Knowledge and Practice of Women With HIV on Cervical Cancer Prevention and Control and their Attributes to Utilize the Screening Services in Ethiopia: A Cross Sectional Study

Abstract

Background

Previous studies underscore the crucial link between awareness and timely cervical cancer screening and treatment, particularly among women of reproductive age. Yet, insights remain limited when it comes to women living with HIV in Addis Ababa. This study examined the knowledge and practices of these women regarding cervical cancer screening and treatment, illuminating the factors that both enable and hinder their uptake.

Methods

This cross-sectional study took place in six public hospitals in Addis Ababa, Ethiopia, involving 578 women with HIV. The recruitment spanned 10 months, from January 1^st to October 31^st, 2021. Trained clinicians utilized the Open Data Kit for data collection, ensuring real-time submission to the server. Statistical analysis was performed using SPSS version 25, employing descriptive and inferential statistics. The logistic regression model identified predictors of outcome variables, and open-ended questions were thematically narrated for qualitative insights.

Results

A notable 51.2% of women with HIV exhibited inadequate knowledge regarding cervical cancer prevention and control programs. Furthermore, a substantial 68.5% had never undergone cervical examination, citing reasons such as considering themselves healthy (49.6%), perceiving the examination as painful (28.4%), and feeling shy to undergo screening (23.3%). Notably, participants with non-formal education were 70% less likely to possess knowledge about cervical cancer prevention and control (AOR = 0.30; 95% CI = 0.13-0.71). Income emerged as an independent predictor for both knowledge and practice in women’s approach to cervical cancer prevention and control (P < 0.05). Additionally, occupation and duration of HIV diagnosis independently predicted practice, even after adjusting for confounding factors.

Conclusion

Half of the participating HIV-positive women lacked adequate awareness about cervical cancer prevention and control, underscoring the urgent need for comprehensive awareness initiatives tailored to this population. Relevant ministries, health care providers, and advocacy groups must collaborate to implement targeted education programs, utilizing diverse channels like community outreach, health care settings, and media campaigns.

Keywords

knowledge practice cervical cancer awareness screening women with HIV Ethiopia

Introduction

Cervical cancer looms large as a significant health concern for women in Sub-Saharan Africa, holding the top position among prevalent cancers.¹ This daunting reality transcends borders, with over 85% of fatalities concentrated in low-and-middle-income countries.² In Ethiopia, cervical cancer stands as the second most common female cancer, following closely behind breast cancer.³ The burden intensifies for women living with HIV, facing a 10-fold increased risk of developing invasive cervical cancer compared to their HIV-negative counterparts.^4-6 While research indicates that HIV-positive women may possess more accurate information about cervical cancer compared to their HIV-negative counterparts,⁷ this knowledge alone falls short in ensuring adequate protection. Accurate information plays a crucial role in promoting awareness of cervical cancer screening and early diagnosis, ultimately reducing mortality.⁸ Early screening and treatment are pivotal for cervical cancer prevention.⁹ However, various factors contribute to challenges in cervical cancer screening, including fear of results, economic barriers, negative attitudes toward providers, discomfort with male medical providers, and inadequate information.¹⁰ Additionally, barriers reported by women with HIV encompass poor knowledge of cervical cancer screening,^11,12 time constraints, perceptions of low risk, health considerations, and fear of screening.¹³ A notable lack of awareness regarding the risk factors of cervical cancer and uptake of the human papillomavirus (HPV) vaccine, essential for cancer prevention, has been observed.^14,15 Moreover, a recent pocket study in southeast Ethiopia revealed a low practice of screening among women with HIV attending adult anti-retroviral treatment clinics.¹⁶

Assessing knowledge, practices, and barriers related to cervical cancer screening is crucial for developing effective prevention strategies, especially among vulnerable populations. Unfortunately, such studies are limited in Ethiopia, particularly among women facing increased vulnerability. This study addressed this gap by focusing on women with HIV and aimed to assess their knowledge, practices, and contributing factors regarding cervical cancer prevention and control. The overarching objective was to generate evidence that will inform the development and prioritization of targeted strategies to enhance screening uptake among eligible women, ultimately contributing to the reduction of the cervical cancer burden in the country.

