BackgroundPhD programs typically emphasize scientific competencies but may insufficiently prepare graduates to lead complex global health challenges. Persistent inequities, weak governance and emerging threats to global peace demand leaders who can critically assess systems, respond to local needs, and foster equitable, sustainable change. Such leadership requires reflexivity, humility, and collaborative learning. This study explores how PhD graduates across world regions perceive transformational leadership competencies and compares competencies developed during PhD training with those relevant in their current workplace.Methodology/findingsUsing an expert-validated survey based on a previously published competency framework and Delphi-derived behavioral descriptors (CROSS-guided; internationally piloted), we surveyed 618 graduates from Swiss TPH, CARTA, SSPH+, and CAPHRI; 71 graduates from 27 countries responded (response rate 11.5%). Median age was 45 years (IQR 41–51), 49% were women; median time since graduation was 6 years (IQR 3–9.5). One third completed their PhD in Africa and two thirds in Europe. Most worked in education (53.5%) or health care (10%), with others in NGOs, government, or international organizations. Competencies were rated highly relevant in the workplace (means 5.58–6.23, 1–7 scale). However, mean ratings (5.29–5.97) suggest that PhD training contributed less to competency development than the level relevant in the current workplace. Graduates from low- and middle-income countries reported better alignment between training and workplace relevance than those from high-income countries. Remaining in one location during the PhD was associated with higher perceived development. There was no evidence for gender effects.Conclusions/significanceTransformational leadership competencies are highly valued in the workplace but not consistently developed through PhD training, particularly in high-income countries. Programs with formally structured leadership-related educational components and dedicated pedagogical approaches were associated with higher levels of self-reported competency development. These findings should be interpreted cautiously given the low response rate and reliance on self-reported data. Future research is needed to determine curricular elements that contribute to leadership competency development. A transformational leadership lens may provide a useful framework for strengthening doctoral education in global health while incorporating lessons from low-income settings.

ABSTRACT Background Human immunodeficiency virus (HIV) increases the risk of developing cancer. We aimed to assign HIV status to cancers diagnosed in public laboratories recorded in the National Cancer Registry (NCR) in South Africa, guided by HIV counselling and testing guidelines. Methods We used natural language processing to extract HIV‐related information from free‐text reports and probabilistic record linkage to match cancers diagnosed between 2004 and 2021 to HIV‐related tests from the National Health Laboratory Service Corporate Data Warehouse. We assigned HIV status based on the results of the HIV‐related tests and their timing relative to cancer diagnosis. We used descriptive statistics and logistic regression to examine HIV status documentation patterns and HIV prevalence in cancer patients. Results Of the 496,517 cancers reported to the NCR, 41% (n = 203,937) had a documented HIV status. Documentation increased from 29% in 2004–2009 to 52% in 2016–2021. The odds of having a documented HIV status were 20% higher in females than in males and 16%–28% lower in other population groups compared with Black Africans. Patients with infection‐related cancers had almost threefold higher odds of having a documented HIV status than patients with infection‐unrelated cancers. Among cancer patients with documented HIV status, HIV prevalence was 75% for infection‐related and 32% for infection‐unrelated cancers. Conclusion HIV status documentation among people with cancer has improved over time, but it is still suboptimal. Clinicians and pathologists in HIV endemic areas need to improve HIV ascertainment at cancer diagnosis and reporting to cancer registries to inform patient care and guide cancer control efforts.

