Acceptability of Integration of Cervical Cancer Screening Into Routine HIV Care, Associated Factors and Perceptions Among HIV- Infected Women: a Mixed Methods Study at Mbarara Regional Referral Hospital

Acceptability of Integration of Cervical Cancer Screening Into Routine HIV Care, Associated Factors and Perceptions Among HIV- Infected Women: a Mixed Methods Study at Mbarara Regional Referral Hospital | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Acceptability of Integration of Cervical Cancer Screening Into Routine HIV Care, Associated Factors and Perceptions Among HIV- Infected Women: a Mixed Methods Study at Mbarara Regional Referral Hospital Mackline Ninsiima, Agnes Nyabigambo, Joseph Kagaayi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1727362/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Apr, 2023 Read the published version in BMC Health Services Research → Version 1 posted 9 You are reading this latest preprint version Abstract Background Integrating Cervical Cancer Screening (CCS) into routine HIV care has been endorsed as an effective strategy for increasing uptake of CCS, and facilitating early detection and treatment of pre-cancerous lesions among HIV-infected women. In Uganda, this strategy has not been implemented yet in most HIV clinics. Assessing the acceptability of this intervention among HIV-infected women is of great relevance to inform its implementation. This study assessed acceptability of integration of CCS into routine HIV care, associated factors and perceptions among HIV-infected women enrolled in the Immune Suppression Syndrome clinic at Mbarara Regional Referral Hospital (MRRH). Methodology: A mixed methods study utilizing the explanatory sequential approach was conducted among 327 eligible HIV-infected women. Acceptability of integration of CCS into routine HIV care was measured using the Theoretical Framework of acceptability (TFA). A pre-tested questionnaire was used to collect quantitative data. Focus group discussions to explore perceptions regarding the intervention were conducted among purposively selected HIV-infected women. Modified poisson regression with robust variance analysis was utilized to determine factors associated with the acceptability of the intervention. Statistical significance was determined at p-value < 0.05. Thematic analysis utilizing inductive coding was used to analyze qualitative data. Results Majority of the HIV-infected women (64.5%) accepted the integration of CCS into routine HIV care. Religion, perceived risk of developing CC and ever screened for CC were statistically significantly associated with the acceptability of integration of CCS into routine HIV care. Perceived benefits of the proposed intervention were: convenience to seek for CCS, motivation to undergo CCS, improved archiving of CCS results, confidentiality of HIV patient information, and preference to interact with ISS clinic health workers. Shame to expose their privacy to the ISS clinic health workers and increased waiting time were the only perceived challenges of the intervention. Conclusion Study findings highlight the need to take advantage of this acceptability to prioritize implementation of the integration of CCS into routine HIV care. HIV-infected women should be reassured of confidentiality and reduced waiting time to increase uptake of the integrated CCS and HIV services among HIV-infected women along the continuum of HIV care and treatment services. Acceptability Integration Cervical Cancer Screening HIV Figures Figure 1 Background Globally, cervical cancer (CC) is the fourth most frequently diagnosed cancer and the fourth leading cause of cancer death in women with an estimated 570, 000 incident cases and 311,000 deaths in 2018 ( 1 ). World Health Organisation (WHO) reported a high mortality rate from CC globally at an age-standardized rate of 6.9/100,000 ( 2 ). In low and medium Human Development Index (HDI) regions, CC ranks second to breast cancer among females at world age-standardized incidence and mortality rates of 18.2/100,000 and 12.0/100,000 respectively ( 1 ). In Africa, CC is the most common cause of cancer accounting for 22% of all female cancers and 12% of all newly diagnosed cancer in both men and women every year ( 3 ). 34 out of every 100, 000 women are diagnosed with CC, and 23 out of every 100, 000 women die from CC every year ( 3 ). The cervical cancer incidence and mortality rates have remained high in Sub-Saharan Africa ( 1 , 4 ). In Eastern Africa, age-standardized incidence and mortality rates of CC are 40.1/100,000 and 30.0/100,000 respectively ( 1 ). In Uganda, the prevalence of the human papilloma virus among women is 33.6% with one of the highest CC incidence rates in the world of 47.5 per 100,000 per year ( 5 ). Human Immunodeficiency Virus (HIV) has been associated with the high vulnerability of developing CC, a great public health challenge. Since 1989, research studies have reported an increased incidence of CC among HIV-infected women ( 6 ). HIV-infected women are at increased risk of new and persistent human papillomavirus infection hence an accelerated advancement and incidence of CC compared to HIV uninfected women ( 2 , 7 – 12 ). HIV-infected women develop CC 5 to 10 years earlier compared to HIV uninfected women ( 2 ). Susceptibility to HPV infection and progression to CC is highly attributed to the weakened cellular immunity among HIV-infected women ( 2 , 6 , 8 ). Due to the association between HIV and CC, WHO recommended that all sexually active girls and women should undergo CCS as soon as they are diagnosed HIV positive and further emphasized regular screening and treatment of pre-cancer lesions among HIV infected women ( 13 ). With alignment to the WHO guidelines, CCS using Visual Inspection with Acetic acid and treatment of pre-cancerous cervical lesions by cryotherapy was recommended for all HIV-infected sexually active girls and women at enrolment into HIV Care and repeated annually in Uganda ( 14 ). Nevertheless, reports have indicated persistent low uptake of CCS among the highly susceptible population ( 15 , 16 ). A nationally representative population-based survey carried out in Uganda reported that only 30.3% HIV-infected women had received CCS ( 17 ). Integration of CCS into routine HIV care has been endorsed as an effective strategy to increase uptake of CCS, achieve early detection and treatment of pre-cancerous lesions among HIV-infected women in Sub Saharan Africa where the cervical cancer burden parallels that of HIV ( 4 , 15 – 22 ). In Uganda, this strategy has not been implemented yet in most HIV clinics. It has been noted that published studies from Uganda explored perceptions and preferences of health care providers, policy makers, and community members including women, men, and village health teams, regarding the integration of HIV and CCS services in a single-visit approach without focussing on HIV-infected women ( 23 , 24 ). It’s difficult to utilize these findings to understand the perceptions of HIV-infected women enrolled in HIV care which would be instrumental in guiding the implementation phase. Furthermore, the acceptability of this intervention has not been assessed among HIV-infected women using the Theoretical Framework of Acceptability (TFA); the approved framework for assessing acceptability of healthcare interventions. This indicates the need to generate scientific evidence regarding acceptability of the intervention among its targeted recipients. Assessing acceptability of this proposed intervention is of great relevance to inform its implementation into comprehensive HIV programming ( 25 ). HIV-infected women enrolled in the ISS clinic are either referred or voluntarily undergo CCS conducted by health workers in the CCS department at MRRH. Despite establishing the referral or client-initiated cervical cancer screening system at MRRH for the last 10 years, only 11.3% of the HIV-infected women enrolled in the ISS clinic at MRRH were reported to have undergone CCS by 30th September 2019. HIV-infected women miss CCS opportunities for early detection of pre-cancerous cervical lesions at enrolment and during the subsequent annual intervals despite their frequent visits to the HIV clinics for medical reviews, viral load monitoring, and monthly ART refills. Such missed opportunities increase the risk of presenting late with advanced cervical cancer and poor prognosis among this vulnerable population. Implementation of