Methods

Study Setting and Population

Prospective cross-sectional study was conducted from six public hospitals in Addis Ababa, Ethiopia, spanning from January to October 2021. The selected hospitals were Zewditu Memorial Hospital, St. Paul Hospital Millennium Medical College, Alert Hospital, Yekatit-12 Hospital, Menelik Hospital, and St. Paul hospital. The selection of these hospitals was made based on the ART burden and the initiation of cervical cancer screening in the facility. From the given hospitals, a total of 578 women with HIV participated in the study with a response rate of 100%, and were enrolled consecutively until the sample size calculated and allocated for each facility was reached. The main eligibility requirements for this study were HIV positive women who visited the facility for diagnosis and ART service and who were interested to take cervical cancer pre-screening service and volunteering to participate in the study with age of 25 years and older. The age limit was taken into consideration due to the recommendation by WHO, indicating that HIV positive women were eligible to be screened at the age of 25 years and older considering the persistence of the infection due to co-infection with HPV, while for the general population of women, WHO prioritize 30 - 49 years of age for screening.² Ethical approvals for this study were obtained from the National Research Ethics Review Committee (NRERC) (MoSHE/04/246/832/21), the Aklilu Lemma Institute of Pathobiology Institutional Review Board (ALIPB IRB/35/2013/21), the City Government of Addis Ababa Health Bureau (A/A/H/6092/227), the St. Paul’s Hospital Millennium Medical College Institutional Review Board (SPHHMC-IRB/PW/23/398), and the Yekatit 12 Hospital Medical College (07/21). Written informed consent was obtained from all eligible and volunteering women to participate in the study. The reporting of this study conforms to the STROBE guidelines.¹⁷

Data Collection, Entry and Processing

This study utilized data extracted from a comprehensive dataset collected by experienced and trained clinicians using open data kit (ODK Collect v1.29.2) loaded in their personal tablet. Information was promptly submitted to the Ethiopian Public Health Institute (EPHI) server and managed by information technology (IT) professionals of the institute. Day-to-day communication was held between the IT professional and the principal investigator (PI) regarding the collected and entered data. The assigned IT professional downloaded the data and shared them to the PI to check the data for any missing information timely and maintain data quality. Besides, site-based supervision and frequent phone calls were made to solve any encounter during the data collection process. The final collected data were downloaded from the EPHI server with the responsible IT professional in the form of comma-separated values (CSV) file and converted into an Excel format. The data were then cleaned, coded and exported to SPSS version 25 for analysis.

The data encompassed various parameters, including age category, educational level, occupational status, income category, condom use, modern contraceptive methods, duration of women living with HIV, and duration of women on antiretroviral therapy (ART). Outcome variables focused on women’s knowledge and their practices concerning cervical cancer prevention and control. Sixteen knowledge items structured and reported as ‘yes/no’. Meaning, the correct responses were coded as ‘yes’, while the incorrect responses were coded as ‘no’. Those coded items were computed to derive the mean score, considering a score equal to or greater than the mean as indicative of adequate knowledge based on our previous published article.¹⁸ Those knowledge items are depicted in Table 2 and Figure 1A and B.

Figure 1.

A and B: Number and percentage of correct responses regarding prevention mechanisms and common symptoms of cervical cancer among participants.

Cervical screening practice was determined by women who had undergone cervical examination at least once in the past year and responded affirmatively.

Statistical Analysis

A descriptive and inferential statistics through SPSS version 25 was made, and a logistic regression model was used to examine the associations between the outcome variables (knowledge and practice towards cervical cancer prevention and control) with the various independent factors (socio-demographic and other important variables included in the study). The results were presented using odds ratios (ORs) and confidence intervals (95% CI).

Stepwise logistic regression was applied to rule out the predictors of the outcome variables, and those covariates associated in the univariate with P < 0.2¹⁸ were included in the multivariate analysis. Adjusted odds ratio (AOR) and confidence intervals (95% CI) were obtained, and P < 0.05 was considered a statistically significant. The results are presented in graphs and tables, and open-ended questions were thematically narrated for qualitative insights.