BACKGROUND:Timely cervical cytology results are crucial for effective screening and early management of precancerous lesions. However, many low- and middle-income countries face delays in turnaround time (TAT). This study assessed TAT for cytology screening results in South Africa from 2005 to 2023 and identified factors associated with TAT delays. METHODS:We conducted a cross-sectional analysis of public health routine program data from the National Health Laboratory Service for women aged ≥ 15 years. We defined TAT as the time from sample collection to the release of results. The recommended TAT benchmark is 14 days; we defined delays as TAT exceeding 14 days. We used descriptive statistics and multivariable logistic regression to assess TAT trends and factors associated with delays. RESULTS:From 2005 to 2023, 12,246,041 cervical cytology smears were processed. The median age at screening was 38.8 years (IQR: 31.0-41.1), ranging from 15 to 95 years. Median TAT consistently exceeded 14 days, peaking at 25 days between 2014 and 2019. Delays were significantly associated with location, with higher odds in self-sufficient (aOR 2.33; 95% CI: 2.32-2.34) and laboratory-dependent regions (aOR 1.61; 95% CI: 1.61-1.62). Samples processed in referral laboratories had higher odds of delay (aOR 4.08; 95% CI: 4.07-4.10). Seasonal variation also affected TAT delays, with higher odds observed in the third quarter (aOR 1.40; 95% CI: 1.39-1.40) as compared to the first quarter. CONCLUSION:Throughout South Africa, cervical cytology TAT remains above the recommended benchmarks. Delays are driven by structural and operational factors. Strengthening laboratory capacity, optimizing workflows, and transitioning to organized screening programs are critical for timely results and improved cervical cancer prevention outcomes.

Background The impact of HIV on incident non-Hodgkin lymphoma (NHL) varies by subtype. We compared the incidence rates of NHL subtypes (aggressive and indolent) between Black Africans with and without HIV in South Africa from 2010 to 2021. Methods We identified incident NHL among children and adults from the South African National Cancer Registry and stratified yearly population by HIV status, sex, age group and health care sector. We applied Poisson regression models, adjusting for sex, age, and calendar period, to estimate adjusted incidence rate ratios (aIRRs) for NHL and its subtypes among Black Africans with and without HIV. We calculated aIRR stratified by calendar period, sex, and age group. Findings We identified 11,187 new NHL; 54% (n = 6023) occurred in male individuals. The risk of all NHL combined was higher among Black Africans with HIV than those without HIV, but the strength of the association varied by subtype. The aIRRs were highest for cutaneous T-cell lymphoma, diffuse large B-cell lymphoma and Burkitt lymphoma. There was no evidence that the strength of association changed over calendar period for most subtypes. The positive association with HIV was stronger among male individuals and those <45 years for all NHL combined and many subtypes. Interpretation In South Africa, incidence rates of all NHL subtypes are higher among Black Africans with HIV than those without HIV. Further context specific studies are needed to clarify the underlying mechanisms such as immune dysfunction, chronic inflammation, or oncogenic co-infections to inform early NHL diagnosis and timely treatment. Funding US National Institutes of Health, Swiss National Science Foundation and Swiss Cancer Research foundation.

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. 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. We included 73,179 women: 6680 (9.1

BACKGROUND:Most research on human immunodeficiency virus-1 (HIV-1) viremia and cancer risk is from high-income countries. We evaluated the association between HIV-1 viremia and the risk of various cancer types among people with HIV (PWH) in South Africa. METHODS:We analyzed data from the South African HIV Cancer Match study, based on laboratory measurements from the National Health Laboratory Service and cancer records from the National Cancer Registry from 2004 to 2014. Using Cox proportional hazards models, we estimated hazard ratios (HR) for cancer incidence per unit increase in time-updated Log10 HIV-1 RNA viral load copies/mL. We created partially adjusted (sex, age, calendar year) and fully adjusted models (additionally including time-updated CD4 count). RESULTS:We included 2 770 200 PWH with 10 175 incident cancers; most common were cervical cancer (N = 2481), Kaposi sarcoma (N = 1902), breast cancer (N = 1063), and non-Hodgkin lymphoma (N = 863). Hazard ratios for the association of HIV-1 viremia and cancer risk changed after partial and full adjustment and were generally attenuated for infection-related cancers but tended to increase for infection-unrelated cancers. In the fully adjusted model, HIV-1 viremia was associated with an increased risk of Kaposi sarcoma (HR per unit increase in Log10 HIV-1 RNA viral load: 1.38; 95% confidence interval [CI], 1.35-1.42), leukemia (HR: 1.28; 95% CI, 1.13-1.45), non-Hodgkin lymphoma (HR: 1.24; 95% CI, 1.19-1.29), conjunctival cancer (HR: 1.19; 95% CI, 1.11-1.25), and colorectal cancer (HR: 1.11; 95% CI, 1.02-1.21). Associations with other cancer types were weaker or absent. CONCLUSIONS:Our findings underline the importance of sustained viral suppression for cancer prevention among PWH in South Africa.