integration of CCS into routine HIV care is expected to increase the uptake of CCS services at enrolment and during the subsequent annual HIV clinic visits among the HIV infected women enrolled in the ISS clinic at MRRH compared to the currently practiced referral or client-initiated CCS system. It’s upon this background that this study assessed the acceptability of the integration of CCS into routine HIV care, associated factors and perceptions among HIV-infected women enrolled in the Immune Suppression Syndrome clinic at Mbarara Regional Referral Hospital. Methods Study Site The study was conducted at the Immune Suppression Syndrome Clinic (ISS) at Mbarara Regional Referral Hospital (MRRH) in Mbarara District in South Western Uganda. Cervical cancer is the leading cancer and also the leading gynaecological cancer at MRRH ( 26 ). With a proportion of 25.2%, cervical cancer is the single leading cancer; contributing to 10.1% of all diseases on the gynaecological ward and 73.9% of all gynaecological cancers at MRRH ( 26 ). The Immune Suppression Syndrome Clinic in Mbarara University of Science and Technology (MUST) and Mbarara Regional Referral Hospital has provided HIV Care since November 1998. The clinic has two sections: the adult care section, under the Department of Internal Medicine and the Paediatric and adolescents care section under the Department of Paediatrics. A total of 7212 HIV-infected women were reported to be active in HIV care by 30th September 2019. On average 168 HIV-infected women receive HIV care and treatment services on a typical clinic day. HIV-infected women enrolled in the ISS clinic are either referred or voluntarily undergo CCS conducted by health workers in the cervical cancer screening department at MRRH. It is on these grounds that the ISS clinic at MRRH was selected to study the acceptability of integration of CCS into routine HIV care, associated factors and perceptions among HIV-infected women. Study Design Mixed methods study design utilizing the explanatory sequential approach was used to assess the acceptability of integration of CCS into routine HIV care, associated factors and perceptions among HIV-infected women. Using the explanatory sequential approach, the quantitative phase of the study was first conducted followed by analysis of the quantitative data. HIV-infected women were then selected based on the generated quantitative results of the acceptability of integration of CCS into routine HIV care; to participate in the qualitative investigations. The rationale for the explanatory sequential approach was to explain quantitative study findings in more detail using qualitative research. Study Population The study was conducted among HIV-infected women receiving HIV Care and Treatment services from the ISS Clinic at MRRH. Only HIV-infected women aged 18 and above who turned up for Anti-Retroviral Therapy (ART) refills at the ISS clinic on the interview dates were included in the study. HIV-infected women aged 18 and above who turned up for ART refills on unscheduled dates were excluded based on the electronic appointment list generated for the respective appointment date. Rationale : HIV-infected women who turned up on unscheduled dates were excluded because they were not on the appointment list from which study respondents were systematically selected to participate in the study. Quantitative phase Measurement of study variables Dependent variable The dependent variable for this study was acceptability of integration of CCS into routine HIV care. The Theoretical Framework of Acceptability (TFA) was adapted to measure the acceptability of integration of CCS into routine HIV care. The TFA was proposed as a multi-component framework and systematic approach to assess intervention acceptability across prospective, concurrent, and retrospective temporal perspectives ( 25 ). Questions based on the TFA constructs namely: affective attitude, burden, perceived effectiveness, ethicality, intervention coherence, opportunity costs, and self-efficacy, were administered to eligible participants. Responses were based on a 5-point rating ordinal scale per construct. The summated score of the constructs of acceptability per study participant was computed by summing the weights assigned to construct responses; henceforth a continuous dependent variable. Independent variables Information on sociodemographic characteristics, awareness of CC, knowledge of risk factors of CC, knowledge of symptoms of CC, CCS awareness, uptake of CCS, and perceived risk of CC was obtained. Sociodemographic characteristics included age in completed years, marital status, highest education level attained, religion, area of residence, number of living biological children, and duration of HIV disease. To assess knowledge of risk factors and symptoms of CC, participants were requested to select from the response options “1. Yes” “2. No” for each item. A correct answer was awarded “1” whereas a wrong answer was awarded “0”. According to the African Women Awareness of CANcer (AWACAN) tool, the codes to the response options were assigned without any meaning. So, out of the two options, if the participant selected an appropriate answer as per the item, one received an award of "1" for the respective item because it was the correct answer. If the participant selected an inappropriate answer as per the item, one received an award of "0" for the respective item because it was the wrong answer. A summated score was obtained for variables: knowledge of risk factors and knowledge of signs and symptoms of CC. Knowledge of risk factors of CC was categorised into two categories: “1. Poor Knowledge” and “2. Good Knowledge”; based on the mean score evidenced in recent published studies ( 27 , 28 ). “1. Poor Knowledge” was awarded to HIV-infected women whose summated score of the weights of the items of knowledge of risk factors of CC was less than the mean score value of 8.34. “2. Good Knowledge” was awarded to HIV-infected women whose summated score of the weights of the items of knowledge of risk factors of CC was greater than or equal to the mean score value of 8.34. Knowledge of signs and symptoms of CC was also categorised into two categories: “1. Poor Knowledge” and “2. Good Knowledge”; based on the mean score demonstrated in recent published studies ( 27 , 28 ). “1. Poor Knowledge” was awarded to HIV-infected women whose summated score of the weights of the items of knowledge of signs and symptoms of CC was less than the mean score value of 7.99. “2. Good Knowledge” was awarded to HIV-infected women whose summated score of the weights of the items of Knowledge of signs and symptoms of CC was greater than or equal to the mean score value of 7.99. Sample size and sampling For the quantitative component, sample size was calculated using the sample size estimation formula ( 29 , 30 ): where Z α/2 =1.96 standard normal value at 5% level of significance σ 2 = Variance of the continuous outcome of interest or s 2 where s is the standard deviation Estimated standard deviation = Range/4 = (35 − 0)/4 = 8.75 ( 30 ) δ= Marginal error the researcher is willing to allow; for this study, the marginal error was considered not to exceed 1 On adjusting for a 10% non-response rate, the overall sample size for this study was 327 HIV infected women. Systematic sampling method was used to select participants among HIV-infected women who had been scheduled to turn up at the ISS clinic for ART refills based on the respective appointment dates. Data Collection Quantitative data were collected using administered questionnaires. The pre-coded questionnaire was pre-tested at Kawaala Health Centre IV to check for suitability of various aspects such as translations, skip procedures, filtering questions and modifications were made thereafter. The questionnaire was translated into Runyankole/Rukiiga. Selection and recruitment of experienced research assistants was based on competence, quantitative data collection skills and qualifications. Research assistants received training on how to administer the study questions before data collection. After meeting the selected participants to take part in the study, the researcher introduced herself and explained the purpose of the study. Eligible participants provided written informed consent before the interview was conducted. Each questionnaire was completed within 15–20 minutes. During data collection, questionnaires were reviewed at the end of each interview