Results

Behavioral and Clinical Characteristics of Participants

A subset of participants, sixteen (5.6%), practiced polygyny. The majority, comprising 68.4%, had more than one sexual partner in their lifetime. Notably, 98.6% reported having no multiple sexual partners in the past 12 months. Concerning condom use, 72.3% did not use condoms during their last sexual debut in the past 12 months. Additionally, 37.9% of participants utilized modern contraceptives (Table 1). Exploring the specifics of modern contraceptive usage, responses from open-ended questions revealed that 80 participants used contraceptive injection/Depo-Provera, 71 used oral contraceptive pills, 65 respondents used implant or Norplant, 2 had Bilateral tubal ligation, 14 used Intrauterine Contraceptive Device (IUCD), and another 14 used condoms, with a median duration of three years for contraceptive use. Other popped out points from the open-ended questions were early and regular screening and treatment as a preventative strategy for cervical cancer.

Table 1.

Behavioral and Clinical Characteristics of participants.

Characteristics	Frequency	Percent
Type of union
Polygynous	16	5.6
Non- polygynous	267	93.4
Not currently in union	3	1.0
Number of sexual partners
1	178	31.6
>1	385	68.4
Multiple sexual partner
Yes	8	1.4
No	569	98.6
Condom use in the past 12 months
Yes	159	27.7
No	416	72.3
Contraceptive use
Yes	219	37.9
No	359	62.1
Recent HIV viral load
Not detected	480	91.6
≤1000 copies/ml	31	5.9
>1000 copies/ml	13	2.5
CD4 category
<350	114	25.4
≥350	334	74.6
WHO clinical stage
I	314	54.3
II	209	36.2
III	9	1.6
IV	5	0.9
STI history
Yes	91	15.7
No	487	84.3
STI treated
Yes	90	98.9
No	1	1.1
Have you ever been vaccinated for HPV?
Yes	3	0.5
No	575	99.5
Duration with HIV (in years)
<12	274	47.7
≥12	300	52.3
Duration on ART (in years)
<10	254	44.4
≥10	318	55.6

Participants’ duration of life with HIV ranged from a minimum of 1 month to a maximum of 25 years, with a median duration of 12 years. Their median ART experience was 10 years. Attempts were made to categorize the duration of life with HIV and ART treatment experience into two groups: less than the median value and greater or equal to the median value (<12 and >=12 years) and (<10 and >=10 years), respectively. This categorization aimed to explore any significant associations with participants’ knowledge and practices towards cervical cancer prevention and control.

The median CD4 value of the participants was 515.5, with approximately a quarter (25.4%) having a value lower than 350 cells/mm³. The majority (91.6%) had an HIV viral load below the detection limit, and 54.3% had a WHO clinical stage of I. A history of sexually transmitted infections (STIs) was reported by 15.7% of participants, with almost all (98.9%) receiving treatment. Notably, only 0.5% of participants had received vaccination for HPV (Table 1).

Understanding the Perspectives of HIV-Positive Women on Cervical Cancer Prevention and Control

In Table 2, various inquiries were made to gauge the understanding of participants regarding cervical cancer prevention and control. A significant majority (90.8%) acknowledged that cervical cancer primarily affects women. Regarding the age to commence cervical screening, over half (59.0%) suggested initiating screening at 20 years or older. Only a small fraction (3.9%) believed screening should be done monthly.

Table 2.

Knowledge Assessment: Participant Responses on Cervical Cancer Prevention and Control.

Characteristics	Number	Percent
Who should be eligible to get cervical cancer?
Female only	522	90.8
Male only	2	0.3
Both male and female	51	8.9
At what age should cervical screening/examination commence for girls?
At age less than 20 years	119	22.6
At age 20 years and above	311	59.0
Don’t know	97	18.4
Could you provide information on the frequency of cervical screening?
Every month	20	3.9
Every 1 year	188	36.6
Every 2 years	192	37.4
Every 3 years	53	10.3
Every 5 years	60	11.7
Is unprotected sexual intercourse the cause for cervical cancer?
Yes	463	80.1
No	51	8.8
Don’t know	64	11.1
Are HIV positive women more likely to develop cervical cancer?
Yes	453	78.4
No	69	11.9
Don’t know	56	9.7
Is cigarette smoking a risk factor for cervical cancer?
Yes	382	66.1
No	75	13.0
Don’t know	121	20.9
Is deep kissing the cause of cervical cancer?
Yes	80	13.8
No	228	39.4
Don’t know	270	46.7
Is cervical cancer a preventable disease?
Yes	426	73.8
No	51	8.8
Don’t know	100	17.3

More than 70% of respondents recognized that early unprotected sexual activity increases the risk of cervical cancer, and a similar percentage (73.8%) correctly identified cervical cancer as preventable. Interestingly, a sizable portion (46.7%) were uncertain about whether deep kissing contributes to cervical cancer.