BACKGROUND:A competent public health workforce is essential for resilient health systems, where transformational leadership helps navigate complexity, drive innovation, and foster collective action. However, leadership development remains underrepresented in health-related PhD curricula, limiting their capacity to prepare future leaders. Existing evidence is sparse and often limited to clinical contexts in high-income countries, offering little guidance for broader public health needs. OBJECTIVE:To explore how transformational leadership can be developed in health-related PhD programs and assess the effects of curricular elements, including content and teaching techniques. METHODS:A scoping review was conducted following PRISMA-ScR and Joanna Briggs Institute guidelines, with a registered protocol on the Open Science Framework. We systematically searched Medline, PsycInfo, and ERIC (2000-2024), including peer-reviewed studies assessing how mentorship, experiential learning, and collaboration contribute to transformational leadership development. Multiple reviewers independently screened and extracted data. A narrative synthesis was conducted, and methodological quality was appraised using the Mixed Methods Appraisal Tool. RESULTS:Of 394 records screened, seven studies met inclusion criteria. Four focused on transformational leadership; three used alternative models. All used experiential learning and collaborative feedback. Common themes included leadership, teamwork, and personal growth. Only one study used a validated tool (MLQ); others used reflective or descriptive evaluations. Most reported positive impacts, with mentoring, group learning, and reflection identified as key drivers. CONCLUSIONS:Strengthening transformational leadership in PhD education is key to preparing a future-ready public health workforce. While promising practices exist, clearer frameworks, stronger evaluation tools, and research on context-specific approaches are needed.

BACKGROUND:Zambia has the third highest cervical cancer incidence rate globally, and it remains the leading cause of cancer-related death among women. We explored the experiences of Zambian women who accessed cervical cancer screening and precancer treatment services to understand factors influencing care-seeking and access across urban, peri-urban, and rural settings. METHODS:In 2020, we conducted eight focus group discussions with women living with and without Human Immunodeficiency Virus (HIV) who underwent cervical cancer screening between 2016 and 2020. To explore their care journey, participants were grouped by screening outcome-those with cervical precancerous lesions and those without. We also conducted 18 in-depth interviews with healthcare workers providing antiretroviral treatment, cervical cancer screening, or precancer treatment at government health facilities. Transcripts were coded and analyzed using thematic analysis. RESULTS:Care-seeking unfolded across five stages: recognition of need to screen, hesitation and consultation, screening, result interpretation, and treatment. Women were generally knowledgeable about cervical cancer and sought screening promptly, though some delayed due to fear. Social networks and interactions with healthcare workers facilitated screening, while logistical and financial barriers, along with delays in histopathology services particularly in rural areas, hindered access to timely diagnosis and treatment. CONCLUSION:Improving cervical cancer screening and precancer treatment in Zambia requires addressing systemic inefficiencies by strengthening laboratory capacity, decentralizing diagnostics, and training healthcare workers to provide respectful, consistent counselling. Expanding community engagement to counter misinformation, leveraging social networks, and providing financial protection are also critical to ensuring timely, equitable, and reassuring care.