so that corrections were made in addition to checking for completeness before departure of the participants. Supervision was conducted to ensure compliance throughout the study. Data Management Data capture screens with in-built checks for consistency, logical flow, range and accuracy of data was designed in Epi-data version 3.0. EPIDATA software package version 3.0 was used for data entry. Data was cleaned and stored daily. Double-entry of data was done to check for any errors. Stored data was backed up on different flash discs. The questionnaires were kept securely throughout the study and thereafter. Data Analysis Linear regression analysis is the recommended method of modelling since the dependent variable, the acceptability of the integration of CCS into routine HIV care, was a continuous variable. The summated scores of the acceptability of the integration of CCS into routine HIV care were converted into percentages. The regression modelling predicting the acceptability of the integration of CCS into routine HIV care from all the independent variables was conducted. Residuals were generated followed by testing the assumptions of linear regression: normality of residuals and homogeneity of variance. Linear regression analysis was not utilised for this study because both the assumptions of normality and homogeneity of variance of residuals were violated. The acceptability of integration of CCS into routine HIV care was dichotomized into two categories: “0. Not Accepted” and “1. Accepted” based on the value of 26.25, the 75th percentile of the highest possible summated score of 35 from the seven constructs of the Theoretical Framework of Acceptability. The 75th percentile was recommended as the cut-off value based on a published study which utilised likert - type scale responses assessing constructs to measure the composite dependent variable ( 31 ). “0. Not Accepted” was awarded to HIV-infected women whose summated score of the weights of the constructs of acceptability of integration of CCS into routine HIV care was less than the value of 26.25. “1. Accepted” was awarded to HIV-infected women whose summated score of the weights of the constructs of acceptability of integration of CCS into routine HIV car was greater than or equal to the value of 26.25. Frequencies and percentages of HIV-infected women who had accepted and those who had not accepted integration of CCS into routine HIV care were computed. Univariable analysis Univariable data analysis was conducted; all variables were analysed to describe the study sample. For all independent categorical variables, data was tabulated and presented as frequencies and percentages. Bivariable analysis Cross tabulations of the outcome variable and independent variables were done to obtain the frequencies and corresponding percentages of the HIV-infected women who accepted and those who did not accept the integration of CCS into routine HIV care per independent variable. Selection of the regression model to use at bivariable analysis was conducted. Using occupation as an example, the logistic regression, log binomial and modified poisson regression models were used. It was noted that the logistic regression and log binomial models overestimated the measures of association compared to the modified poisson regression model. Given that the outcome had a higher percentage of 64.5%, modified poisson regression with robust variance was selected for the bivariable analysis to obtain crude prevalence ratios, 95% confidence interval, and the corresponding p-values. Multivariable analysis Multicollinearity among the independent variables was checked for using variance inflation factor. The regression modelling predicting the acceptability of the integration of CCS into routine HIV care from all the independent variables was conducted and then the vif command was issued to check for multicollinearity. The variance inflation factors for all the independent variables were less than 2.5. Ultimately, all the independent variables were included in the multivariable analysis. Modified poisson regression with robust variance using the stepwise logical model building technique was conducted to obtain adjusted prevalence ratios, 95% confidence interval and the corresponding p-values. Checking for goodness of fit of the model was done based on the Akaike Information Criteria (AIC). Significance of independent variables was set at p < 0.05. Statistical analysis was conducted using Stata/SE Version 14.0. Qualitative phase Sample size and sampling With reference to the 5 – point likert - type Scale, acceptability of integration of CCS into routine HIV care was categorised into five categories; “1. Very Unacceptable”, “2. Unacceptable”, “3. Neutral”, “4. Acceptable” and “5. Very Acceptable” based on the summated score of the weights of the constructs of acceptability. “1. Very Unacceptable” was awarded to respondents whose summated score of the weights of the constructs of acceptability was 7 and below; “2. Unacceptable” was awarded to respondents whose overall score of the weights of the constructs of acceptability was 8–14; “3. Neutral” was awarded to respondents whose summated score of the weights of the constructs of acceptability was 15–21; “4. Acceptable” was awarded to respondents whose overall score of the weights of the constructs of acceptability was 22–28; and “5. Very Acceptable” was awarded to respondents whose summated score of the weights of the constructs of acceptability was 29 and above out of the 35 criteria. Based on the category of acceptability of integration of CCS into routine HIV care, 6 Focus Group Discussions (FGDs) were conducted among HIV-infected women as shown in Table 1 . The number of FGDs per level of acceptability of the integration of CCS into routine HIV care was based on the number of HIV-infected women within the respective categories. Sample size of 6 FGDs was further determined by the data saturation point; a point at which further sampling did not generate any new concepts or ideas about the phenomenon under investigation. Purposive sampling was used to select HIV-infected women from the quantitative phase to participate in the FGDs. Table 1 Criteria for selection of participants for Focus Group Discussions (FGDs) Summated Score Range Level of Acceptability Number of HIV-infected women Number of Focus Group Discussions Number of participants per Focus Group Discussions 0–7 Very Unacceptable 6 1 6 8–14 Unacceptable 15–21 Neutral 22 1 6 22–28 Acceptable 157 2 6 29–35 Very Acceptable 142 2 6 Data Collection The FGD guide was specifically developed for this study with questions aimed at eliciting HIV-infected women’s perceptions of integration of CCS into routine HIV care. The FGD guide was pre-tested and recommended changes in the questions were made to ensure that the guide captured relevant and appropriate information before use. FGD guide was translated into Runyankole/Rukiiga. Key questions in the FGD guide explored the participants’ impressions, anticipated benefits, and challenges of integration of CCS into routine HIV care in a single visit approach in the HIV clinics in Uganda. An experienced research assistant at collecting qualitative data through conducting FGDs was recruited. Data Management Focus group discussions were audio-recorded. The collected audio-recorded data was adequately and appropriately backed up. All audio recorded local language interviews were translated into English and transcribed verbatim simultaneously. The transcripts were proof-read before importing them into Atlas.ti Version 6.0, a qualitative data management software. Data Analysis Thematic analysis method using inductive coding was used to analyse qualitative data. Exploration of data and synthesis of codes, subthemes and themes was done in Atlas.ti Version 6.0. Relevant verbatim quotations were selected as evidence to support the generated themes. Results Socio-demographic characteristics of study respondents Table 2 shows the baseline characteristics of the study respondents. Majority of the respondents (33.0%) were aged 40–49. Majority of the respondents (60.2%) resided in rural areas. Primary education was the highest level attained by majority of the respondents (45.0%) whereas only 21.4% had not attained any education. Most of the study respondents were Protestants (46.8%). Most respondents (47.4%) were self-employed in the agriculture sector. Majority of the respondents (56.0%) had delivered 1–3 children. Based on self-reports, 59.0% of the respondents had lived with HIV for 10 years and above since they were diagnosed HIV positive. 