Knowledge of HPV / cervical cancer and acceptability of HPV self-sampling among women living with HIV : A scoping review

Cervical cancer rates are disproportionately high among women living with the human immunodeficiency virus (wlhiv). Cervical cancer is preventable through hpv screening, regular Pap tests, and early cancer detection. Evidence indicates that hpv and cervical cancer screening are suboptimal among wlhiv, who face a myriad of access barriers. Considering that screening is an effective first-line defense to cervical cancer, we conducted a scoping review with the aim of gaining a better understanding about: (1) the knowledge and perceptions of hpv and cervical cancer screening among wlhiv; and (2) the acceptability of self-sampling for hpv among wlhiv. We searched five electronic databases for peer-reviewed articles that were published in English within the last ten years, reported on studies with hiv-positive women who were aged 16 or older, and satisfied the topics of the review. A total of 621 articles were found. After accounting for duplicates and unmet criteria, 17 articles and 1 abstract, reporting on studies in the United States and Africa, were included in this review. The review highlighted that most wlhiv had inadequate knowledge of hpv transmission and cervical cancer prevention, which influenced their perceptions of risk and susceptibility. Screening barriers included misconceptions about Pap tests, fear of diagnosis of serious illness, perceived pain, embarrassment, bodily modesty, and limited access to female health care providers. This review also affirms that self-sampling is an acceptable and promising screening option for wlhiv. Implications for policy, research, and practice are discussed.


INTRODUCTION
Women account for a growing proportion of hiv cases in Canada and elsewhere.Between 1985 and 2014, a cumulative total of 80,469 hiv cases were reported in Canada, with women accounting for 18.2% of all cases.Of the 2,044 hiv cases reported in 2014, women accounted for 24.6%.Further, over three-quarters of these new cases were identified as Aboriginal women (30.6%),Black women (35.6%), and other women of colour (9.6%).Heterosexual contact was identified as the key category of exposure 1 .
With the widespread use of highly active antiretroviral therapy (haart), the incidence of hiv-defining cancers such as Kaposi sarcoma and non-Hodgkin lymphoma have declined dramatically, but cervical cancer rates have remained high among women living with hiv (wlhiv) 2 .Cohort studies in Canada and the United States have consistently shown that the risk of invasive cervical cancer is higher among wlhiv than hiv-negative women 3,4 .Other studies have confirmed that the prevalence of high risk human papillomavirus (hrhpv) infection is also higher and more persistent in wlhiv 5,6 .There is general agreement t hat a long histor y of hiv infection and prolonged immunosuppression are associated with persistent hpv infection and invasive cervical cancer 7,8 .
Current Canadian guidelines on cervical cancer screening recommend that wlhiv receive Papanicolaou (Pap) tests at the initial assessment and at six months, with an annual follow-up for women with normal results 9 .However, cervical cancer screening remains suboptimal among wlhiv.Results of a Canadian retrospective population-based study of 2,661 wlhiv living in Ontario show that only up to half of the women had adhered to the cervical cancer screening guidelines 10 .Similarly, results of another retrospective cohort study of 218 wlhiv in Ottawa indicated that 42% of the participants did not undergo cervical cancer screening during the 3-year period even though 94% of them listed that they had primary care providers in their medical records 11 .
Studies in Canada have identified myriad barriers that deter wlhiv from accessing health care, including structural racism 12,13 , hiv-related stigma a nd discrimination within and outside of the health care system 14,15 , and criminalization of hiv non-disclosure 16 .Other studies show that the utilization of health services and the uptake of cancer screening among marginalized groups are associated with their health literacy 17,18 .These findings suggest that socially inclusive, innovative, and relevant strategies are needed to promote hpv and cervical cancer screening among wlhiv.Insights from studies on hiv self-testing 19 suggest that hpv self-sampling is a potential strategy to effectively engage marginalized wlhiv.
Drawing on a critical health-literacy framework 20 , we conducted a scoping review to explore two questions: (1) What has been reported on the knowledge of hpv and/ or cervical cancer screening among wlhiv in Canada and other countries?(2) What has been reported on the acceptability of hpv self-sampling among wlhiv in Canada and other countries?

