Impact of the 2013 WHO guidelines for screening and treatment of cervical pre-cancerous lesions on women's screening uptake, by HIV-status, in Eastern and Southern Africa: a regression discontinuity design analysis.
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BACKGROUND: The 2013 World Health Organization (WHO) guidelines for cervical pre-cancer screening recommended screening women aged 30–49 and women living with HIV (WLHIV) starting at age 25. However, the impact of the guidelines and the age to start screening on screening uptake has not been studied. METHODS: We used a regression discontinuity design analysis of population-based data to assess the impact of the guidelines on the screening rates for women according to HIV status and age group in Ethiopia, Malawi, Rwanda, Tanzania, Zambia, and Zimbabwe. Although the PHIA surveys were conducted after 2014, when countries adopted the guidelines, the women were asked to report whether they had been screened for cervical pre-cancer at any point between 2008 and 2018. From the women’s screening reports, we identified reports of being screened from 2008 to 2014 and after 2014 to 2018. These reports were random and unique. They enabled us to compare the screening rates from the period 2008 to 2014 and after 2014 to 2018 ‒ pre and post the intervention ‒ by HIV status, and before and after the age of 25 years. We used a data-driven optimal bandwidth selection procedure to estimate the guidelines’ average treatment effect with local polynomial regression discontinuity and robust bias-corrected confidence intervals. RESULTS: We included 73,179 women: 6680 (9.1%) living with HIV, 4328 (5.9%) with unknown HIV status, and 62,171 (85.0) with a negative HIV status. Adolescent girls and young women living with HIV (AGYWLHIV) aged 15–24 reported screening less often (102 (6.1%)) than their peers with unknown (66 (7.2%)) (P < 0.001), or or older women. CONCLUSIONS: We found no evidence the 2013 WHO guidelines impacted women’s cervical pre-cancer screening uptake. However, AGYWLHIV reported screening less often. Policymakers should lower the age to screen WLHIV from 25 to 15 to screen more AGYWLHIV. Studies are required to examine the impact of the guidelines on cervical pre-cancer screening in more countries.