95.1% and 75.8% reported that they were aware about CC and CCS programme respectively. Majority of the respondents (54.4%) had good knowledge of the risk factors of CC; whereas 63.6% had good knowledge of signs and symptoms of CC. Majority of respondents (52.0%) had “Much Above Average” perceived risk of developing CC; and 65.1% reported to have undergone CCS. Table 2 Characteristics of study respondents Study variables Frequencies (n = 327) Percentages (%) Completed Age 18–29 43 13.2 30–39 91 27.8 40–49 108 33.0 50 and above 85 26.0 Residence Rural 197 60.2 Urban 130 39.8 Highest Education Level None 70 21.4 Primary Education 147 45.0 Secondary or Higher Education 110 33.6 Marital Status Not Married 205 62.7 Married 122 37.3 Religion Anglican 153 46.8 Catholic 107 32.7 Muslim 34 10.4 Others (Pentecostal & SDA) 33 10.1 Occupation Not working 28 8.6 Employed (Paid) 29 8.9 Self Employed (Businesswoman) 115 35.1 Self Employed (Agriculture) 155 47.4 Number of Children None 26 8.0 1–3 183 56.0 4 and above 118 36.0 HIV Duration (Number of years since diagnosed HIV positive) 1–4 50 15.3 5–9 84 25.7 10 and above 193 59.0 Awareness of Cervical Cancer (CC) Yes 311 95.1 No 16 4.9 Knowledge of risk factors of Cervical Cancer (CC) Poor Knowledge 149 45.6 Good Knowledge 178 54.4 Knowledge of signs and symptoms of Cervical Cancer (CC) Poor Knowledge 119 36.4 Good Knowledge 208 63.6 Perceived risk of developing cervical cancer Much Below Average 67 20.4 Below Average 28 8.6 Average 31 9.5 Above Average 31 9.5 Much Above Average 170 52.0 Awareness of Cervical Cancer Screening (CCS) Yes 248 75.8 No 79 24.2 Ever screened for Cervical Cancer Yes 213 65.1 No 114 34.9 Acceptability of integration of Cervical Cancer Screening into routine HIV care Table 3 shows the frequencies and percentages of acceptability of integration of CCS into routine HIV care. Majority of the respondents (64.5%) accepted the integration of CCS into routine HIV care as shown in Fig. 1 . Table 3 Acceptability of integration of CCS into routine HIV care among HIV-infected women Study variable Frequencies (n = 327) Percentages (%) Acceptability of integration of cervical cancer screening into routine HIV care Not Accepted 116 35.5 Accepted 211 64.5 Factors associated with acceptability of integration of Cervical Cancer Screening into routine HIV care among HIV infected women Table 4 shows unadjusted and adjusted prevalence ratios with their respective corresponding confidence intervals. At bivariable analysis, religion, awareness of CC, knowledge of signs and symptoms of CC, perceived risk of developing CC, awareness of CCS, and ever screened for CC were associated with the acceptability of integration of CCS into routine HIV care among HIV-infected women at MRRH. At multivariable analysis, based on 95% confidence intervals and p – values, religion, perceived risk of developing CC and ever screened for CC were statistically significantly associated with the acceptability of integration of CCS into routine HIV care among HIV-infected women at MRRH. On adjusting for other independent variables, the prevalence of the acceptability of integration of CCS into routine HIV care among Muslims was 1.47 [95% CI = 1.21–1.78] times the prevalence of the acceptability of integration of CCS into routine HIV care among Protestants. Muslims were 47% more likely to accept the integration of CCS into routine HIV care compared to Protestants. The prevalence of the acceptability of integration of CCS into routine HIV care among HIV-infected women with “Much Above Average” perceived risk of developing CC was 1.43 [95% CI = 1.11–1.85] times the prevalence of the acceptability of integration of CCS into routine HIV care among HIV-infected women with “Much Below Average” perceived risk of developing CC. HIV-infected women with “Much Above Average” perceived risk of developing CC were 43% more likely to accept the integration of CCS into routine HIV care compared to HIV-infected women with “Much Below Average” perceived risk of developing CC. The prevalence of the acceptability of integration of CCS into routine HIV care among HIV-infected women who had not undergone CCS was 0.71 [95% CI = 0.58–0.86] times the prevalence of the acceptability of integration of CCS into routine HIV care among HIV-infected women who had undergone CCS. HIV-infected women who had not undergone CCS were 29% less likely to accept the integration of CCS into routine HIV care compared to HIV-infected women who had undergone CCS. Table 4 Factors associated with acceptability of integration of CCS into routine HIV care among HIV-infected women Independent variables Acceptability of integration of CCS into routine HIV care Unadjusted Prevalence Ratios 95% Confidence Intervals Adjusted Prevalence Ratios 95% Confidence Intervals Not Accepted n (%) Accepted n (%) Completed Age 18–29 19 (44.2) 24 (55.8) Ref. Ref. 30–39 30 (33.0) 61 (67.0) 1.20 [0.89–1.63] 1.11 [0.83–1.49] 40–49 37 (34.3) 71 (65.7) 1.18 [0.87–1.59] 1.16 [0.86–1.56] 50 and above 30 (35.3) 55 (64.7) 1.16 [0.85–1.58] 1.15 [0.86–1.55] Residence Rural 77 (39.1) 120 (60.9) Ref. Ref. Urban 39 (30.0) 91 (70.0) 1.15 [0.98–1.35] 1.13 [0.97–1.31] Highest Education Level None 28 (40.0) 42 (60.0) Ref. Ref. Primary Education 58 (39.5) 89 (60.5) 1.01 [0.80–1.27] 0.88 [0.70–1.11] Secondary or Higher Education 30 (27.3) 80 (72.7) 1.21 [0.97–1.52] 0.99 [0.78–1.26] Marital Status Not Married 75 (36.6) 130 (63.4) Ref. Ref. Married 41 (33.6) 81 (66.4) 1.05 [0.89–1.23] 0.97 [0.82–1.15] Religion Protestant 66 (43.1) 87 (56.9) Ref. Ref. Catholic 34 (31.8) 73 (68.2) 1.20 [0.99–1.45] 1.16 [0.96–1.39] Muslim 5 (14.7) 29 (85.3) 1.50 [1.23–1.83] 1.47 [1.21–1.78] *** Others (Pentecostal & SDA) 11 (33.3) 22 (66.7) 1.17 [0.89–1.55] 1.14 [0.88–1.48] Occupation None 7 (25.0) 21 (75.0) Ref. Ref. Employed (Paid) 7 (24.1) 22 (75.9) 1.01 [0.75–1.36] 1.03 [0.80–1.33] Self Employed (Business) 38 (33.0) 77 (67.0) 0.89 [0.70–1.15] 0.91 [0.73–1.14] Self Employed (Agriculture) 64 (41.3) 91 (58.7) 0.78 [0.61–1.01] 0.81 [0.64–1.03] Number of Children None 13 (50.0) 13 (50.0) Ref. Ref. 1–3 50 (27.3) 133 (72.7) 1.45 [0.98–2.16] 1.25 [0.86–1.83] 4 and above 53 (44.9) 65 (55.1) 1.10 [0.73–1.67] 0.95 [0.63–1.43] HIV Duration (Number of years since diagnosed HIV positive) 1–4 24 (48.0) 26 (52.0) Ref. Ref. 5–9 26 (31.0) 58 (69.0) 1.33 [0.98–1.80] 1.18 [0.89–1.58] 10 and above 66 (34.2) 127 (65.8) 1.27 [0.95–1.68] 1.08 [0.81–1.44] Awareness of Cervical Cancer (CC) Yes 104 (33.4) 207 (66.6) Ref. Ref. No 12 (75.0) 4 (25.0) 0.38 [0.16–0.88] 0.46 [0.20–1.02] Knowledge of risk factors of Cervical Cancer (CC) Poor Knowledge 61 (40.9) 88 (59.1) Ref. Ref. Good Knowledge 55 (30.9) 123 (69.1) 1.17 [0.99–1.38] 1.01 [0.85–1.20] Knowledge of signs and symptoms of Cervical Cancer (CC) Poor Knowledge 52 (43.7) 67 (56.3) Ref. Ref. Good Knowledge 64 (30.8) 144 (69.2) 1.23 [1.02–1.48] 1.14 [0.96–1.35] Perceived risk of developing Cervical Cancer (CC) Much Below Average 33 (49.3) 34 (50.7) Ref. Ref. Below Average 10 (35.7) 18 (64.3) 1.27 [0.88–1.82] 1.27 [0.91–1.78] Average 15 (48.4) 16 (51.6) 1.02 [0.67–1.54] 1.13 [0.75–1.70] Above Average 11 (35.5) 20 (64.5) 1.27 [0.89–1.81] 1.23 [0.87–1.73] Much Above Average 47 (27.6) 123 (72.4) 1.43 [1.11–1.84] 1.43 [1.11–1.85] ** Awareness of Cervical Cancer Screening (CCS) Yes 76 (30.7) 172 (69.3) Ref. Ref. No 40 (50.6) 39 (49.4) 0.71 [0.56–0.90] 1.03 [0.74–1.45] Ever screened for Cervical Cancer (CC) Yes 59 (27.7) 154 (72.3) Ref. Ref. No 57 (50.0) 57 (50.0) 0.69 [0.57–0.85] 0.71 [0.58–0.86] ** * p < 0.05 ** p < 0.01 *** p < 0.001 Perceptions of HIV infected women regarding the integration of Cervical Cancer Screening into routine HIV care Characteristics of Focus Group Discussion (FGD) participants Table 5 shows the characteristics of Focus Group Discussion (FGD) participants. The mean age of the FGD participants was 40.0 (9.8). Majority of the participants (33.3%) were aged 40–49. Majority of the respondents (55.6%) resided in rural areas. Primary education was the highest level attained by majority of the respondents (47.2%) whereas only 16.7% had not attained any education. Most of the FGD participants (36.1%) were self-employed in the agriculture sector. Only 5.6% and 11.1% of the Focus Group Discussion participants were selected from the “Very Unacceptable” and “Unacceptable” levels