METHODS
This scoping review is informed by the framework of Arksey and O'Malley 21 .We applied a multi-step approach that included the following: (1) identifying our search topics and questions; (2) searching for relevant studies; (3) selecting relevant studies based on the review questions; (4) charting the data collected; and (5) synthesizing the data collected into themes.Further, we adopted an additional step proposed by Levac and her colleagues 22 , that is, connecting the meaning of the findings to the overall study purpose and discussing the implications for future research, policy, and practice.

Search Strategies and Inclusion Criteria
Our search focused on peer-reviewed articles that report on either primary or secondary sources of evidence.We searched five databases: PubMed, CINAHL, OVID/ Medline, ProQuest, and Google Scholar.The search terms included acceptability, attitudes, perceptions, knowledge, human papillomavirus/hpv, cervical cancer screening, self-sampling/self-collection/self-testing/self-screening, home-based collection, human immunodeficiency virus/ hiv, wlh, wlhiv, and wlha.Inclusion criteria consisted of (1) peer-reviewed English language publications within the last ten years, (2) engaged women, aged 16 or older, living with hiv in Canada or elsewhere, and (3) the researched topics fitted with the two foci of this scoping, review, i.e., knowledge of hpv and cervical cancer, and the acceptability of hpv self-sampling.We limited our search to a ten-year period to coincide with the establishment of the Screening Performance Indicators Working Group (spiwg) in 2007.The spiwg defines core performance indicators for cervical cancer screening programs in Canada and facilitates interjurisdictional comparison 23 .A total of 621 articles were retrieved from the five databases.After accounting for duplicates (n=150) and unmet criteria (n=453), a total of 603 articles were excluded (see Figure 1).A table was used to identify pertinent study information on study authors, location of study, and study characteristics/population (see Table I).Each item included in this review was reviewed in its entirety, and relevant information was extracted to inform this synthesized review.

RESULTS
The results of this review show that there is a paucity of research on wlhiv's knowledge on hpv and cervical cancer screening, and their acceptability of self-sampling.A total of 17 articles and 1 abstract met the inclusion criteria.We included 1 published abstract of a relevant study that was informative but had not yet been published as an article or report.Ten of the articles focused on knowledge of hpv and cervical cancer screening among wlhiv, but 3 of these 10 articles were from the same research study reporting on different aspects of the study results.The

Part 1: Knowledge of WLHIV about HPV and cervical cancer screening
Of the eight studies (10 articles) included in the knowledge section of this review, three used qualitative methods of focus groups or individual interviews to explore knowledge and perceptions of hpv and cervical cancer screening [24][25][26] , and five used questionnaires to test knowledge, attitudes, perceptions, and screening behaviours [27][28][29][30][31][32][33] .A synthesized analysis of the data derived resulted in five major themes: (1) knowledge of hpv and cervical cancer screening; (2) factors influencing knowledge; (3) perceived risks and susceptibility; (4) misconceptions and barriers; and (5) screening compliance and adherence.

Knowledge of HPV and Cervical Cancer Screening
Our review results revealed that wlhiv across all regions had limited knowledge regarding hpv transmission and cervical cancer prevention.Most of them had not heard of hpv and did not know how hpv is transmitted 24,29,33 .Further, many wlhiv were unaware of the risk of cervical cancer and did not know that it is preventable 25,31 and that hiv infection increases the risk of hpv and cervical cancer 29 .Although some women were aware that their hivpositive status and current sexual activities put them at risk of cervical cancer 26 , and that cervical cancer screening is important for wlhiv 27,32,33 , their knowledge about followup screening was mixed.Some recognized the need for regular Pap tests and repeated Pap tests after an abnormal test, but others thought that 'doing nothing' was one of the acceptable follow-up options 27 .Many were unaware of the screening recommendations for wlhiv 25,26 .