Overall, these findings underscore both areas of solid understanding and gaps in knowledge among HIV-positive women regarding cervical cancer prevention and control.

Besides the variables, the multiple-choice questions used in the assessment of prevention mechanisms of cervical cancer and the most common symptoms of cervical cancer were summarized using Figure 1A and B. Less than half, 272 (47.1%) participants mentioned that avoiding multiple sexual partners was a preventative mechanism of cervical cancer followed by avoiding early sexual debut (35.1%). The most common symptoms of cervical cancer mentioned in less than half the respondents were unusual discharge (45.0%), and abnormal vaginal bleeding (41.2%).

The mean knowledge score of the study participants was 8.41. Participants with a score greater than or equal to the mean (8.41) were categorized as having adequate knowledge, comprising 282 individuals (48.8%). Conversely, those with a score less than the mean were considered to have inadequate knowledge, totaling 296 participants (51.2%).

Utilization of Cervical Cancer Screening Among Women with HIV in Addis Ababa, Ethiopia

In this study, 182 women (31.5%) reported practicing cervical examination. The primary reason for undergoing cervical examination was the recommendation from health professionals, cited by 138 participants (79.8%), followed by the desire for early detection and treatment, mentioned by 22 individuals (12.7%), and fear of developing cervical cancer, cited by 8 participants (4.6%) [Figure 2].

Figure 2.

Reasons for undergoing cervical examination among women with HIV in Addis Ababa, Ethiopia.

The majority, 153 participants (84.1%), underwent cervical screening once in their lifetime, while 24 participants (13.2%) reported undergoing screening twice in their lifetime. The median age at which participants initiated cervical examination practice was 35 years. Among the 182 participants who underwent screening, the vast majority, 180 (98.9%), reported no challenges during the procedure. Two respondents reported discomfort (one participant) and a long waiting time (one participant). Regarding result delivery, the majority, 155 participants (85.2%), received their results on the same day, while 21 received results on subsequent days, and 8 participants could not recall the timing of result delivery.

Most of the participants had no practice of cervical examination due to the following reasons distributed as follows; participants felt healthier, 194 (49.6%), the examination was painful, 111 (28.4%), and about a quarter got shy, 91 (23.3%) [Figure 3].

Figure 3.

The reason not to perform a cervical examination among women with HIV in Addis Ababa, Ethiopia.

Predictors of Knowledge and Practice Regarding Cervical Cancer Prevention and Control among Women with HIV in Addis Ababa, Ethiopia

Crudely associated variables of interest towards knowledge about cervical cancer prevention and control were educational level, residence, parity, occupational status, income, and contraceptive use. When adjusted for the confounding effect, only educational level and income category retained their significant associations. Those participants with no formal education were 70% less likely to know about cervical cancer prevention and control compared with college or university educational level (AOR = 0.30; 95% CI = 0.13-0.71). Similarly, those participants with the educational level of elementary school were 54% less likely to know about cancer prevention, (AOR = 0.46; 95% CI = 0.23-0.90). Participants with income of less than 5000.00 ETH Birr per month were 44% to 67% less likely to know about cancer prevention (AOR = 0.56; 95% CI = 0.35-0.88), and (AO R = 0.33; 95% CI = 0.13-0.81) [Table 3].

Table 3.

Bivariate and Multivariate Analysis of predictors of Knowledge and Practice Towards cervical Cancer Prevention and Control Among women With HIV in Addis Ababa, Ethiopia.