of acceptability respectively. Of the FGD participants, 16.7% were selected from the “Neutral” level of acceptability; whereas 33.3% were selected from each of the “Acceptable” and “Very Acceptable” levels of acceptability. The FGD participants were grouped into 6 groups based on the level of acceptability to ensure homogeneity of the groups. FGD 1 comprised of 2 and 4 participants from the “Very Unacceptable” and “Unacceptable” levels of acceptability respectively. FGD 2 comprised of 6 participants from the “Neutral” level of acceptability. FGD 3 comprised of 6 participants from the “Acceptable” level of acceptability. FGD 4 comprised of 6 participants from the “Acceptable” level of acceptability. FGD 5 comprised of 6 participants from the “Very Acceptable” level of acceptability. FGD 6 comprised of 6 participants from the “Very Acceptable” level of acceptability. Table 5 Characteristics of Focus Group Discussion (FGD) participants Study variables Frequencies (n = 36) Percentages (%) Completed Age Age [Mean Age (SD)] 40.0 (9.8) 20–29 7 19.4 30–39 10 27.9 40–49 12 33.3 50 and above 7 19.4 Residence Rural 16 44.4 Urban 20 55.6 Highest Education Level None 6 16.7 Primary Education 17 47.2 Secondary or Higher Education 13 36.1 Occupation Not working 6 16.7 Employed (Paid) 6 16.7 Self Employed (Businesswoman) 11 30.5 Self Employed (Agriculture) 13 36.1 Level of acceptability of integration of CCS into routine HIV care Very Unacceptable 2 5.6 Unacceptable 4 11.1 Neutral 6 16.7 Acceptable 12 33.3 Very Acceptable 12 33.3 Table 6 shows the codes, sub-themes and themes of the perceptions of HIV-infected women regarding the integration of CCS into routine HIV care. The perceptions of HIV-infected women were presented in two thematic areas: i) Perceived benefits of the integration of CCS into routine HIV care and ii) Perceived challenges of the integration of CCS into routine HIV care. Table 6 Codes, sub-themes and themes Codes Sub -Themes Theme - Receiving HIV drugs and CCS services at the same scheduled date - Cost saving - Receiving HIV care and CCS services from the same place - Prior preparation to undergo CCS on the scheduled date - Time saving - Reduced disturbance and movements seeking for HIV care and CCS services from different clinics Convenience to seek Cervical Cancer Screening services Perceived benefits of the integration of CCS into routine HIV care - HIV-infected women will be encouraged to receive CCS services - Increased awareness about cervical cancer and the rationale to undergo CCS services - Easier to remember the next appointment for undergoing CCS annually - Health workers will easily remind HIV-infected women about their next scheduled check-up for CCS - Reduces the fear to receive CCS services - Early treatment of precancerous lesions - Early detection of Cervical Cancer - Compliance and adherence to undergo CCS services annually - Increased opportunities to undergo CCS services Motivation to undergo Cervical Cancer Screening - Record keeping of CCS results and HIV related information in the one HIV patient’s file - Easy follow-up of CCS results Improved archiving of Cervical Cancer Screening results - HIV-infected women don’t want to interact with HIV uninfected women at the CCS unit - Reduction in HIV stigma from the HIV uninfected women and non-ISS health workers at the CCS unit - Privacy of the HIV positive status - HIV-infected women will be interacting with ISS health workers and fellow HIV-infected women who know their HIV status without stigma Confidentiality of HIV patient information - Free interaction and opening up to ISS health workers whom the HIV-infected women are used to - ISS health workers do not neglect the HIV infected women - Fear to disclose the HIV status to non-ISS health workers - Some non-ISS health workers fear to conduct CCS procedure on the HIV-infected women Preference to interact with ISS clinic health workers - Ashamed to expose private parts to health workers who have known the HIV-infected women - Preference to open up and share experiences to health workers who don’t know them - Fear and shame to continue interacting with the same health workers to whom they have exposed their private parts for any other HIV related services - Shyness to expose private parts to health workers who have known the HIV-infected women - Fear to receive HIV related services from the health workers to whom HIV- infected women have exposed to their private parts Shame to expose their privacy to the ISS clinic health workers Perceived challenges of the integration of CCS into routine HIV care - Increase on the time spent at the ISS clinic to undergo CCS - Delay at the ISS clinic to receive both HIV and CCS services - Very many women to undergo CCS since the women are more than the men enrolled in the ISS clinic Increased waiting time Perceived benefits of integration of Cervical Cancer Screening into routine HIV care Convenience to seek Cervical Cancer Screening services Convenience to seek cervical cancer screening (CCS) services was the most predicted advantage of the integration of CCS into routine HIV care. In all FGDs, HIV-infected women acknowledged that the integration of CCS into routine HIV care would grant them an opportunity to receive both CCS in addition to HIV Care and Treatment services from the ISS Clinic compared to the currently practiced referral or client – initiated CCS conducted at the CCS unit at MRRH. Furthermore, HIV-infected women claimed that the proposed strategy of delivering CCS would reduce the disruption and movement from one clinic to another since all the CCS and HIV related services would be available and received under one roof in a single HIV clinic visit comprehensively. “Sending you down there wouldn’t have a problem but it can somehow disturb you …, but if they are here, you can know that I am going to pick drugs and then test so I get all services from one place...” (Respondent 1, FGD 6 _ Very Acceptable) “But when you bring it here, you will have helped us truthfully, you examine us from here, we go there and get medicine …, I would prefer that they examine me from here and everything gets done from here…” (Respondent 1, FGD 5 _ Very Acceptable) HIV-infected women in majority of the FGDs revealed that the referral or client – initiated CCS services have been quite hectic and inconveniencing to an extent that some of them have missed several opportunities to undergo the CCS procedure; hence supporting the integrated mode of delivery of CCS and HIV related services. “I say that it is right because of a reason. When you come for treatment, to pick drugs, even when you are in pain, it will be hard for you to tell the doctor because you know that he will send you down there ... But if it is here and you know that I will just do like this, reach here, they test me for cancer of the cervix and I go home, there is no problem in that.” (Respondent 4, FGD 5 _ Very Acceptable) HIV-infected women in most FGDs affirmed that the convenience attributed to the integration of CCS into routine HIV care would eventually save the time spent at the health facility compared to the currently delivered stand-alone CCS and HIV services. “… because when she comes here, she has to pick drugs and then slope down there or first slope there and hurry back to get drugs and in this she may be caught by time, or even by the time she gets down, she may find that they have already closed but if those services are here, she can get drugs and later enter the room and they test for cancer of the cervix.” (Respondent 1, FGD 3 _ Acceptable) “If these services are brought here inside, it will be faster for us …, you can even put your paper at the window and you say that let me go to the cancer room and they test me meanwhile. When I am coming from the cancer clinic, I find when they are working on my drugs, get them and go. So, if you bring these services here, it will be faster for us.” (Respondent 1, FGD 2 _ Neutral) HIV-infected women in some FGDs who had endeavoured to undergo the CCS procedure reported that they missed receiving ART refills due to having spent quite many hours seeking for the CCS services from the CCS unit at MRRH. “…the day I tested from down there, I didn’t get the drugs because I found that health workers here had left and so I had to come back the following day” (Respondent 5, FGD 5 _ Very Acceptable) HIV-infected women in most FGDs believe that such scenarios of missing HIV Care and Treatment services