Factors Influencing Knowledge
Numerous individual and social factors shaped the knowledge of wlhiv regarding hpv and cervical cancer screening, including adequate and effective communication of health information from service providers 28,31,33 , media messages 32 , higher levels of education, previous history of cervical cancer screening, older age, being employed 33 .In the case of the United States and African countries, where health care access is not universal, access to hpv screening also increased wlhiv's knowledge. 33ssessment of the relationship between health literacy and increased knowledge of hpv produced mixed results.One study showed that having high or low health literacy did not make any difference to the participants' scores specific to knowledge of hpv, cervical cancer screening knowledge, and awareness of the hpv vaccine 30 .However, in a study of wlhiv with a history of abnormal Pap tests, participants with a high level of health literacy were 3.5 times more likely to read information about abnormal Pap tests given by health care providers and 4.7 times more likely to have understood the information compared with those with low health literacy 28 .Since these studies used quantitative methods, it was difficult to gain a better understanding about how the wlhiv's lived experiences,  social environments, and cultural contexts shaped their access to knowledge, as well as how they made sense of hpv and hpv-related messages or materials.

Perceived Risks and Susceptibility
Most of the wlhiv in this review lacked a clear understanding about the risks of cervical cancer associated with hiv and hpv co-infections 24,25,29,31,32 , which may explain their mixed and often contradictory perceptions about risk and susceptibility to cervical cancer.In an American study of 300 wlhiv, most participants identified having multiple sex partners and early onset of sexual intercourse as risks for cervical cancer, but few knew about hpv and other risks 31 .Women in another study conducted in the United States spoke about risks and susceptibility in the context of what they knew about hiv.Some felt that they were more susceptible to cervical cancer because they had "weak bodies" and they could catch "everything."Other women in the same study rejected the idea that being hiv-positive increased their susceptibililty 25 .Further, while some women recognized increased susceptibility among wlhiv, they did not perceive themselves to be at risk until they experienced symptoms 26,33 .Others cited a lack of family history of cervical cancer and current sexual inactivity as reasons for not considering themselves at risk 25 .

Misconceptions and Barriers
This review uncovered many myths and misconceptions held by wlhiv, which might have inf luenced t heir participation in cervical cancer screening and follow-up behaviours.Over half of the wlhiv in a Kenya-based study believed that family planning increased the risks of cervical cancer and that vaginal washing would decrease the risks.Further, many considered cervical cancer as fate or the will of God and therefore felt nothing could prevent it 33 .Some participants in the Ugandan study did not engage in screening as they believed that service providers would remove their ovaries and uterus during the procedure 26 .
In terms of barriers to hpv and cer vical cancer screening, wlhiv identified hiv stigma and discrimination from health care providers, family, and friends as a key barrier 24,25,31 .Other barriers to screening were related to psychological, sociocultural, and structural factors, including worries about finding out more health problems such as cervical cancer in addition to their hiv illnesses 25 , embarrassment, body modesty, and fear of painful procedures 26,31,31 .Many wlhiv indicated their need to have female primary care providers perform the cervical cancer screening due to their cultural and religious practices 25,32 .Others identified long wait time as a barrier to screening.

Screening Compliance and Adherence
This review also uncovered an interesting phenomenon.Many wlhiv who received instructions from health care providers to undergo follow-up screening tended to comply.For example, in a study based in the United States, participants had received a Pap test in the previous year even though none of them understood the purpose of a Pap test 24 .In a study of wlhiv with a history of abnormal Pap tests, close to half of the women indicated that they did not fully understand the information given by their primary care providers, but a majority of them complied with their recommendations of getting follow-up tests and procedures 28 .This shows that health care providers' endorsement and recommendation for screening can influence women's uptake.
Other studies suggest that screening adherence is associated with health literacy and social support.In the study of 399 women in an hiv clinic in Tanzania, only 9% of the participants had cervical cancer screening; 96% expressed the desire to learn more about cervical cancer screening and 87% prefer to have hiv-positive peer navigators to support them in learning and seeking screening services 32 .

Part 2: Acceptability of HPV Self-Sampling among Women Living with HIV
Literature on the acceptability of hpv self-sampling among wlhiv is also very limited; we included a total of eight studies (seven published articles and one abstract 34 ) in this section.In synthesizing the evidence from these eight studies, we identified three major themes: (1) acceptability and preference for self-sampling vs. clinician-collected sampling; (2) concerns regarding self-sampling; and (3) feasibility and effectiveness of self-sampling devices.

