Cervical cancer screening and rates of HPV vaccination among women and people with a cervix living with HIV in Canada

Cervical cancer, caused by Human Papillomavirus (HPV) infection, is one of the most common gynecologic cancers. Cervical cancer is preventable through vaccination, routine screening, and follow-up of abnormal screening results. Women and people with a cervix living with HIV (women with HIV) experience higher rates of persistent HPV infection and cervical cancer, yet, in Canada, rates of vaccine uptake within this population remain largely unknown. Moreover, women with HIV are less likely to participate in cervix screening due to higher rates of discrimination, trauma, and HIV stigma. HPV testing with the option of self-sampling has been implemented in select provinces in Canada. HPV testing is a highly sensitive screening method, and can be self-collected by patients, mitigating many barriers to screening; however, understanding how this screening method impacts referrals to colposcopy and further follow-up procedures remains underexplored. In the context of unknown HPV vaccination rates and very limited screening program data, the aims of this thesis are to determine rates of HPV vaccination and the acceptability of HPV self-sampling among women with HIV in Canada, in the context of a reduced-dosing trial of the nonavalent HPV vaccine. Additionally, this thesis aims to investigate HPV prevalence and estimates for colposcopy referrals according to the BC Cervix screening algorithm among a cohort of women with HIV from a prospective vaccine immunogenicity study. Among five study sites located across Canada, vaccination rates among women with HIV were low (47.2%). Regarding women with HIV’s acceptability of HPV self-sampling, among a cohort of 117 women with HIV, 82.1% agreed that they would use HPV self-sampling for future cervix screening. Many participants were concerned about the implications of receiving a positive HPV result. Almost half (47.2%) of participants had oncogenic HPV detected at study entry, and 15.9% of participants had oncogenic HPV detected each year for three years, which would have resulted in three consecutive referrals to colposcopy. Our data suggest that more efforts are needed to increase HPV vaccine access and uptake among women with HIV in Canada, and to provide education and support around HPV self-sampling and follow-up procedures of screen-positive women with HIV.