STI Research Programme / Studies on Human Papilloma Virus infection and Cancer of the Cervix in Uganda

Lead Research Organisation: MRC/UVRI Uganda Research Unit on AIDS

Abstract

Cancer of the cervix of the uterus which is thought to be caused by Human Papilloma Virus (HPV), a sexually transmitted viral infection, is the commonest cancer of women in sub-Saharan Africa. Different strains of HPV are involved. A vaccine is now available that has been shown to protect women from acquiring infection with HPV strains 16 and 18. However, the pattern of the type of strains causing cervical cancer in East Africa is not fully known. Most women infected with HPV do not necessarily develop cancer, but clear the infection spontanously. It may be that this is different in women who are also HIV infected. Early stages of the cervical disease, before it develops into full cancer, can often be detected by a screening technique, using simple visual inspection combined with the application of acetic acid. This technique can be applied by midwives and nurses, e.g. in areas where specialists are not available. In Uganda, the use of this approach has become policy. However, the validity of the approach when used by nurses has not been established yet. - Our study in southern Uganda will establsh which HPV strains are the cause of cervical cancer in this setting, to what extent the pattern of strains may be different if women are also HIV infected, and how well the pattern of HPV strains fits the currently available vaccine. We will also determine the pattern of HPV strains that can be found in otherwise healthy women, and whether HPV infected women with and without HIV infection differ with respect to their ability to clear a cervical HPV infection spontaneously, or with respect to their risk of developing pre-cancerous lesions (that may eventually lead to full cancer). We are also determing how well the VIA screening technique performs if applied by nurses and midwives, and whether a simple training intervention package can be developed that improves the performance of the technique in the hands of health workers, so that it can be applied at peripheral health units in the country.

Technical Summary

To investigate the epidemiology of Human Papilloma Virus (HPV) genotypes associated with cervical cancer in Uganda; and to evaluate and further improve the performance of a screening approach using visual inspection of the cervix with acetic acid (VIA) applied by health workers at peripheral health units.||This is a cross-sectional study involving 8 hospitals situated in Southern and Central Uganda and 6 peripheral health centres within Kampala. (i) At hospitals, a total of 400 consenting women with suspected cervical cancer undergo cervical biopsies to confirm the diagnosis and to establish the HPV genotypes associated with the cancer of the cervix in the country. HIV tests are also performed to detect possible associations between HIV infection and the pattern of HPV aetiology. (ii) At one hospital and at the 6 health centres, up to 4000 women from the general population from urban and periurban locations of Kampala are invited to participate in a screening programme to detect HPV infection and precancerous cervical lesions. A questionnaire is applied to collect demographical information and data on various risk factors. A genital examination is performed by a physician with specialist training. Specimens are collected for cervical cytology, for HPV detection and genotyping, and for the diagnosis of other reproductive tract infections and of HIV infection. (iii) At the same session, women are briefly examined by a nurse or midwife who apply the VIA screening technique. The diagnosis made by these health workers is evaluated, using the laboratory supported gynaecological diagnosis as gold standard. - The prevalence of HPV infection and its possible associations with HIV infection and other factors is determined. Women detected with high grade squamous lesions (HSIL) of the cervix or other gynaecological disorders are referred for specialist treatment. - Women infected with high risk HPV strains are invited to join a cohort study and to be followed up for 2 years to establish the rate of clearance of the infection, again comparing HIV-positive and HIV-negative individuals. Those diagnosed with low grade squamous intraepithelial lesions (LSIL) of the cervix are also followed up to establish the rate of disease progression, stratified by HIV status, and are treated if they develop HSIL. Based on the results from the VIA screening evaluation, a simple training intervention will be designed and evaluated to improve the performance of health workers.

Publications

10 25 50
 
Description Technical Advisory Committee MoH
Geographic Reach Africa 
Policy Influence Type Membership of a guideline committee
 
Description training of health workers
Geographic Reach Africa 
Policy Influence Type Influenced training of practitioners or researchers
Impact feedback into guidelines for cervical cancer screening, and access to antiretroviral treatment for HIV/AIDS
 
Title HPV strains detected in cervical cancer tissue 
Description cervical cancer tissues, blood specimens from same patients, PCR extracts, data on HPV infection including strain typing 
Type Of Material Biological samples 
Provided To Others? No  
Impact data presented at international conference; publication under preparation; information to MoH towards introduction of vaccination against high risk HPV infection 
 
Description St Francis Hospital, Nsambya, Kampala 
Organisation St Francis Hospital, Kampala
Country Uganda 
Sector Hospitals 
PI Contribution Protocol development, data management and analysis
Collaborator Contribution Contributed the expertise in gyaenacology, and histopathology
Impact Scientfic presentations at international conferences; scientfic manuscripts are in preparation