Acceptability and Preference for Self-Sampling
With the exception of one questionnaire-based study 35 , a wide array of hpv and cervical cancer self-sampling devices were assessed for acceptability in the reviewed studies: cervico-vaginal self-lavaging devices 36-38, , cervical brushes 37 , cytobrushes 34,39 , tampon-like self-collection devices 37,40 , and a vaginal swab 41 (for descriptions of these devices, see Table II).
There was a universal acceptance among wlhiv across all studies in this review for self-sampling.Familiarity with the self-sampling device was a key factor associated with women's willingness to use it.In one study of 325 wlhiv in South Africa 40 , the mini-tampon self-sampling device was used to assess the accuracy, agreement, and acceptability of self-sampled specimens versus cliniciancollected specimens.The results showed that 90% of the participants reported no difficulties with self-sampling and that the instructions were clear and easy to understand, likely because over half of the women indicated familiarity in using tampons.
Other studies found that the self-lavaging device was highly accepted by participants at hiv clinics 36,38 .The women in these studies indicated that they would prefer self-lavaging for future cervical screening because this device felt more comfortable and less painful and was quick and easy to use.Some also identified increased privacy, decreased stress and embarrassment, and the possibility of performing the test on their own time as desirable 36 .Further, one-fifth of the women sampled in Rwanda preferred self-sampling over Pap tests mainly because of detesting the pelvic examination 38 .
While all the participants remained steadfast to selfsampling being the preferred option for cervical screening, they had varying preferences regarding the location for retrieval of their self-samples.Women in a study in Kenya preferred at-home collection 35 ; women in the Ugandan study did not indicate any preference 41 .However, in a study in Pretoria, only one-tenth of the women preferred to perform self-sampling at home, while close to 65% preferred clinic-based self-collection, likely because they felt better cared for in the presence of a clinician during the collection procedure 40 .

Concerns Regarding Self-Sampling
Despite the wide acceptance of self-sampling among wlhiv, a small proportion had concerns regarding the devices and the self-sampling procedures.Some participants in an American study indicated that a pelvic exam performed by a physician would provide them with an increased sense of security; they felt that the physician would make minimal mistakes and could immediately intervene in case an abnormality was found 36 .Other women in the Rwandan and Kenyan studies expressed concerns about proper self-sample collection, pain, ability to insert the device, and not knowing how to interpret the results 35,38 .These concerns were in stark contrast to women in a study in Uganda, who expressed confidence and self-efficacy about self-sampling at home 41 .This contrast could possibly be related to the Advances in Screening and Prevention in Reproductive Cancers (aspire) project in Uganda, which has been established since 2013 to introduce self-sampling to this region and has likely helped to normalize cervical cancer self-sampling 42 .

Feasibility and Effectiveness of Self-Sampling Devices
In the context of this review, effectiveness referred to the similarity in testing scores between self-collected and physician-collected specimens, i.e., sensitivity and specificity, and feasibility was defined as the ability of participants to obtain the required amount of specimen during self-sampling without any self-or clinician-reported problems.
One study reported high specificity for cytobrush tests: the study found Pap tests were normal among 81.5% of negative home self-collected cytobrush tests 34 .Another study that utilized mini-tampons as a self-sampling device found no difference in sensitivity between the cliniciancollected samples and the self-collected samples 40 .
Previous research reported that cytologic testing of hrhpv using specimens collected through self-lavaging and those collected by clinicians had equivalent sensitivity for detecting high-grade cervical intraepithelial neoplasia 36 .
However, effectiveness of the self-lavaging devices was not assessed in any of the studies in this review.On the other hand, the self-lavaging device used with a cohort of 60 women in the Rwandan study showed moderate feasibility 38 .

