The broad, long-term objective of this project is to reduce the rates of cervical cancer in Botswana and other sub-Saharan African countries. In Botswana, the HIV prevalence rate among adults 15 to 49 years of age in 2011 was 23.4%, which was the second highest prevalence rate in the world. The primary mode of HIV transmission in Botswana is heterosexual exposure. Of particular concern is the high prevalence in antenatal clinics, where the age-adjusted HIV prevalence among pregnant women ages 15 to 49 years was 30.4% in 2011. The high HIV prevalence in Botswana contributes to an increased prevalence of HIV-associated comorbidities, including cervical cancer. Among women in Botswana, cervical cancer is the most common cancer and the second most common cause of cancer deaths. About 21% of women in the general population of Botswana harbor cervical HPV infection, and considerable evidence suggests increased risk of HPV in people living with HIV. This project addresses the urgent need for research on factors affecting screening for HPV, risk of HPV and HIV acquisition, treatment seeking, and retention in treatment among women in Botswana. The project will utilize data from participants in the 3 cohorts of the grant: Cohort 1 ^ first-year undergraduate women at the University of Botswana, Cohort 2women captured at the time of their cervical-cancer screening, and Cohort 3women diagnosed with cervical cancer who are undergoing treatment. An important first step in increasing any health-related behavior is the identification of factors that affect that behavior. Some of these factors will be immutable, stable characteristics that are not amenable to intervention such as demographic variables (e.g., age, family history, and socioeconomic background). Identifying stable immutable predictors helps to identify subgroups of women with differential needs for intervention. Other factors will be modifiable, amenable to change, variables that behavioral interventions can target to increase healthful behavior (e.g., knowledge, beliefs, and attitudes). Behavior-change interventions are likely to be most efficacious if they draw upon a theoretical framework and are tailored to the population. The proposed research will draw upon social cognitive theory and the reasoned action approach, which are theoretical frameworks that have been used in a wide variety of behavior-change interventions, including interventions in sub-Saharan Africa. Qualitative research will be used to identify salient beliefs about the behaviors of interest in the target populations. The prospective cohort designs will allow us to identify the predictors of the target behaviors and to examine whether theoretical variables explain them. Participants will complete confidential web-based surveys at 6-month intervals for 3 years in Cohorts 1 and 2 and for 2 years in Cohort 3.
The Specific Aims are to identify prospective predictors of cervical-cancer screening, acquisition of HIV and HPV infection, treatment seeking in women screened for cervical cancer, and remaining in treatment among women diagnosed with cervical cancer.
The proposed research has important public health relevance. The rates of cervical cancer are disproportionately high in developing countries, women in countries with a generalized HIV epidemic are especially vulnerable to HPV, the virus associated with cervical cancer, screening for cervical cancer is an effective prevention strategy, screening is underutilized in Botswana and other developing countries, early treatment is important to reduce the deleterious consequences of cervical cancer, but limited research has examined the determinants of screening, acquisition of HPV, seeking of treatment for cervical cancer, and retention in treatment for cervical cancer in developing countries, including Botswana. This research is designed to address these gaps in the literature.