Characteristics	Outcome		COR (95%CI)	AOR (95%CI)	Outcome		COR (95%CI)	AOR (95%CI)
	Inadequate Knowledge (<8.41)	Adequate Knowledge (≥8.41)			Not Practiced	Practiced
	Freq (%)	Freq (%)			Not Practiced	Practiced
Age Group
≤30	29(54.7)	24(45.3)	1		41(77.4)	12(22.6)	0.55(0.28-1.08)	0.61(0.29-1.32)
31-35	54(56.3)	42(43.8)	0.94(0.48-1.85)		75(78.1)	21(21.9)	0.53(0.31-0.89)	0.70(0.39-1.27)
>35	213(49.7)	216(50.3)	1.23(0.69-2.17)		280(65.3)	149(34.7)	1	1
Age at sexual debut
<18	88(52.7)	79(47.3)	1		107(64.1)	60(35.9)	1
>=18	183(49.9)	184(50.1)	1.12(0.78-1.62)		250(68.1)	117(31.9)	0.84(0.57-1.23)
Marital status
Un-married	32(52.5)	29(47.5)	1		42(68.9)	19(31.1)	1
Married	136(47.2)	152(52.8)	1.23(0.71-2.14)		196(68.1)	92(31.9)	1.04(0.57-1.88)
Divorced	63(60)	42(40)	0.74(0.39-1.39)		71(67.6)	34(32.4)	1.06(0.54-2.09)
Widowed	61(51.7)	57(48.3)	1.03(0.56-1.91)		82(69.5)	36(30.5)	0.97(0.49-1.89)
Separated	4(80.0)	1(20.0)	0.28(0.03-2.61)		4(80.0)	1(20.0)	0.55(0.06-5.28)
Educational level
No formal education	42(75.0)	14(25.0)	0.15(0.07-0.30)	0.30(0.13-0.71)	46(82.1)	10(17.9)	0.44(0.19-0.97)	0.70(0.27-1.81)
Read and write	12(57.1)	9(42.9)	0.33(0.12-0.86)	0.42(0.14-1.27)	15(71.4)	6(28.6)	0.80(0.28-2.25)	1.15(0.33-3.96)
Elementary school	94(60.3)	62(39.7)	0.29(0.17-0.49)	0.46(0.23-0.90)	99(63.5)	57(36.5)	1.15(0.68-1.96)	1.56(0.76-3.17)
High school	118(48.2)	127(51.8)	0.47(0.29-0.77)	0.61(0.34-1.12)	170(69.4)	75(30.6)	0.88(0.54-1.45)	1.01(0.54-1.91)
College or university	30(30.3)	69(69.7)	1	1	66(66.7)	33(33.3)	1	1
Residence
Urban	274(50.2)	272(49.8)	1	1	375(68.7)	171(31.3)	1
Rural	20(66.7)	10(33.3)	0.50(0.23-1.09)	0.62(0.27-1.43)	19(63.3)	11(36.7)	1.27(0.59-2.73)
Parity
Nulliparous	52(45.6)	62(54.4)	1	1	78(68.4)	36(31.6)	1
Primiparous	78(48.4)	83(51.6)	0.89(0.55-1.44)	0.96(0.57-1.62)	115(71.4)	46(28.6)	0.87(0.51-1.46)
Multiparous	157(53.8)	135(46.2)	0.72(0.47-1.11)	0.93(0.56-1.52)	194(66.4)	98(33.6)	1.09(0.69-1.74)
A grand multipara	7(77.8)	2(22.2)	0.24(0.05-1.20)	0.45(0.08-2.44)	7(77.8)	2(22.2)	0.62(0.12-3.13)
Occupational status
Unemployed	118(59.6)	80(40.4)	1	1	139(70.2)	59(29.8)	1	1