DISCUSSION
We conducted this scoping review with the aim of obtaining an overall picture of wlhiv's knowledge of hpv and cervical cancer screening, their acceptance of hpv self-sampling, and current gaps in research and knowledge.The results of this review showed both a concerning and a hopeful picture.
We found that wlhiv across all countries and regions had limited knowledge regarding hiv and hpv co-infection, cervical cancer prevention, and screening recommendations.There was also inadequate communication between wlhiv and their health care providers about screening for hpv and related cancers.Many wlhiv held misconceptions about cervical cancer screening.Although some women complied with cervical cancer screening and follow-up procedures based on their service providers' recommendations, their lack of understanding about these tests impedes sustainable health behaviours.Further, their passive compliance reinforced their marginalization and disempowerment, which are contradictory to the principles of health promotion 43 .At the same time, wlhiv also reported a number of screening barriers in addition to their low hpv literacy.Women in the United States and African countries identified stigma as a barrier to access hpv and cervical cancer screening 24,25,31 .African-American wlhiv in one American study indicated that they avoid screening due to their fear of being diagnosed with cancer or serious illnesses 25 .These psychological challenges were likely unique to wlhiv, related to their experiences of being diagnosed hiv-positive 44 and encountering everyday hiv-related stigma 45 .These women and women in the Tanzanian study also indicated their need for bodily modesty and having female primary care providers perform internal exams in order to maintain their cultural and religious practice 25,32 .Perhaps because of these barriers, hpv and cervical cancer self-sampling was found to be widely accepted by wlhiv in studies across countries and settings.Participants named many advantages, including flexibility and convenience in terms of time and location, privacy, and less discomfort and pain.However, some women expressed concerns about collecting proper self-samples and felt more secure about accessing tests at health care facilities.A device that a woman inserts into her vagina.It contains a syringe in which 5 mm of buffered saline was plunged into the vagina, and the fluid specimen was retrieved by pulling back on the plunger.
Cytobrushes 37 (brand name: Evalyn Brush) A device consisting of an extended-tip spatula with an endocervical brush, which a woman inserts into her vagina and rotates the brush at the cervix five times to collect cells.
Tampon-like plastic wand device 37 (brand name: Fournier) A tampon-like plastic wand device with an electable tip which a woman inserts into her vagina and rotates the device to collect cells.
Mini-sized tampon 40 (brand name-Lil-Lets) A mini-size tampon that a woman inserts and leaves in her vagina for one to two hours before removing it and putting it in the specimen container.
Other devices 39,41 The brands and procedures for the self-sampling devices used in some studies were not specified.
Based on the results of this review, we offer a number of critical insights and recommendations.The concerns expressed by wlhiv have important policy and practice implications for primary health service delivery and health systems responses in Canada and across different countries.First, hiv and cancer have evolved over the past two decades into chronic health challenges as biomedical treatments have increased the survival rate of affected individuals.At the same time, we have also witnessed increased health disparities among individuals and groups who are simultaneously affected by multiple conditions, or what is known as synergistic epidemics (e.g., addiction and mental illness, diabetes and depression, hiv and Hepatitis C, hiv and hpv, etc.).It is important to note that synergistic epidemics (syndemics) are not merely concurrent physical diseases.Rather, they are health problems that are exacerbated by historical, sociocultural, economic, and political conditions, such as stigma and discrimination, access barriers to knowledge and services, uncoordinated health system responses, and lack of clear treatment guidelines or policies 46 .In the context of screening for hpv and related cancers among wlhiv, the adoption of a syndemic approach at the policy level will inform changes at the practice levels.For example, over the past few years, the Public Health Agency of Canada has adopted an integrated approach to address the syndemics of hiv, Hepatitis C, and other sexually transmitted and blood borne infections (stbbis) in Canada.This policy change was translated into the hiv and Hepatitis C Community Action Fund program, under which research and community service organizations were steered through funding incentives towards working more collaboratively at the local, regional and national levels, as well as expanding their program foci beyond hiv to address the co-infection of stbbi among priority (marginalized) populations 47 .However, judging by the organizations that had applied to this funding program, more deliberate efforts to promote cross-disciplinary collaboration among researchers and health care providers from the sectors of hiv and hpv-related cancer prevention is needed to develop effective responses.
Second, the framework of critical health literacy 20 offers a potentially effective strategy to address the inadequate awareness about hiv-hpv co-infection and low screening for hpv and related cancers among wlhiv.Critical health literacy can be defined as the processes and outcomes that both increase people's capacity to engage in a range of individual and collective actions that enhance their health, and also promote equitable access to health resources through policy change 20 .Critical health literacy is achieved and measured at three interconnected levels.In the context of this review, the first or basic level is measured by wlhiv's ability to access, understand, critically appraise, and then apply health information on hiv-hpv co-infection to improve or maintain their health.To support wlhiv in achieving this basic level of health literacy, accurate, socioculturally inclusive, and accessible information on hiv-hpv co-infection (e.g., fact sheets, pamphlets, quizzes, videos, stories, posters, social marketing campaigns, etc.) must be made available.At the same time, hiv-hpv care competence must also be built among other stakeholders such as hiv specialists, primary care providers, and hiv/ aids community service providers.
