Leveraging HIV infrastructure to implement cervical cancer prevention: A study to integrate HPV vaccination in adolescent HIV clinics in Zambia

摘要/总结 宫颈癌是赞比亚癌症死亡的主要原因，艾滋病毒流行率也很高（11.3%）。 艾滋病毒增加了患宫颈癌和死于宫颈癌的风险。人乳头瘤病毒（HPV）疫苗 是一种世卫组织认可的循证工具，可预防90%的宫颈癌，建议用于 9-14岁的女孩然而，HPV疫苗在低收入和中等收入国家的覆盖率较低（16%）， 我们团队的实地经验表明，赞比亚的HPV疫苗接种率甚至更低， 在感染艾滋病毒的女孩中，她们最有可能患上癌症。目前，HPV疫苗是 通过以学校为基础的运动提供，这被认为是有效的广泛覆盖面，但也排除了 最脆弱的儿童--那些失学或不定期上学的儿童（例如，孤儿，穷人）。青少年 艾滋病毒感染者（ALHIV）更有可能具有这些额外的脆弱性。此外，世卫组织建议， ALHIV接受第三剂HPV疫苗，这是传统的2剂学校运动所没有的。 为了确保ALHIV能够获得WHO推荐的3剂，我们建议将HPV纳入 在青少年艾滋病诊所将疫苗接种纳入常规护理。赞比亚的青少年艾滋病毒诊所定期 与ALHIV接触，是社区健康信息的可靠来源。鉴于已知 在包括赞比亚在内的中低收入国家提供宫颈癌预防的挑战（例如，耻辱，错误的信息， 人员配备，供应链），整合HPV疫苗接种需要多层次的方法，利益相关者 参与和多样化的实施战略。为了取得成功，我们将共同设计一套 使用以前成功的执行研究方法， 低收入国家的宫颈癌预防：实施研究的综合系统实践（INSPIRE）。 INSPIRE是一个新颖、正式和全面的框架，用于开发、实施和评估 实施科学的努力。根据INSPIRE的关键要素，我们的具体目标是：1）确定 艾滋病毒背景下（农村、城市、城郊）独特的多层次背景因素（障碍和促进因素）， 影响HPV疫苗接种; 2）使用实施映射来转化利益相关者的反馈和发现 从目标1中的一个目标纳入一揽子实施战略，将HPV疫苗纳入艾滋病毒诊所; 3）开展一项 混合型3有效性-实施试验，以评估多层次实施方案 将HPV疫苗纳入艾滋病诊所的战略。我们的研究团队在艾滋病方面有着丰富的专业知识， HPV，癌症预防，实施科学和LMIC研究。我们有强大的机构支持， 包括研究期间的325，000美元;强有力的支持，技术专长和资源（例如， 赞比亚卫生部提供的疫苗;以及扩大规模的政治意愿。如果成功，这 以艾滋病患者为基础的实施模式可以推广到赞比亚各地的艾滋病毒诊所， 在其他低收入国家，艾滋病毒感染者的癌症预防优先事项。

ABSTRACT/SUMMARY Cervical cancer is the leading cause of cancer death in Zambia, where HIV prevalence is also high (11.3%). HIV heightens the risk of developing and dying from cervical cancer. The human papillomavirus (HPV) vaccine is a WHO-endorsed, evidence-based tool that can prevent 90% of cervical cancers, and is recommended for girls ages 9-14. However, HPV vaccine coverage is low (16%) in low- and middle- income countries (LMICs), and our team's on-the-ground experience suggests HPV vaccination is even lower in Zambia, particularly among girls with HIV, who are most at risk of poor cancer outcomes. Currently, HPV vaccination is delivered via school-based campaigns, which are viewed as efficient for broad coverage but also exclude the most vulnerable children—those out-of-school or who irregularly attend (e.g., orphans, poor). Adolescents living with HIV (ALHIV) are more likely to have these additional vulnerabilities. In addition, WHO recommends ALHIV receive a 3rd dose of the HPV vaccine, which is not given in traditional 2-dose school-based campaigns. To ensure that ALHIV have access to the WHO-recommended 3-doses, we propose to integrate HPV vaccination into routine care in adolescent HIV clinics. Adolescent HIV clinics in Zambia have regular contact with ALHIV and are trusted sources of health information for the community. Given the known challenges of providing cervical cancer prevention in LMICs, including Zambia (e.g., stigma, misinformation, staffing, supply chain), integrating HPV vaccination requires a multilevel approach, stakeholder engagement, and diversified implementation strategies. To achieve success, we will co-design a package of implementation strategies using a previously successful implementation research approach developed for cervical cancer prevention in LMICs: the Integrative Systems Praxis for Implementation Research (INSPIRE). INSPIRE is a novel, formal, and comprehensive framework to develop, implement, and evaluate implementation science efforts. Following key elements of INSPIRE, our specific aims are to: 1) Identify the unique multilevel contextual factors (barriers and facilitators) across HIV settings (rural, urban, peri-urban) that influence HPV vaccine uptake; 2) Use Implementation Mapping to translate stakeholder feedback and findings from Aim 1 into a package of implementation strategies to integrate HPV vaccine into HIV clinics; 3) Conduct a Hybrid Type 3 effectiveness-implementation trial to evaluate the package of multilevel implementation strategies for integrating HPV vaccine into HIV clinics. Our research team has significant expertise in HIV, HPV, cancer prevention, implementation science, and LMIC research. Wehave strong institutional backing, including$325,000 over the course of the study;strong support, technical expertise, and resources (e.g., vaccines) from the Zambian Ministry of Health; and political will for scale-up. If successful, this stakeholder-based implementation model could be transported to HIV clinics across Zambia and serve as a model to address cancer prevention priorities for those with HIV in other LMICs.