due to the disruption of seeking CCS services from the CCS unit at MRRH would be minimised by implementation of the integrated mode of delivery of CCS and HIV related services. “The problem is going there and you find there very many people or sometimes you fail to get treatment and they tell you to come back the following day. You come early in the morning but you fail to get treatment but if they are here, you can be sure that at least today, I will go back when I have gotten treatment. And remember, you won’t jump the whole of that line that you are going in front. You will go behind and by the time they finish that line, and remember you have to get HIV drugs from up. And you might find when the health workers at the ISS clinic have closed. And now imagine having to come back the next day” (Respondent 3, FGD 6 _ Very Acceptable) Furthermore, HIV-infected women in “Very Acceptable” FGDs stated that integrated services would save time since a client would easily receive both HIV and CCS services in a single HIV clinic compared to spending a lot of time while travelling to the health facility twice; to seek for CCS and HIV related services from two separate clinics on different days which would in due course reduce the travel costs. “Sending you down there wouldn’t have a problem but it can somehow disturb you because sometimes you can be home without money waiting to use the one you have the time you are coming to pick drugs, and there still, they want you to go and test. It can disturb you a bit if you go down there to get tested and then by the time you come back, you find the health workers here have closed. And you have to come back the next day to pick drugs… but if they are here, you can know that I am going to pick drugs and then test so I get all services from one place, I test for cancer of the cervix and at the same time, pick my drugs on the same day.” (Respondent 1, FGD 5 _ Very Acceptable) Motivation to undergo Cervical Cancer Screening HIV-infected women in all FGDs reported that integration of CCS into routine HIV care would motivate HIV infected women to undergo CCS services. This would ultimately increase the uptake of CCS among HIV infected women; hence achieving the primary goal of implementing the integration of CCS into routine HIV care. “What I think about is that when they bring those services here so that when we have come for treatment and we find them here, we would get inspired to go and test...” (Respondent 3, FGD 6 _ Very Acceptable) “When you find that they have brought that clinic here, it will be really so good for it will give us morale to access it.” (Respondent 2, FGD 2 _ Neutral) “I think that when those services come here, even those who fear themselves will no longer do so because we have been with our doctors, and they know how our lives are and how they handle us. So, I think that everyone will be encouraged to participate in it.” (Respondent 2, FGD 3 _ Acceptable) Furthermore, HIV-infected women in majority of the FGDs alleged that integration of CCS into routine HIV care would inspire HIV-infected women, the targeted recipients to comply and adhere to recommended annual CCS services. Since documentation about when one last conducted CCS would be captured in the same file with all the other HIV related information, it would be easier for the health worker to remind the client about the appointment date for conducting the next CCS procedure. “That that you have decided that when you are coming to pick drugs, they also test you from here is really so good because I went down there and they tested me … They also gave me a card but unfortunately, the card got lost but I was negative. They told me to go back … but like how you said it at the beginning, I have never gone back. But if it is here and I have come to pick drugs or I have come for treatment, they can check in my file and remind me that on such a date, you are supposed to come and they test you.” (Respondent 1, FGD 4 _ Acceptable) “If we are receiving services from here in our clinic, it will be helping us so much because if they have given you the date for treatment as that of testing for cancer of the cervix, it will be helping us so much to find that you cannot be disturbed a lot because you know the dates for treatment and testing for cancer of the uterus. …if I have tested this year, I have another date next year when I will come back! It being the same date for treatment” (Respondent 2, FGD 3 _ Acceptable) Improved archiving of Cervical Cancer Screening results HIV-infected women in some FGDs acknowledged that integration of CCS into routine HIV care would enhance improved record keeping of CCS results. This was highly attributed to the fact that documentation about when the client last conducted CCS would be captured in the same file with all the other HIV related information. “For me I see that the beauty about testing me from here is that everything will be done from here and all will be put in one file and anyone who gets your file will have to see all the diseases that you have.” (Respondent 5, FGD 5 _ Very Acceptable) HIV-infected women in few of the FGDs anticipated that undergoing CCS from the ISS Clinic would make it quite easier for follow up of CCS results. “You see when we are examined from this our clinic, even when results don’t come there and then, …, when you come back, you know that you will find your results in your file and still the health worker will have the responsibility of telling you what the outcome of the results was, …, even when you may forget, your health worker will definitely remind you.” (Respondent 3, FGD 5 _ Very Acceptable) Confidentiality of HIV patient information HIV-infected women in majority of the FGDs claimed that the proposed intervention of integrating CCS into routine HIV care would promote confidentiality of the HIV status and any other health related information due to interaction with only health workers and fellow HIV infected women; as opposed to the current situation where HIV-infected women are forced to interact with other health workers and HIV uninfected women while undergoing CCS at the CCS unit of MRRH. Confidentiality was very much appreciated as a great attribute of the integrated delivery of CCS comprehensively with all other routine HIV care services due to reduced stigma. “You see when they are sending us down there; they send us with our files and remember there are people who have come so early to test for cancer of the cervix. …, they see people bombarding them and then they start to ask, where are these ones coming from? Ahh they are HIV/AIDS victims. You see them pointing fingers because they have isolated us. But if it has come to our clinic and you know that if I have come to test for cancer of the cervix I will find services at the ISS clinic, I will also be confident wherever I will be seated because I will know that the people I am seated with are my fellows. ...and even when they say that, you should start with the ones from the ISS clinic, you see them start to grumble… eh we are going to rest from such at least. The thing of grumbling at us, pin pointing us, isolating us…” (Respondent 2, FGD 6 _ Very Acceptable) “… there are women who don’t want others to know that they are sick. So she will go down there, and meet a friend whom she has been keeping it away from, and this person is going to see her in the line of those with HIV virus. That will bring an effect because she has found there her friend who has not been knowing her stand and now she’s going to know. But if they bring the services for cancer of the cervix, I think it will help all of us and those who don’t want their stand to be known…” (Respondent 4, FGD 5 _ Very Acceptable) Preference to interact with ISS clinic health workers HIV-infected women in most FGDs appreciated the integrated strategy whereby health workers from the ISS Clinic will perform the CCS procedure in addition to other HIV related services. HIV-infected women preferred receiving CCS conducted by the ISS clinic health workers to the currently practiced system where the CCS procedure is conducted by the health workers at the ISS unit of MRRH. HIV-infected women revealed that they can freely share their experiences or any health-related issues with the health workers at the ISS Clinic due to the strong relationship built over time as opposed to health workers at the CCS Unit of MRRH. “me I think that if they bring them here, it will be easy for