At the second or intermediate level, health literacy is measured by wlhiv's ability to navigate the health care systems to access the screening they need.We postulate that when wlhiv acquire adequate knowledge about hiv-hpv co-infection, they are more likely to take part in screening.However, knowledge alone does not address other systemic and sociocultural barriers.To support wlhiv in developing confidence and effective communication with their health care providers, we recommend the use of peer empowerment programs, whereby wlhiv who are knowledgeable about hiv-hpv co-infection and have positive experiences in hpv screening are recruited and trained as peer leaders to support other wlhiv to navigate the hpv and related cancer screening systems 32,48 .
At the third and highest level, health literacy is measured by wlhiv's ability to recognize the structural determinants of health and policy contexts of health care, and their engagement in social and political action that advance their individual and collective health.In Canada, under the Canadian Charter of Rights and Freedoms (1982), the Canadian Human Rights Act (1985), the Canadian Multiculturalism Act (1988), and various provincial human rights codes, health care providers and policy-makers are required to establish practice and policy guidelines that uphold and respect service users' cultural and religious beliefs and practices 49 .Within the contexts of screening for hpv and related cancers among immigrant and racialized wlhiv, the availability of hpv self-sampling in home, community, or clinical settings offers a potential solution in addressing many wlhiv's current unmet needs of time constraints, bodily privacy, or access to same-gender primary care providers.Currently, hpv self-sampling is not available in Canada.Engaging affected wlhiv in policy think-tanks is critical for the development of effective and inclusive responses on cervical cancer prevention.
Finally, we were not able to identify any Canadian research on our chosen topics during this scoping review.There are a number of plausible explanations.Within the field of cancer prevention research, research attentions have shifted to examining the clinical effectiveness and efficiency of hpv vaccines, vaccination as prevention, and the uptake of hpv vaccines among different vulnerable populations such as young women, young men, and men who have sex with men (msm).Within the hiv research field, the advent of haart has led to the assumptions that people living with hiv (plhiv) are no longer faced with serious health challenges.Research attentions have turned to hiv Pre-Exposure Prophylaxis (prep) and treatment as prevention, which, while they are important prevention strategies, do not address syndemic challenges such as disparities in hiv-hpv co-infection and hpv-related cancers among plhiv.Further, research does not take place in a vacuum.It is driven by available funding, human resources, and sociopolitical forces such as silos in education, research, and practice within and across disciplines.Research funding organizations and their review panels play an important role in shaping the topics and designs of research, as well as reinforcing or dismantling disciplinary silos in research.In Canada, it was only recently that the Canadian Institute of Health Research (cihr) began to address these silos by bringing different cihr institutes together to co-sponsor research funding opportunities.For example, in August 2017 cihr launched the Catalyst Grant: hpv Screening & Vaccination in Underserved Populations, sponsored by the Institute of Cancer Research in partnership with the Institute of Infection and Immunity in consultation with the Institute of Aboriginal Peoples' Health."Men who have sex with men (msm) and people living with hiv" were added to the original target populations (indigenous peoples, newcomers to Canada, sex workers, injection drug users and remote populations) to promote synergy 50 .
In conclusion, as Canada and other countries move forward with the 90-90-90 targets 51 to achieve population hiv viral suppression and end the aids epidemic by 2030, policy-makers and service providers must not lose sight of the commitment to promote the health and quality of life of people who are living with hiv/aids.They must ensure that the health systems work in synergy to address hiv-related syndemics, including persistent hpv infections and hpvrelated cancers 46 .Synergistic collaboration is also needed in the field of health education and health promotion to address the knowledge gap, among wlhiv and communities, about the complex interplay of hiv, hpv, and cervical cancer.Community empowerment and capacity building strategies 52 are needed to address structural violence (stigma, discrimination, racism, cultural domination, etc.) that deters wlhiv from accessing hpv and cervical cancer screening and other health services.Despite a paucity of research, hpv self-sampling seems to offer the possibility of increasing screening among wlhiv.The adoption of hpv screening in Canada will open up dialogue about hiv-hpv syndemic challenges and increase awareness in the hiv/ aids communities.Building on the principles of greater and meaningful involvement of people living with hiv/ aids (gipa/mipa), peer leadership models 48,53 may enhance self-efficacy and confidence of wlhiv who engage in hpv self-sampling.
HIV-positive women, 30 to 69 years old, attending the Kisenyi Health Unit (N=87) Quantitative: cross-sectional validated survey (open-ended and closed-ended questions) Self-sampling tool: self-collected vaginal swab Ndayisaba Verwijs, van Eeckhoudt, et al., 2013 Rwanda This study determined the feasibility and acceptability of the Delphi Screener (a novel cervico-vaginal lavage self-sampling device) among high-risk Rwandan women.60 Rwandan women, 22 to 35 years old (n=30 HIVnegative female sex workers [FSW] and n=30 HIVpositive women at an HIV clinic at Muhima Hospital) Quantitative, prospective study: 7 study visits (clinician-observed self-sampling visits scheduled between visits 5 and 7, followed by interviews) Self-sampling tool: Delphi Screener (cervico-vaginal self-lavaging device) HPV = human papillomavirus; WLHIV = women living with HIV; HBM = Health Belief Model; VIA = visual inspection with acetic acid; VILI = visual inspection with lugol's iodine; hrHPV = high risk human papillomavirus.