Government employee	37(40.7)	54(59.3)	2.15(1.29-3.57)	1.07(0.57-2.01)	65(71.4)	26(28.6)	0.94(0.55-1.63)	0.85(0.42-1.70)
Non-governmental employee	43(44.3)	54(55.7)	1.85(1.13-3.03)	1.36(0.78-2.38)	72(74.2)	25(25.8)	0.82(0.47-1.41)	0.92(0.49-1.72)
Self-employed	75(50.7)	73(49.3)	1.44(0.93-2.21)	1.15(0.71-1.87)	98(66.2)	50(33.8)	1.2(0.76-1.89)	1.21(0.71-2.07)
Other	23(52.3)	21(47.7)	1.35(0.69-2.59)	1.18(0.50-2.75)	22(50.0)	22(50.0)	2.36(1.21-4.58)	3.20(1.31-7.87)
Income with ETH Birr
0-499	51(64.6)	28(35.4)	0.27(0.15-0.48)	0.45(0.23-0.88)	52(65.8)	27(34.2)	0.76(0.43-1.35)	0.80(0.39-1.64)
500-999	20(69.0)	9(31.0)	0.22(0.09-0.52)	0.33(0.13-0.81)	24(82.8)	5(17.2)	0.31(0.11-0.85)	0.26(0.09-0.78)
1000-4999	162(54.4)	136(45.6)	0.41(0.27-0.62)	0.56(0.35-0.88)	218(73.2)	80(26.8)	0.54(0.35-0.82)	0.50(0.30-0.82)
>=5000	47(32.9)	96(67.1)	1	1	85(59.4)	58(40.6)	1	1
Family history of cervical cancer
yes	14(51.9)	13(48.1)	1		18(66.7)	9(33.3)	1
No	282(51.2)	269(48.8)	1.03(0.47-2.23)		372(68.3)	173(31.7)	0.92(0.40-2.08)
Multiple sexual partners
Yes	4(50.0)	4(50.0)	1		6(75.0)	2(25.0)	1
No	291(51.1)	278(48.9)	0.95(0.24-3.86)		389(68.4)	180(31.6)	1.39(0.28-6.95)
Number of sexual partners
1	91(51.1)	87(48.9)	1		117(65.7)	61(34.3)	1
>1	205(51.2)	195(48.8)	0.99(0.69-1.42)		279(69.8)	121(30.3)	0.83(0.57-1.21)
Condom use during coitus in the past 12 months
Yes	75(47.2)	84(52.8)	1		99(62.3)	60(37.7)	1	1
No	220(52.9)	196(47.1)	0.79(0.55-1.15)		294(70.7)	122(29.3)	0.69(0.47-1.01)	0.75(0.49-1.15)
Modern contraceptive use
Yes	122(55.7)	97(44.3)	1	1	157(71.7)	62(28.3)	1	1
No	174(48.5)	185(51.5)	1.34(0.95-1.87)	1.25(0.85-1.85)	239(66.6)	120(33.4)	1.27(0.88-1.84)	1.43(0.94-2.19)
Prior STI history
Yes	50(54.9)	41(45.1)	1		60(65.9)	31(34.1)	1
No	246(50.5)	241(49.5)	1.19(0.76-1.87)		336(69.0)	151(31.0)	0.87(0.54-1.39)
Duration of women with HIV
<12 years	146(49.8)	128(45.6)	0.84(0.61-1.17)		213(54.3)	61(33.5)	0.42(0.29-0.61)	0.49(0.29-0.84)
>=12 years	147(50.2)	153(54.4)	1		179(45.7)	121(66.5)	1	1
Duration on HIV ART
<10 years	131(44.9)	123(43.9)	0.96(0.69-1.34)		194(49.6)	60(33.1)	0.50(0.35-0.73)	0.85(0.49-1.46)
>=10 years	161(55.1)	157(56.1)	1		197(50.4)	121(66.9)	1	1