us because let’s say they put a particular person to carry out the tests, it will be easier for one to explain to her how someone is, not like the one down there because you find in most cases, when they would send us there, the health workers would look at you as if there is something on you, they would all be neglecting to attend to you, because the people down there may not be as free to you as this one who can be here, you can explain everything to her and another thing it becomes easier for you because after picking the drugs, you can go and test.” (Respondent 3, FGD 3 _ Acceptable) Perceived challenges of integration of Cervical Cancer Screening into routine HIV care Shame to expose their privacy to the ISS clinic health workers HIV-infected women in the “Very Unacceptable and Unacceptable” FGD reported that they would prefer receiving CCS conducted by the health workers at the CCS Unit of MRRH as opposed to the health workers at the ISS Clinic. They argued that due to having interacted for quite a very long time, they would always be overwhelmed with fear and shame to continue interacting with the same health workers to whom they have exposed their private parts for any other HIV related services. They confessed that they would honestly prefer undergoing the CCS conducted by the health workers at the CCS Unit of MRRH because they rarely interact with them; hence no fear and shame to expose their private parts. “… ever since l started picking drugs from here, the nurse I found here is the one still there, the doctor I found there is the one still there, but there is a way we are created in our private parts, if someone has ever seen you, you feel ashamed as if she knows how you are exactly, as if she will tell others that so and so is like this and that, but down there where we go, sometimes you find they have changed them, you find that those who are always there are very different. And even by the time you go there, they can’t be remembering you because you go there once, but here, we come every month, every after two months, someone knows how you are created down, but down there, someone cannot even be remembering that you are the one but here they know us as patients in and out … you say that now that he has seen me, he has remembered how I look like down there in my private parts...” (Respondent 5, FGD 1 _ Very Unacceptable and Acceptable) HIV-infected women in only the “Very Unacceptable” and “Unacceptable” FGD anticipated that the fear and shame to undergo CCS conducted by the health workers at the ISS Clinic would even generate non-adherence to scheduled HIV clinic visits. “Sometimes, those people will start irregular treatment. The day they gave her, if she knows that she is going to be tested for cancer of the cervix, she won’t come or that day when she is to come, she will come when she is in her periods.” (Respondent 4, FGD 2 _ Neutral) “Testing us from here… No… I too don’t like that. Me too I can’t like that because I can know that all these people seated here know what I am from doing. Now he himself will be looking at me as if he knows exactly how I was created. As if he sees me naked. No No. They should put us there where others have been because personally you will put me here, when you look at me, I look down, you do like this, I look down, now my CD4s will go down or even my thoughts be low because of that thing.” (Respondent 3, FGD 1 _ Very Unacceptable and Unacceptable) Increased waiting time HIV-infected women in majority of the FGDs argued that delivering CCS comprehensively with other routine HIV care services during the scheduled HIV clinic visits would be very time consuming hence increasing the waiting time at the ISS clinic. With the increased numbers of HIV-infected women enrolled into HIV care at the ISS Clinic, the participants were worried of the potential delay at the ISS clinic attributed to the integration of CCS into routine HIV care. “…you come when you have put your attention on the health worker to explain to him how you are feeling and where you are paining. By the time you get to the line of picking drugs, in fact you be already tired. And now imagine, you will also have to go the cancer room… don’t you think women will go back at night or even the next day [laughs] …” (Respondent 5, FGD 1 _ Very Unacceptable and Unacceptable) “The problem … the one of time because there is when you see someone who came very early in the morning sitting there up to around 11am. She has not yet seen the doctor so that she can ask the nurse for the file, so it is always that they have not yet reached her. So, you see her start to complain that I came here in the morning and up to now I am still there. So, by the time she finishes all that to come back to test for cancer of the cervix, I see that that is the only problem we are going to find…” (Respondent 6, FGD 6 _ Very Acceptable) Due to the time-consuming challenge, HIV-infected women in very few FGDs expressed concern on how the integrated approach of CCS and HIV services in a single HIV clinic visit would be delivered since some of the recipients travel from very far to seek for HIV treatment services from the ISS clinic. “… so I don’t know, like how I told you that women are more than men in this clinic, l don’t know, shall we be making a line like this here, shall we be having numbers, shall we be having 4 rooms, how will that thing be done …? Some of us come from far. Not that this clinic covers only the Mbarara people, we even have those from Fortportal, Kamwenje, generally people come from far. So, let’s say I have come from Kamwenje, to pick drugs because l know that l have to get drugs. Yet I also have to test for cancer from our clinic. Which arrangement do you have that the time I have here doesn’t be increased?” (Respondent 4, FGD 4 _ Acceptable) Discussion This study aimed at assessing the acceptability of integration of Cervical Cancer Screening (CCS) into routine HIV care, associated factors and perceptions among HIV-infected women enrolled in the Immune Suppression Syndrome (ISS) clinic at Mbarara Regional Referral Hospital (MRRH). Analysis of data showed that 64.5% of the HIV-infected women enrolled in the ISS clinic at MRRH accepted the integration of CCS into routine HIV care. This study finding is lower than the acceptance among HIV-infected women to undergo the CCS procedure reported at 87.6% after incorporating Visual Inspection with Acetic acid (VIA) into the routine clinical services offered at Family AIDS Care and Education Services (FACES) clinics in Kisumu, Kenya ( 32 ). The acceptability of the proposed intervention at 64.5% is lower than the CCS acceptance of 79.8% among HIV-infected women at the HIV treatment centre, Nigerian Institute of Medical Research (NIMR), Lagos, Nigeria who participated in the study assessing the acceptability of the integration of CCS into HIV care ( 8 ). In addition, the reported finding of 64.5% is lower than the 96.5% acceptability to undergo Visual Inspection with Acetic acid (VIA) after integrating CCS and HIV care and treatment services in a district hospital in Abuja, Nigeria ( 33 ). This could be attributed to the perceived challenges of the integration of CCS into routine HIV care among HIV-infected women enrolled at the ISS clinic. Results of the multivariable regression analysis indicated that religion, perceived risk of developing Cervical Cancer (CC) and ever screened for Cervical Cancer (CC) were statistically significantly associated with the acceptability of integration of CCS into routine HIV care among HIV-infected women. Despite the fact that Muslims accepted the integration of CCS into routine HIV care compared to protestants, a study conducted among HIV-infected women at the HIV treatment centre, Nigerian Institute of Medical Research (NIMR), Lagos, Nigeria reported that religion was not significantly associated with the acceptability of the integration of CCS into routine HIV care ( 8 ). Additionally, a study conducted in Ethiopia reported that religion differences were not significantly associated with acceptability and uptake of CCS among HIV-infected women at St. Paul's and Zewditu Hospitals where CCS had been integrated into HIV care and treatment services ( 34 ). Despite the fact that this was a surprising finding, it is unclear why most Christians inclusive of protestants regard fatal illnesses like CC to be a punishment from God and believe that the prevalence of CC is very low among children