of age were WLWH compared to 64.9% of women who were ≥40 years old (P < 0.001). Mean CD4 counts for WLH who were < 40 years was 655.10 cells/µL and 18.2% had detectable viral load, while mean CD4 count for ≥40 years was 619.58 cells/µL with 23.8% having a detectable viral load. The most common FIGO stage of presentation in patients < 40 years was stage II (39.9%) compared to stage III (39.7%) in ≥40-year-old women (P = 0.08). Over three quarters (84.0%) of women < 40 years old were single compared to 60.8 % in those ≥40 years. Among women < 40 years old who were screened for cervical cancer, 87.4% (n = 111) were WLHV, and among women ≥40 years 70.5% (n = 308) were WLHV. Women < 40 years were more likely to have ever been screened than women ≥40 years old (59.1% vs 50.7%, P = 0.03). CONCLUSION Age of cervical cancer diagnosis may be younger in countries with higher prevalence of HIV, like Botswana. Approximately 20% of the patients present with cancer < 40 years of age and should have been screened 10 years prior to cancer diagnosis to prevent cancer. However, these patients will not be screened per the current WHO screening guidelines. Changing international cervical cancer screening guidelines to women at younger ages than 30-49 years should be urgently considered especially in setting with high prevalence of HIV. Furthermore, engaging women without HIV in screening programs is critical for cervical cancer elimination.