ObjectiveTo assess the competence of students and academic staff to use generative artificial intelligence (GenAI) as a tool in epidemiological data analyses in a randomised controlled trial (RCT).MethodsWe invited postgraduate students and academic staff at the Swiss Tropical and Public Health Institute to the RCT. Participants were randomized to analyse a simulated cross-sectional dataset using ChatGPT’s code interpreter (integrated analysis arm) vs. a statistical software (R/Stata) with ChatGPT as a support tool (distributed analysis arm). The primary outcome was the trial task score (out of 17, using an assessment rubric). Secondary outcome was the time to complete the task.ResultsWe invited 338 and randomized 31 participants equally to the two study arms and 30 participants submitted results. Overall, there was no statistically significant difference in mean task scores between the distributed analysis arm (8.5, ±4.6) and the integrated analysis arm (9.4, ±3.8), with a mean difference of 0.93 (p = 0.55). Mean task completion time was significantly shorter in the integrated analysis arm compared to the distributed analysis arm.ConclusionWhile ChatGPT offers advantages, its effective use requires a careful balance of GenAI capabilities and human expertise.

Background: Of women with cervical cancer (CC) and HIV, 85% live in sub-Saharan Africa, where 21% of all CC cases are attributable to HIV infection. We aimed to generate internationally acceptable facility-based indicators to monitor and guide scale up of CC prevention and care services offered on-site or off-site by HIV clinics. Methods: We reviewed the literature and extracted relevant indicators, grouping them into domains along the CC control continuum. From February 2021 to March 2022, we conducted a three-round, online Delphi process to reach consensus on indicators. We invited 106 experts to participate. Through an anonymous, iterative process, participants adapted the indicators to their context (round 1), then rated them for 5 criteria on a 5-point Likert-type scale (rounds 2 and 3) and then ranked their importance (round 3). Results: We reviewed 39 policies from 21 African countries and 7 from international organizations; 72 experts from 15 sub-Saharan Africa countries or international organizations participated in our Delphi process. Response rates were 34% in round 1, 40% in round 2, and 44% in round 3. Experts reached consensus for 17 indicators in the following domains: primary prevention (human papillomavirus prevention, n = 2), secondary prevention (screening, triage, treatment of precancerous lesions, n = 11), tertiary prevention (CC diagnosis and care, n = 2), and long-term impact of the program and linkage to HIV service (n = 2). Conclusion: We recommend that HIV clinics that offer CC control services in sub-Saharan Africa implement the 17 indicators stepwise and adapt them to context to improve monitoring along the CC control cascade.

Objectives: This Delphi study intended to develop competencies for transformational leadership in public health, including behavioral descriptions (descriptors) tailored to individuals and their contexts.Methods: The study involved five rounds, including online “e-Delphi” consultations and real-time online workshops with experts from diverse sectors. Relevant competencies were identified through a literature review, and experts rated, ranked, rephrased, and proposed descriptors. The study followed the Guidance on Conducting and REporting DElphi Studies (CREDES) and the COmpeteNcy FramEwoRk Development in Health Professions (CONFERD-HP) reporting guidelines.Results: Our framework comprises ten competencies for transformational public health leadership (each with its descriptors) within four categories, and also describes a four-stage model for developing relevant competencies tailored to different contexts.Conclusion: Educators responsible for curriculum design, particularly those aiming to align curricula with local goals, making leadership education context-specific and -sensitive, may benefit from the proposed framework. Additionally, it can help strengthen links between education and workforce sectors, address competency gaps, and potentially reduce the out-migration of graduates in the health professions.

