Cancer Causes & Control

, Volume 30, Issue 4, pp 365–374 | Cite as

“My husband says this: If you are alive, you can be someone…”: Facilitators and barriers to cervical cancer screening among women living with HIV in India

  • Timothy-Paul H. Kung
  • Janna R. Gordon
  • Asha Abdullahi
  • Apurva Barve
  • Vipul Chaudhari
  • Jayendrakumar K. Kosambiya
  • Ambuj Kumar
  • Sukesha Gamit
  • Kristen J. WellsEmail author
Original Paper



Women living with human immunodeficiency virus (WLWH) have a higher risk of cervical cancer than women without HIV. In addition, women in India experience a high burden of death from cervical cancer. This qualitative study evaluated individual and interpersonal factors influencing cervical cancer screening among WLWH in Surat, India.


In-depth interviews were conducted with 25 WLWH and 15 stakeholders in Surat, India. Data were analyzed using directed content analysis to identify individual and intrapersonal barriers and facilitators.


WLWH lacked knowledge and reported being afraid of cervical cancer and cervical cancer screening but were interested in learning more about it. Interpersonal factors influencing cervical cancer screening included receipt or lack of instrumental and emotional family support, interactions with healthcare providers, and receipt or lack of information about cervical cancer and the Pap test from healthcare providers.


Widespread public education is necessary to increase awareness of cervical cancer and cervical cancer screening and to encourage family members to support women who wish to obtain screening. Patient- and provider-focused interventions may facilitate the process of providing cervical cancer care to WLWH who are obtaining care in busy public healthcare systems in India.


Qualitative research Uterine cervical neoplasms HIV Papillomavirus infections Papanicolaou test Early detection of cancer 



This study was funded by the San Diego State University’s University Grants Program. Research reported in this publication was also supported by the National Cancer Institute of the National Institutes of Health under award numbers: U54CA132384 and U54CA132379. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors would like to thank all patients and stakeholders who took part in the interviews, as well as the many individuals who assisted with facilitating the study.


