A stigma responsive service delivery model for HPV-based screening among women living with HIV - ABSTRACT Women living with HIV (WLWH) are at increased biologic risk for infection with human papillomavirus (HPV) and development of pre-invasive and invasive cervical cancer. The World Health Organization has recently called for HIV-programs to bolster their efforts to prevent cervical cancer through integrated screening services. Understanding and addressing stigma, including the intersection of HIV, HPV and cervical cancer-related stigma, will be crucial to designing interventions that will facilitate the uptake of cancer screening among WLWH and women in high HIV prevalence settings like western Kenya. Cancer-related stigma negatively influences several determinants of cancer screening uptake, including perception of cancer risk, cancer screening benefit, and acceptability of screening methods. In our prior work to evaluate HPV-based screening in Kenya, we found that lack of education about cervical cancer and low awareness of screening benefits, both of which can potentiate cancer-related stigma, were major barriers to screening uptake. Our team also found that misperceptions and stigma about an HPV diagnosis and cancer were associated with reduced rates of follow-up among women who tested positive for HPV. Our team developed a stigma framework to inform and validate a measurement tool for HPV-, cervical cancer- and HIV-related stigmas. We found that educational messages focused on cancer-related outcomes and HPV epidemiology, including risks related to sexual behavior and HIV, were stigmatizing, while support from social networks and emphasis on the availability of effective treatment reduced stigma and promoted screening uptake. We used this data to develop a stigma-responsive educational intervention which includes simplified scripts for multiple cadres of health workers that provide clear messages about HPV and the benefits of screening and a video aimed at addressing fears and misperceptions from a peer perspective. We propose to incorporate these educational components into “Elimisha HPV,” a multilevel stigma-responsive cervical cancer prevention service delivery model for integration within clinics providing HIV-care in western Kenya. Elimisha HPV, which in Kiswahili means to increase understanding of HPV, will include the following components: HPV-testing via self-collection, simplified scripts and video, peer navigators for women with screening or treatment hesitancy, and the option to receive results and information via text messages. To adapt, implement and test the effectiveness of this model, we will: 1) work with key stakeholders to finalize Elimisha HPV 2) compare cervical cancer prevention outcomes and engagement in HIV care in clinics offering the Elimisha HPV model to clinics providing standard of care outreach, education and screening strategies; and 3) identify individual and institutional factors that moderate the effects of Elimisha HPV on cervical cancer prevention outcomes. If effective, this may represent a new model for HPV-based cervical cancer screening as well as a new paradigm for comprehensive, stigma-responsive service delivery packages for people living with HIV.