Introduction Cervical cancer is the leading cause of cancer-related mortality for Tanzanian women. Multi-level, intersecting factors prevent access to care along the cervical cancer care cascade. However, there is a paucity of data, especially in non-urban areas, exploring the specificity and nuances of these factors locally, such as perceptions and embodied experiences of cervical cancer, use of traditional medicine, stigma, information generation and circulation and loss to follow up care. TRACCTION is an exploratory, mixed-methods study running from 2023-2025 to expand understanding of barriers to and facilitators of uptake of cervical pre-cancer screening and treatment and cervical cancer care in southeastern Tanzania. Methods and analysis Research activities include a two-stage randomised cross sectional survey of women 18 years of age and older, qualitative data collection using diverse, community-based methods and a longitudinal public health facility record linkage of patients accessing cervical pre-cancer screening and treatment. By employing a transdisciplinary approach, TRACCTION will inform a participatory process to formulate cervical cancer education and policy recommendations. Ethics and Dissemination This study received ethical approval in Tanzania and Switzerland. Informed written consent will be obtained from each study participant and a waiver of informed consent was obtained to retrospectively analyse public health facility records related to study objectives. A Policy and Technical Advisory Group, comprised of a diverse group of stakeholders including community members, will co-design a policy and service delivery analysis, followed by recommendations and dissemination plans. Study results for each work package will be published in peer reviewed journals and shared at relevant conferences globally. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The study is funded by the Swiss National Science Foundation (SNSF IZSTZ0_208429 / 1, Principal Investigators: Dr. Sonja Merten and Dr. Sally Mtenga). The project is implemented in partnership between the Swiss Tropical and Public Health Institute, an associated institute of the University of Basel, Switzerland, Ifakara Health Institute Dar es Salaam and Ifakara, Tanzania and Kibaoni Health Center, Kibaoni, Morogoro, Tanzania. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Internal Review Board of the Ifakara Health Institute, the National Institute for Medical Research in Tanzania and Ethikkommission Nordwest- und Zentralschweiz in Switzerland gave ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors

Background Breast cancer (BC) is the leading cause of cancer-related morbidity and mortality in women living in South Africa, a country with a high HIV burden. However, characteristics of the double burden of HIV and BC in South Africa have not been properly investigated. We described characteristics of BC cases by HIV status in South Africa. Methods In this nationwide South African study, we obtained BC records for women aged ≥15 years diagnosed in the public health sector between January 2004 and December 2014. We included records from the National Cancer Registry that had been linked to HIV-related laboratory records from the National Health Laboratory Service. We assessed the odds of being HIV positive versus HIV negative in relation to patient-, cancer-, and municipality-related characteristics. Results From 2004–2014, 40 520 BC cases were diagnosed in women aged ≥15 years. Of these, 73.5% had unknown HIV status, 18.7% were HIV negative, and 7.7% were HIV positive. The median age at BC diagnosis was 43 years (interquartile range [IQR]: 37–52) in HIV positive and 57 years (IQR: 46–68) in HIV negative women, respectively. The odds of being HIV positive was higher for women who were aged 30–34 years compared to women aged 35–39 years at cancer diagnosis (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.10–1.71), Black versus non-Black (OR 6.41, 95% CI 5.68–7.23), diagnosed with cancer in rural versus urban areas (OR 1.59, 95% CI 1.40–1.82) and diagnosed in municipalities with low and middle (OR 3.46, 95% CI 2.48–4.82) versus high socioeconomic position (OR 2.69, 95% CI 2.11–3.42). Conclusion HIV status was unknown for the majority of BC patients. Among those with known HIV status, being HIV positive was associated with a younger age at cancer diagnosis, being Black and receiving care in municipalities of poor socioeconomic position. Future studies should examine opportunities to integrate HIV and BC control programs.

INTRODUCTIONTo eliminate cervical cancer (CC), access to and quality of prevention and care services must be monitored, particularly for women living with HIV (WLHIV). We assessed implementation practices in HIV clinics across sub-Saharan Africa (SSA) to identify gaps in the care cascade and used aggregated patient data to populate cascades for WLHIV attending HIV clinics.METHODSOur facility-based survey was administered between November 2020 and July 2021 in 30 HIV clinics across SSA that participate in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. We performed a qualitative site-level assessment of CC prevention and care services and analysed data from routine care of WLHIV in SSA.RESULTSHuman papillomavirus (HPV) vaccination was offered in 33% of sites. Referral for CC diagnosis (42%) and treatment (70%) was common, but not free at about 50% of sites. Most sites had electronic health information systems (90%), but data to inform indicators to monitor global targets for CC elimination in WLHIV were not routinely collected in these sites. Data were collected routinely in only 36% of sites that offered HPV vaccination, 33% of sites that offered cervical screening and 20% of sites that offered pre-cancer and CC treatment.CONCLUSIONSThough CC prevention and care services have long been available in some HIV clinics across SSA, patient and programme monitoring need to be improved. Countries should consider leveraging their existing health information systems and use monitoring tools provided by the World Health Organization to improve CC prevention programmes and access, and to track their progress towards the goal of eliminating CC.

