ABSTRACT
Background: The COVID-19 pandemic rapidly altered cancer care delivery globally, providing a compelling opportunity to empirically study how these changes impacted persistent disparities in care. Cervical cancer is one of the most common female cancers worldwide, with approximately 90% of cases and deaths occurring in low- and middle-income countries (LMICs). In Botswana, a LMIC with a particularly high prevalence of HIV and cervical cancer, delays in cervical cancer diagnosis and treatment have been documented but is unknown how these delays may have been mitigated or exacerbated since the pandemic. Methods: The objective of this analysis is to evaluate patterns of cervical cancer diagnosis and treatment initiation before (January 2015-March 2020) and during the pandemic (April 2020-July 2021) using longitudinal clinical and patient-reported data from a cohort of over 1,000 patients receiving care for gynecologic cancers in Botswana. The primary outcome is timeliness of treatment defined by the number of days between first clinical visit and initiation of first-line treatment and categorized dichotomously (> 30 days classified as delay). Primary exposure is the time period (prepandemic and pandemic) defined by the month of first visit. We calculated unadjusted proportion of delays and covariates stratified by time period and used bivariate analysis to examine factors associated with each time period. We used multivariable logistic regression models to examine the association between delay and time period, adjusting for all covariates (age, stage, HIV status, rurality, screening history, and partner status). Results are presented as unadjusted proportions, adjusted odds ratios (AOR), and 95% confidence intervals. Results: Of the 1,200 patients treated for cervical cancer at the multidisciplinary clinic, 990 (82.5%) were diagnosed pre-pandemic and 210 (17.5%) during the pandemic. Among all patients with gynecologic cancers (n = 1,568), the proportion of patients with cervical cancer significantly decreased from 78.6% pre-pandemic to 68.0% during the pandemic (p < 0.001). In comparison to pre-pandemic, patients with cervical cancer during the pandemic were significantly less likely to have attended a screening clinic prior to their treatment (57.6% vs 15.3%;p < 0.001) and significantly more likely to experience treatment delays (61.6% vs 92.9%;p < 0.001). In the multivariable model, patients diagnosed during the pandemic had a 7-fold higher likelihood of treatment delays than those patients diagnosed pre-pandemic (AOR: 7.95;95% CI: 4.45-14.19). Conclusions: The pandemic significantly increased delays in treatment for nearly all patients with cervical cancer in Botswana. Given persistent global disparities in cervical cancer, there is a great need to implement evidence-based strategies for improving screening and timeliness of care in Botswana and other LMICs.
ABSTRACT
Background: Botswana has a high prevalence of women living with HIV (WLHIV) and experienced a severe nationwide COVID-19 epidemic in 2021. We evaluated adverse birth outcomes among women routinely tested for COVID-19 by HIV status, during a period when few women had access to COVID-19 vaccination. Methods: The Tsepamo Study performs birth outcomes surveillance at government hospitals throughout Botswana. We analyzed data from 13 Tsepamo sites that performed routine COVID-19 screening at delivery with rapid antigen or PCR testing between Sept 1, 2020 and Sept 30, 2021 (start dates differed by site). This analysis includes singleton deliveries with known HIV status and a COVID-19 screening test between 14 days prior and 3 days after delivery. Outcomes included maternal death, preterm delivery (PTD), very preterm delivery (VPTD), small for gestational age (SGA), very small for gestational age (VSGA), stillbirth, and neonatal death. Differences in outcomes by COVID-19 and HIV status were assessed using log binomial regression adjusted for maternal age. Results: A total of 17,627 deliveries occurred at the included sites during COVID-19 screening, and 11,149 (63.3%) were screened for COVID-19;among 10,090 (99.7%) with a known HIV status, 530 (5.3%) COVID-19 tests were positive, including 141/2129 (6.6%) among WLHIV and 389/7961 (4.9%) among women without HIV (aRR 1.32, 95% CI 1.09, 1.60). Maternal deaths were reported in 19 (3.8%) women with COVID-19 and 11 (0.12%) women without COVID-19 (aRR 30.5, 95% CI 14.6, 63.7), and did not differ by HIV status. Adverse birth outcomes (any) were more common among infants born to women with COVID-19 (34.3% vs. 26.3%;aRR 1.32, 95% CI 1.16,1.49), including PTD (21.2% vs. 13.3%;aRR 1.60, 95% CI 1.34,1.90) and stillbirth (5.5% vs. 2.8%;aRR 1.89, 95% CI 1.30,2.75), and there was a trend for higher neonatal mortality (2.0% vs. 1.4%, aRR 1.5, 95% CI 0.79, 2.85). Most adverse birth outcomes were highest among infants exposed to both COVID-19 and HIV (Figure 1). Conclusion: Infants born to women with COVID-19 experienced more adverse birth outcomes than other infants, including a 2-fold risk for stillbirth. Those exposed to both COVID-19 and HIV had the highest risk for most adverse outcomes. Further research is warranted to understand the biological interaction between COVID-19, HIV infection, and adverse birth outcomes, and whether some associations were impacted by challenges in care delivery during the height of the COVID-19 epidemic in Botswana.