  1. 1.
    Bruni L, Barrionuevo-Rosas L, Albero G, Aldea M, Serrano B, Valencia S, Brotons M, Mena M, Cosano R, Muñoz J, Bosch F, de Sanjosé S, Castellsagué X (2015) Human papillomavirus and related diseases report. Information centre on HPV and cancer. HPV Information Centre, BarcelonaGoogle Scholar
  2. 2.
    Mathew A, George PS (2009) Trends in incidence and mortality rates of squamous cell carcinoma and adenocarcinoma of cervix-worldwide. Asian Pac J Cancer Prev 10(4):645–650Google Scholar
  3. 3.
    Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin D, Forman D, Bray F (2013) GLOBOCAN 2012: estimated cancer incidence, mortality and prevalance worldwide in 2012 v.1.0. IARC CancerBase No. 11 International Agency for Research on Cancer, LyonGoogle Scholar
  4. 4.
    Shrestha AD, Neupane D, Vedsted P, Kallestrup P (2018) Cervical cancer prevalence, incidence and mortality in low and middle income countries: a systematic review. Asian Pac J Cancer Prev 19(2):319–324. Google Scholar
  5. 5.
    Sahasrabuddhe V, Makhija S (2005) Double jeopardy: HIV and cervical cancer in Indian women. Int J Gynecol Cancer 15(1):1–3. CrossRefGoogle Scholar
  6. 6.
    Danso D, Lyons F, Bradbeer C (2006) Cervical screening and management of cervical intraepithelial neoplasia in HIV-positive women. Int J STD AIDS 17(9):579–584 (quiz 585 – 577)CrossRefGoogle Scholar
  7. 7.
    Nappi L, Carriero C, Bettocchi S, Herrero J, Vimercati A, Putignano G (2005) Cervical squamous intraepithelial lesions of low-grade in HIV-infected women: Recurrence, persistence, and progression, in treated and untreated women. Eur J Obstet Gynecol Reprod Biol 121(2):226–232. CrossRefGoogle Scholar
  8. 8.
    Frisch M, Biggar RJ, Goedert JJ, AIDS-Cancer Match Registry Study Group (2000) Human papillomavirus-associated cancers in patients with human immunodeficiency virus infection and acquired immunodeficiency syndrome. J Natl Cancer Inst 92:1500–1510CrossRefGoogle Scholar
  9. 9.
    Ellerbrock TV, Chiasson MA, Bush T, Sun J, Sawo X-W, Brudney D, Wright TC Jr (2015) Incidence of cervical squamous intraepithelial lesions in HIV-infected women. JAMA 283:1031–1037. CrossRefGoogle Scholar
  10. 10.
  11. 11.
    National AIDS Control Organization (2014) Prevention, management and control of reproductive tract infections and sexually transmitted infections, IndiaGoogle Scholar
  12. 12.
    ICO/IARC Information Centre on HPV and Cancer (2015) India human papillomavirus and related cancers, fact sheet 2017. Accessed 6 June 2018
  13. 13.
    Best A, Stokols D, Green LW, Leischow S, Holmes B, Buchholz K (2003) An integrative framework for community partnering to translate theory into effective health promotion strategy. Am J Health Promot 18(2):168–176CrossRefGoogle Scholar
  14. 14.
    Stokols D (1996) Translating social ecological theory into guidelines for community health promotion. Am J Health Promot 10(4):282–298. CrossRefGoogle Scholar
  15. 15.
    McLeroy KR, Bibeau D, Steckler A, Glanz K (1988) An ecological perspective on health promotion programs. Health Educ Q 15:351–377CrossRefGoogle Scholar
  16. 16.
    Sankaranarayanan R, Rajkumar R, Arrossi S, Theresa R, Esmy PO, Mahe C, Muwonge R, Parkin DM, Cherian J (2003) Determinants of participation of women in a cervical cancer visual screening trial in rural south India. Cancer Detect Prev 27(6):457–465CrossRefGoogle Scholar
  17. 17.
    Aswathy S, Quereshi MA, Kurian B, Leelamoni K (2012) Cervical cancer screening: current knowledge and practice among women in a rural population of Kerala, India. Indian J Med Res 136(2):205–210Google Scholar
  18. 18.
    Documet P, Bear TM, Flatt JD, Macia L, Trauth J, Ricci EM (2015) The association of social support and education with breast and cervical cancer screening. Health Educ Behav 42(1):55–64. CrossRefGoogle Scholar
  19. 19.
    Kim YM, Ati A, Kols A, Lambe FM, Soetikno D, Wysong M, Tergas AI, Rajbhandari P, Lu E (2012) Influencing women’s actions on cervical cancer screening and treatment in Karawang District, Indonesia. Asian Pac J Cancer Prev 13(6):2913–2921CrossRefGoogle Scholar
  20. 20.
    Wasserman MR, Bender DE, Lee SY, Morrissey JP, Mouw T, Norton EC (2006) Social support among Latina immigrant women: bridge persons as mediators of cervical cancer screening. J Immigr Minor Health 8(1):67–84CrossRefGoogle Scholar
  21. 21.
    Lee J, Carvallo M (2014) Socioecological perspectives on cervical cancer and cervical cancer screening among Asian American women. J Community Health 39(5):863–871. CrossRefGoogle Scholar