Introduction In 2013, the World Health Organization (WHO) issued guidelines for cervical pre-cancer screening. It recommended screening women aged 30–49, and younger women once they tested HIV-positive. Subsequent WHO guidelines recommended screening women living with HIV (WLHIV) starting at age 25. However, the impact of 2013 guidelines and age to start screening on screening has not been studied. Methods We used a regression discontinuity design (RDD) analysis of population-based data to assess the impact of the 2013 WHO guidelines on the screening rates for women according to HIV status and age group in Ethiopia, Malawi, Rwanda, Tanzania, Zambia, and Zimbabwe. The outcome was self-reported ever having been screened for cervical pre-cancer between 2008 and 2018. We compared the screening rates according to HIV status and age group, before and after age 25 years. And before and after 2014, the year countries adopted the 2013 guidelines. We then used a data-driven optimal bandwidth selection procedure to estimate the guidelines’ average treatment effect (ATE), with a local polynomial regression discontinuity and robust bias-corrected confidence intervals. We validated the RDD methodology overall and for women with a significant ATE at the country-level analysis. Results We included 73179 women: 6680 (9.1%) living with HIV, 4328 (5.9%) with unknown HIV status, and 62171 (85.0) with a negative HIV status. 5726 (7.9%) reported having ever been screened; 4022 (6.5%) with unknown HIV status, 525 (12.1%) with a negative HIV status and 1179 (17.7%) living with HIV. Adolescent girls and young women living with HIV (AGYWLHIV) aged 15–24 reported screening less often (917 (13.7%)) than their peers with unknown (1677 (38.8%)) or positive HIV status (27278 (43.9%)) (P<0.001), or older women. The ATE of screening was 0 for women with unknown or positive HIV status, for whom the RDD was valid. Conclusion We found no evidence the 2013 WHO guidelines increased or reduced women’s cervical pre- cancer screening. However, AGYWLHIV reported screening less often. Policy makers should lower the age to start screening 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. ### Competing Interest Statement The authors declare no competing interests. ### Funding Statement Olivia Keiser was supported by the Swiss National Science Foundation (grant no 202660). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study did not require ethical review because the personal details in the data are de-identified, and the data is publicly available. It can be accessed with a request at <https://phia-data.icap.columbia.edu> I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data is publicly available. It can be accessed with a request at <https://phia-data.icap.columbia.edu>

Objective This study aimed to provide evidence to improve cervical screening for women living with HIV (WLHIV). We assessed the accuracy of screening tests that can be used in low-resource settings and give results at the same visit. Methods and analysis We conducted a paired, prospective study among consecutive eligible WLHIV, aged 18–65 years, receiving cervical cancer screening at one hospital in Lusaka, Zambia. The histopathological reference standard was multiple biopsies taken at two time points. The target condition was cervical intraepithelial neoplasia grade 2 and above (CIN2+). The index tests were high-risk human papillomavirus detection (hrHPV, Xpert HPV, Cepheid), portable colposcopy (Gynocular, Gynius) and visual inspection with acetic acid (VIA). Accuracy of stand-alone and test combinations were calculated as the point estimate with 95% CIs. A sensitivity analysis considered disease when only visible lesions were biopsied. Results Women included in the study had well-controlled HIV infection (median CD4 count=542 cells/mm 3 ) and all except one were on antiretroviral therapy. Among 371 participants with histopathological results, 27% (101/371) women had CIN2+ and 23% (23/101) were not detected by any index test. Sensitivity and specificity for stand-alone tests were: hrHPV, 67.3% (95% CI 57.7% to 75.7%) and 65.3% (95% CI 59.4% to 70.7%); Gynocular 51.5% (95% CI 41.9% to 61.0%) and 80.0% (95% CI 74.8% to 84.3%); and VIA 22.8% (95% CI 15.7% to 31.9%) and 92.6% (95% CI 88.8% to 95.2%), respectively. Combining tests did not improve test accuracy measures. All test accuracies improved in sensitivity analysis. Conclusion The low accuracy of screening tests assessed might be explained by our reference standard, which reduced verification and misclassification biases. Better screening strategies for WLHIV in low-resource settings are urgently needed. Trial registration number NCT03931083 .