Regarding the practice of cervical examination, the variables of interest crudely associated were age category, educational level, occupational status, income category, condom use, modern contraceptive, and duration of women with HIV using a median year as a cutoff, and duration of women on ART. Among these factors, occupation, income, and duration of HIV diagnosis emerged as consistently significant predictors of women’s practice after adjusting for confounders. Other occupations, including housewife, had 3.2 times higher experience practices of cervical examination than their counterparts, (AOR = 3.20; 95%CI = 1.31-7.87). Participants with income category of below 5000.00 ETH Birr were 50% to 74% less likely to practice cervical examination compared with women with a greater income (AOR = 0.50; 95%CI = 0.30-0.82), and (AOR = 0.26; 95%CI = 0.09-0.78). Women who were living with HIV of a duration below 12 years were 51.0% (AOR = 0.49, 95% CI = 0.29-0.84) less likely to practice cervical examination in their lifetime [Table 3].

Out of the total 27 women with HIV who reported a family history of cervical cancer, 10 (37.0%) indicated that their aunts had a history of cervical cancer, followed by mothers, with 8 individuals (29.6%).

Discussion

There is no doubt that cervical pre-cancer screening and treatment are the cornerstones for the prevention and control of the disease. To enhance the screening and treatment opportunities, awareness creation in general and improved knowledge of women with HIV in particular is crucial.¹⁹ The findings of this study shed light on various aspects of cervical cancer prevention and control among women with HIV in Addis Ababa, Ethiopia. Several key findings warrant discussion, including the experience of cervical examination practice, reasons for undergoing screening, challenges faced during screening, predictors of knowledge and practice, and the presence of a family history of cervical cancer among participants.

Our study revealed that only 48.8% of women with HIV had adequate knowledge, and 31.5% of them to experience cervical examination practice indicating a relatively low uptake of screening services in this population underscore the need for targeted interventions to increase awareness and uptake the cervical cancer screening.

Compared with some previous studies done in Zambia, which reported 62.4%²⁰ and West Shoa Zone, Central Ethiopia that documented 49.6% among similar participants²¹ our present finding was lower. Other studies in different settings reported lower knowledge score of 43.0% than our present findings, including the pool knowledge estimate.²² The study among the general population of women indicated a 43.1% knowledge score on cervical cancer,²³ and 27.7% had adequate knowledge of cervical cancer screening.²⁴ In addition, women of the reproductive age group had an overall knowledge of 19.87% of cervical cancer and its prevention.²⁵ Lower finding among women with HIV was also reported elsewhere, 20.7%.²⁶ HIV-seropositive women had adequate knowledge scores than seronegative women,²⁷ and those with unknown HIV status.²⁸ This is likely²⁹ because of their frequent HIV clinic visits and follow-ups lending better health literacy regarding the facts about cervical cancer prevention among women with HIV.³⁰

The primary reason reported for undergoing cervical examination was the recommendation from health professionals, indicating the influential role of health care providers in promoting screening uptake. However, it is noteworthy that fear of developing cervical cancer was indicated as a reason by a small proportion of participants, highlighting the importance of addressing misconceptions and providing education on the benefits of early detection and treatment.

The observed knowledge score differences in general might be due to the differences in the study participants’ age, settings, sample size, and educational status, among others. Age, education, and other factors had an impact on cervical cancer screening participation,³¹ that might have an impact equally on the variation of the responses of the study participants. In our study, participants with college or university education had better knowledge, and the finding is concordant with the study in Zimbabwe.³² Women with good incomes showed better knowledge and to easily access to cervical cancer screening services is in line with our findings. According to the evidence by Massad et al, and their team, understanding cervical cancer screening was a challenge and the weakest practice for less-educated and lower-income women²⁷ as opposed to those with more education and higher income group whose knowledge and practice was better.²⁹

Regarding practice toward cervical cancer screening and treatment, about 71.3% of women with HIV practiced adequate screening,²⁶ and 50.2% had ever screened for cervical cancer³³ with a pooled estimate of practice toward cervical cancer screening and diagnosis of 41.0%²² and 36.5% of screening practice.²⁰ The reported findings were higher than our recent finding, 31.5%. On the other hand, lower figure of screening practice was reported in Ethiopia among women with HIV, 25.0%,¹⁶ and 22.9% for the general population.²³ The lowest findings of 1.4% cervical screening uptake were reported for the Nigerian study among the general population of women.³⁴

Women with better income practiced cervical examination in our study and this finding is concordant with some previous study which documented income to have an association with the uptake of cervical cancer prevention strategies.³⁵ Our study disclosed that, women who were living with HIV for a longer period had better cervical examination practice that was similar to the northern Tanzanian report.³³

In our study, challenges encountered during cervical screening were minimal, with most participants reporting no difficulties during the procedure. However, it is essential to address any discomfort or long waiting times reported by a minority of participants to ensure a positive experience and encourage future screening attendance. Occupation, income, and duration of HIV diagnosis emerged as significant predictors of women’s practice regarding cervical cancer prevention and control. These findings suggest that socioeconomic factors and duration of HIV diagnosis play a crucial role in shaping healthcare-seeking behaviors among this population. Interventions aimed at improving knowledge and access to screening services should consider these factors to effectively target high-risk groups.