TABLE I Summaries of reviewed articles Citation Location Study objectives Sample/Participants Study approach (1) Knowledge of HPV and cervical cancer among WLHIV
e76 Current Oncology, Vol. 25, No. 1, February 2018 © 2018 Multimed Inc.

TABLE I Continued Citation Location Study objectives Sample/Participants Study approach (1) Knowledge of HPV and cervical cancer among WLHIV Continued Bukirwa
, Mutyoba, Mukasa et al., 2015 Uganda This study assessed barriers and motivations associated with cervical screening uptake (acetic acid and iodine/ VIA and VILI) among HIV-positive women.HIV-positive women, 25+ years of age, attending an HIV clinic (N=18); women who had never screened for cervical cancer (N=6), women who screened only once (N=6), women who fully adhered to screening schedule (n=6) Qualitative: in-depth interviews with HIV-positive women and key informant interviews with health care providers; cross-sectional study Acceptability of HPV self-sampling Murphy, Mark, Anderson, Farley, Allen, 2016 United States This study explored whether an intervention using self-sampling of cervico-vaginal cells for human papillomavirus with results counselling would increase cervical cytology ("Pap") testing among women with HIV.HIV-positive women, 18+ years of age attending an HIV clinic for a primary care visit (N=94) United States This study assessed the acceptability of a self-lavaging device (the Delphi Screener) for cervical cancer screening; compared women's preferences and reports on quality of experiences using the self-lavaging device compared with clinician collection of specimens during a pelvic exam for cervical cancer screening.Low-income women, 18+ years of age, who had received cervical cytological testing in one of three clinics in New York City (N=198), one being the Infectious Disease Clinic (IDC), which provides HIV care services to HIV-positive women of all ages (n=53) United States This study examined HPV prevalence, compared home self-collected and clinician-collected HPV-positivity, and measured the acceptability of self-collection HIV-positive women, 89% of whom were black, in Baltimore (N=68)