Background The main risk factors for squamous cell carcinoma of the conjunctiva (SCCC) are immunodeficiency and exposure to ultraviolet radiation. Little is known about SCCC epidemiology among people with HIV (PWH) in South Africa. Methods We used data from the South African HIV Cancer Match study, a nation-wide cohort of PWH in South Africa, created through a privacy-preserving probabilistic record linkage of HIV-related laboratory records from the National Health Laboratory Service and cancer records from the National Cancer Registry from 2004 to 2014. We calculated crude incidence rates, analyzed trends using joinpoint models, and estimated hazard ratios for different risk factors using Royston-Parmar flexible parametric survival models. Results Among 5 247 968 PWH, 1059 cases of incident SCCC were diagnosed, for a crude overall SCCC incidence rate of 6.8 per 100 000 person-years. The SCCC incidence rate decreased between 2004 and 2014, with an annual percentage change of -10.9% (95% confidence interval: -13.3 to -8.3). PWH residing within latitudes 30 & DEG;S to 34 & DEG;S had a 49% lower SCCC risk than those residing at less than 25 & DEG;S latitude (adjusted hazard ratio = 0.67; 95% confidence interval: 0.55 to 0.82). Other risk factors for SCCC were lower CD4 counts and middle age. There was no evidence for an association of sex or settlement type with SCCC risk. Conclusions An increased risk of developing SCCC was associated with lower CD4 counts and residence closer to the equator, indicative of higher ultraviolet radiation exposure. Clinicians and PWH should be educated on known SCCC preventive measures, such as maintaining high CD4 counts and protection from ultraviolet radiation through sunglasses and sunhats when outdoors.

OBJECTIVE:The objective of this study was to map place of cancer diagnosis in relation to Human Immunodeficiency Virus (HIV) care centre among people living with HIV (PLHIV) within South Africa (SA) using national laboratory database. DESIGN:We linked HIV and cancer laboratory data from 2004-2014 using supervised machine-learning algorithms. We performed a cross-sectional analysis comparing province where individuals accessed their HIV care versus where they had their cancer diagnosis. SETTING:We used laboratory test records related to HIV diagnostics and care, such as CD4 cell counts and percentages, rapid tests, qualitative Polymerase Chain Reaction (PCR), antibody and antigen tests for HIV data that was documented as HIV positive and laboratory diagnosed cancer records from SA. STUDY POPULATION:Our study population consisted of HIV records from the National Health Laboratory Service (NHLS) that linked to cancer record at the National Cancer Registry (NCR) between 2004-2014. PRIMARY AND SECONDARY OUTCOMES:We linked HIV records from NHLS to cancer records at NCR in order to study the inherent characteristics of the population with both HIV and cancer. RESULTS:The study population was 68,284 individuals with cancer and documented HIV related laboratory test. The median age at cancer diagnosis was 40 [IQR, 33-48] years for the study population with most cancers in PLHIV diagnosed in females 70.9% [n = 46,313]. Of all the PLHIV and cancer, 25% (n = 16,364 p < 0.001) sought treatment outside their province of residence with 60.7% (n = 10,235) travelling to Gauteng. KZN had 46.6% (n = 4,107) of its PLHIV getting cancer diagnosis in Gauteng. Western Cape had 95% (n = 6,200) of PLHIV getting cancer diagnosis within the province. CONCLUSIONS:Our results showed health systems inequalities across provinces in SA with respect to cancer diagnosis. KZN for example had nearly half of the PLHIV getting cancer diagnosis outside the province while Western Cape is able to offer cancer diagnostic services to most of the PLHIV in the province. Gauteng is getting over burdened with referral for cancer diagnosis from other provinces. More effort is required to ensure equitable access to cancer diagnostic services within the country.