Like in most studies, health professionals were the sources of information for screening and cervical cancer prevention in our study,^16,28,33 though this was not the case for the Morocco study where media was reported as the source of information about the issue.³⁶ Abnormal vaginal bleeding was a common symptom of cervical cancer mentioned by 41.2% in this study, and the finding was closer to the study conducted in Eastern Uganda which documented 43.3%.³⁷ Our study disclosed that nearly half of the women with HIV did not practice cervical cancer screening because they consider themselves healthy, and some feel shy and others were afraid of the procedure deserves more advocacy work to revert the grave consequences from the diseases which is a silent killer. Additionally, the presence of a family history of cervical cancer among a subset of participants underscores the importance of comprehensive risk assessment and genetic counseling in cervical cancer prevention efforts. Further research is needed to explore the genetic and environmental factors contributing to the clustering of cervical cancer within families and inform personalized screening strategies.

Pain and discomfort were the associated barriers of cervical cancer screening uptake among a quarter of women in our study and similar barriers was reported by Fletcher et al, 2014.¹⁵ The other important findings picked in the present study was that only three participants were vaccinated in this study, unlike the US study which reported 43 participants to be vaccinated as the primary prevention of the virus³⁸ underscores the need for the line ministry to implement the vaccine strategy as a primary prevention and consequently reduce the burden of mortalities due the disease. The fact that vaccination has not been implemented for the last decades in Ethiopia, such an alarming incidence of cancer in the country is not surprising.³⁹

The responses to the open-ended questions revealed that early and regular screening and treatment were mainly mentioned as a prevention strategy for cervical cancer. Other than this, avoiding unprotected sexual activity and sexual partner, using condoms during sexual debut, communicating with health professionals, and having regular follow-up, health education, Holy water, personal hygiene and washing after sexual contact, avoid sexual contact with cancer-positive and HIV-positive individuals were among some of the narratives captured through the respondents. One client in addition to what has been stated above mentioned that ‘avoiding food poisoning’ was an important preventative mechanism for cervical cancer.

Limitation of the Study

In this study, data were collected from hospitals with ART burden that had initiated cervical cancer screening by well experienced and trained clinicians who served as data collectors through a well-designed ODK and submitted the collected data directly to the national server on timely basis is the strength of the study. Nonetheless, there was a resource constraint to reach-out to different regions for the national representativeness, and might be a limitation of the study in the external validity. The knowledge score generated was based on mean score rather than use of validated knowledge scale might be another minor limitations of the study.

Conclusion

More than half of the participants had inadequate knowledge towards cervical cancer screening and prevention, and over two-thirds had no cervical examination practice. Better educational level and income were important factors in boosting knowledge towards cervical cancer screening and prevention strategies. In addition, those with better income utilized the screening and diagnosis services. Moreover, a better cervical examination practice was identified among women whose life experienced with HIV for more than a decade. Addressing barriers to screening uptake, strengthening provider recommendations, and tailoring interventions to address socioeconomic disparities are crucial steps towards reducing the burden of cervical cancer in this vulnerable population. To increase the uptake of the screening strategy, a combination of actions that include vaccination, continual education to boost literacy among women and behavioral change communication, Mobile health, and empowerment of women through income generating scheme is recommended.

Footnotes

Acknowledgments

The authors extend gratitude to the Ministry of Science and Higher Education (MoSHE), National Research Ethics (NRERC), Aklilu Lemma Institute of Pathobiology, City Government of Addis Ababa Health Bureau, Yekatit 12 Hospital Medical College, and St. Paul’s Hospital Millennium Medical College, for clearing the study. We extend our thanks to the Federal Ministry of Health (FMOH) in Ethiopia for writing a support letter to the responsible bodies including Health Bureaus to conduct the study. Kidist Alemayehu, Million Hailu, and Girma Zemedu acknowledged for their support in open data kit template design and data collection training facilitation. Finally, we also thank all study participants and data collectors for their invaluable contribution during the study period.

Authors’ contributions

“AL designed the study and participated in the Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing – original draft; JH participated in the conceptualization and critically reviewed the manuscript and add-up the valuable scientific input for the article; ZS participated in the critical review of the manuscript. All authors read and approved the final manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Seed money was obtained from Addis Ababa University for data collection

Ethical Statement

ORCID iDs

Bogale Agajie Likie

Ali Jemal Haidar

Data Availability Statement

All data generated or analyzed are included in this published article.

Appendix

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