  22. 22.
    Seow A, Huang J, Straughan PT (2000) Effects of social support, regular physician and health-related attitudes on cervical cancer screening in an Asian population. Cancer Causes Control 11(3):223–230CrossRefGoogle Scholar
  23. 23.
    Suarez L, Lloyd L, Weiss N, Rainbolt T, Pulley L (1994) Effect of social networks on cancer-screening behavior of older Mexican-American women. J Natl Cancer Inst 86(10):775–779CrossRefGoogle Scholar
  24. 24.
    Winkler J, Bingham A, Coffey P, Handwerker WP (2008) Women’s participation in a cervical cancer screening program in northern Peru. Health Educ Res 23(1):10–24. CrossRefGoogle Scholar
  25. 25.
    Patton MQ (2002) Qualitative research and evaluation methods. Sage, LondonGoogle Scholar
  26. 26.
    Bansal AB, Pakhare AP, Kapoor N, Mehrotra R, Kokane AM (2015) Knowledge, attitude, and practices related to cervical cancer among adult women: a hospital-based cross-sectional study. J Nat Sci Biol Med 6(2):324–328. CrossRefGoogle Scholar
  27. 27.
    Narayana G, Suchitra MJ, Sunanda G, Ramaiah JD, Kumar BP, Veerabhadrappa KV (2017) Knowledge, attitude, and practice toward cervical cancer among women attending Obstetrics and Gynecology Department: a cross-sectional, hospital-based survey in South India. Indian J Cancer 54(2):481–487. CrossRefGoogle Scholar
  28. 28.
    Rahman H, Kar S (2015) Knowledge, attitudes and practice toward cervical cancer screening among Sikkimese nursing staff in India. Indian J Med Paediatr Oncol 36(2):105–110. CrossRefGoogle Scholar
  29. 29.
    Prateek S, Gupta S, Gupta A, Choudhary S, Prakash D, Nain G (2018) Knowledge and attitude of women attending Subharti Medical College towards Pap smear. J Obstet Gynaecol. Google Scholar
  30. 30.
    Sankaranarayanan R, Chatterji R, Shastri SS, Wesley RS, Basu P, Mahe C, Muwonge R, Seigneurin D, Somanathan T, Roy C, Kelkar R, Chinoy R, Dinshaw K, Mandal R, Amin G, Goswami S, Pal S, Patil S, Dhakad N, Frappart L, Fontaniere B (2004) Accuracy of human papillomavirus testing in primary screening of cervical neoplasia: results from a multicenter study in India. Int J Cancer 112(2):341–347. CrossRefGoogle Scholar
  31. 31.
    Bhatla N, Gulati A, Mathur SR, Rani S, Anand K, Muwonge R, Sankaranarayanan R (2009) Evaluation of cervical screening in rural North India. Int J Gynecol Obstet 105(2):145–149. CrossRefGoogle Scholar
  32. 32.
    Lazcano-Ponce EC, Castro R, Allen B, Nájera P, Ruíz PAd, Hernández-Avila M (1999) Barriers to early detection of cervical-uterine cancer in Mexico. J Women’s Health 8(3):399–408. CrossRefGoogle Scholar
  33. 33.
    Mitchell H (1993) Pap smears collected by nurse practitioners: a comparison with smears collected by medical practitioners. Oncol Nurs Forum 20(5):807–810Google Scholar
  34. 34.
    Shastri SS, Mittra I, Mishra GA, Gupta S, Dikshit R, Singh S, Badwe RA (2014) Effect of VIA screening by primary health workers: randomized controlled study in Mumbai, India. J Natl Cancer Inst 106(3):dju009. CrossRefGoogle Scholar
  35. 35.
    Kim K, Choi JS, Choi E, Nieman CL, Joo JH, Lin FR, Gitlin LN, Han H-R (2016) Effects of community-based health worker interventions to improve chronic disease management and care among vulnerable populations: a systematic review. AJPH 106(4):e3–e28. CrossRefGoogle Scholar
  36. 36.
    Gordon JR, Barve A, Chaudhari V, Kosambiya JK, Kumar A, Gamit S, Wells KJ (2019) “HIV is not an easily acceptable disease”: the role of HIV-related stigma in obtaining cervical cancer screening in India. Women Health. Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Timothy-Paul H. Kung
    • 1
  • Janna R. Gordon
    • 2
  • Asha Abdullahi
    • 1
  • Apurva Barve
    • 3
  • Vipul Chaudhari
    • 4
  • Jayendrakumar K. Kosambiya
    • 4
  • Ambuj Kumar
    • 5
  • Sukesha Gamit
    • 4
  • Kristen J. Wells
    • 1
    • 2
    • 6
    Email author
  1. 1.San Diego State UniversitySan DiegoUSA
  2. 2.San Diego Joint Doctoral Program in Clinical PsychologySan Diego State University/University of CaliforniaSan DiegoUSA
  3. 3.Fielding School of Public HealthUniversity of California, Los AngelesLos AngelesUSA
  4. 4.Government Medical College, SuratSuratIndia
  5. 5.University of South Florida Morsani College of MedicineTampaUSA
  6. 6.Moores Cancer CenterUniversity of California, San DiegoLa JollaUSA

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