Objectives We examined age, residence, education and wealth inequalities and their combinations on cervical precancer screening probabilities for women. We hypothesised that inequalities in screening favoured women who were older, lived in urban areas, were more educated and wealthier. Design Cross-sectional study using Population-Based HIV Impact Assessment data. Setting Ethiopia, Malawi, Rwanda, Tanzania, Zambia and Zimbabwe. Differences in screening rates were analysed using multivariable logistic regressions, controlling for age, residence, education and wealth. Inequalities in screening probability were estimated using marginal effects models. Participants Women aged 25–49 years, reporting screening. Outcome measures Self-reported screening rates, and their inequalities in percentage points, with differences of 20%+ defined as high inequality, 5%–20% as medium, 0%–5% as low. Results The sample size of participants ranged from 5882 in Ethiopia to 9186 in Tanzania. The screening rates were low in the surveyed countries, ranging from 3.5% (95% CI 3.1% to 4.0%) in Rwanda to 17.1% (95% CI 15.8% to 18.5%) and 17.4% (95% CI 16.1% to 18.8%) in Zambia and Zimbabwe. Inequalities in screening rates were low based on covariates. Combining the inequalities led to significant inequalities in screening probabilities between women living in rural areas aged 25–34 years, with a primary education level, from the lowest wealth quintile, and women living in urban areas aged 35–49 years, with the highest education level, from the highest wealth quintile, ranging from 4.4% in Rwanda to 44.6% in Zimbabwe. Conclusions Cervical precancer screening rates were inequitable and low. No country surveyed achieved one-third of the WHO’s target of screening 70% of eligible women by 2030. Combining inequalities led to high inequalities, preventing women who were younger, lived in rural areas, were uneducated, and from the lowest wealth quintile from screening. Governments should include and monitor equity in their cervical precancer screening programmes.

Breast and gynaecologic cancers account for approximately half of all cancers diagnosed amongst women in South Africa, many of whom also live with HIV. We aimed to determine the incidence of and risk factors for developing breast and gynaecologic cancers in women living with HIV (WLHIV) in South Africa. This is a longitudinal analysis of the South African HIV Cancer Match study including women aged ≥15 years with two or more HIV‐related laboratory tests. We used Cox proportional hazard models to determine the association of Human Papilloma Virus (HPV)‐related and hormone‐related gynaecologic cancer with patient‐ and municipal‐level characteristics. From 3 447 908 women and 10.5 million years of follow‐up, we identified 11 384 incident and 7612 prevalent gynaecologic and breast cancers. The overall crude incidence rate was 108/1 00 000 person‐years (pyears) (95% confidence interval [CI]: 106‐110), with the highest incidence observed for cervical cancer (70/1 00 000 pyears; 95% CI: 68.5‐71.7). Low CD4 cell counts and high HIV RNA viral loads increased the risk of cervical and other HPV‐related cancers. Age was associated with both HPV‐related and hormone‐related cancers. Women accessing health facilities in high socioeconomic position (SEP) municipalities were more likely to be diagnosed with HPV‐related cancers and breast cancer than women accessing care in low SEP municipalities. It is important to improve the immunologic status of WLHIV as part of cancer prevention strategies in WLHIV. Cancer prevention and early detection programmes should be tailored to the needs of women ageing with HIV. In addition, SEP disparities in cancer diagnostic services have to be addressed.