of God; hence the need for involvement of religious stakeholders in the advocacy for integration of CCS into routine HIV care. In this study, HIV-infected women with “Much Above Average” perceived risk of developing CC accepted the integration of CCS into routine HIV care. This study finding highly correlates with the finding from the systematic review conducted in Ethiopia where perceived susceptibility to acquiring CC (AOR = 3.26; 95% CI : 2.26, 4.26) was significantly associated with CCS acceptability among HIV-positive women ( 35 ). However, a study conducted among HIV-infected women at the HIV treatment centre, Nigerian Institute of Medical Research (NIMR), Lagos, Nigeria reported that perceived risk of acquiring CC was not significantly associated with the acceptability of the integration of CCS into routine HIV care ( 8 ). Nonetheless, a study conducted in Ghana reported that perceived susceptibility to acquiring CC was not significantly associated with willingness and acceptability to undergo CCS among HIV-infected women ( 36 ). The discrepancies in the influence of perceived risk of CC to the acceptability of integration of CCS into routine HIV care could be explained by the gap of lack of awareness that HIV infected women are more at risk of developing CC compared to their counterparts, the HIV negative women. It was also found out HIV-infected women who had not undergone CCS were less likely to accept the integration of CCS into routine HIV care compared to HIV-infected women who had undergone CCS. A study conducted among HIV-infected women at the HIV treatment centre, Nigerian Institute of Medical Research (NIMR), Lagos, Nigeria reported that ever screened for CC was not significantly associated with the acceptability of the integration of CCS into routine HIV care ( 8 ). HIV-infected women who have previously undergone CCS applaud the integration of CCS into routine HIV care due to the perceived benefits most especially convenience of the integrated CCS and HIV services. Despite the fact that HIV-infected women who had not undergone CCS are highly expected to support the integration of CCS into routine HIV services, this might not necessarily be true because they could be ashamed of exposing their private parts to health workers whom they occasionally interact with in the HIV clinics. Perceived benefits of the proposed intervention were: convenience to seek for CCS, motivation to undergo CCS, improved archiving of CCS results, confidentiality of HIV patient information, and preference to interact with ISS clinic health workers. In all FGDs, HIV-infected women acknowledged that the integration of CCS into routine HIV care would grant them an opportunity to receive both CCS in addition to HIV services conveniently from the ISS Clinic compared to the currently practiced referral or client-initiated CCS conducted at the CCS unit at MRRH. This study finding is in agreement with findings from other studies which reported that the convenience of seeking for integrated HIV and CCS services from one point without forgetting an added advantage of one off relief of anxiety was attributed to the integration strategy compared to stand alone screening services ( 23 , 24 ). The intervention was regarded as a time saving strategy attributed to the convenience through reducing the frequency of health facility visits, necessity of several return journeys, travel time and return transportation costs ( 23 , 24 ). HIV-infected women anticipated that implementation of the proposed strategy of delivering CCS would reduce the disruption and movement from one clinic to another since all the CCS and HIV related services would be available and received under one roof in a single HIV clinic visit comprehensively. HIV-infected women in all FGDs reported that the integration of CCS would motivate HIV infected women to undergo CCS services. Furthermore, HIV-infected women in majority of the FGDs alleged that the integration of CCS into routine HIV care would inspire HIV-infected women, the targeted recipients for the proposed intervention, to comply and adhere to the recommended annual CCS services. Researchers, community members, health care providers and policy makers were also optimistic that the intervention would improve the uptake of initial and annual CCS among HIV-infected women ( 4 , 15 – 24 ). Integration of CCS into routine HIV services would reduce the missed opportunities for HIV-infected women to undergo the CCS procedure; hence increasing the uptake of CCS among the targeted recipients. HIV-infected women in majority of the FGDs claimed that the proposed intervention would promote confidentiality of the HIV status and any other health related information due to interaction with only health workers and fellow HIV-infected women. This study finding was also reported in a study conducted in Uganda where women reported that the integrated screening model would promote confidentiality of HIV and any other health related information due to being accessed and confined to limited teams of health care practitioners at the HIV clinics ( 24 ). In most instances, HIV-infected women prefer confidentiality of their HIV status through interacting with only health workers in HIV clinics and archiving of the CCS information in the same file with all the other HIV related information; due to fear of being stigmatised. Shame to expose their privacy to the ISS clinic health workers and increased waiting time were the only perceived challenges of the integration of CCS into routine HIV care among HIV-infected women. HIV-infected women in only the “Very Unacceptable and Unacceptable” FGD reported that they would prefer undergoing CCS conducted by the health workers at the CCS Unit of MRRH as opposed to the ISS clinic health workers. Based on the study findings from a study conducted in Uganda, discomfort and invasion of privacy expressed by HIV-infected women due to genital illnesses, menstrual periods, and fear to expose their private parts was one of the challenges to undergo CCS integrated into routine HIV services at Mildmay Uganda ( 37 ). HIV-infected women argued that they would be uncomfortable and ashamed to continue interacting with the same health workers to whom they have exposed their private parts for any other HIV related services. HIV-infected women in majority of the FGDs argued that delivering CCS comprehensively with other routine HIV care services during scheduled HIV clinic visits would be very time consuming hence increasing the waiting time at the ISS clinic. This study finding was consistent with findings from other studies where long waiting time was cited as one of the potential challenges HIV-infected women would have to endure through to undergo the CCS procedure integrated into comprehensive HIV services ( 23 , 24 , 37 ). HIV-infected women in some of the FGDs expressed concern on how the integrated approach of CCS and HIV treatment services in a single HIV clinic visit would be delivered to the ever-increasing numbers of recipients within the shortest time possible. The mixed methods study design using the explanatory sequential approach increased the rigor and internal validity of the study. Utilisation of the systematic sampling method for selection of HIV-infected women to participate in the quantitative phase of the study was an added strength to the conduct of the study. However, the theoretical Framework of Acceptability (TFA) adapted to measure acceptability of the integration of CCS into routine HIV care has not yet been validated among the Ugandan populations. HIV-infected women who turned up on unscheduled dates were excluded from participating in the study; increasing potential for information bias. Furthermore, this study was conducted in only one HIV clinic in the entire country due to limited funding; hence affecting the generalisability of study findings to all HIV-infected women in Uganda. Conclusion Study findings highlight the need to take advantage of this acceptability to prioritize implementation of integration of CCS into routine HIV care. Ministry of Health should prioritise of the implementation of the integration of CCS into routine HIV care to increase uptake of CCS among HIV-infected women along the continuum of HIV care and treatment services. Health workers delivering HIV care and treatment services should endeavour to conduct intensified health education and awareness about the increased risk of developing CC among HIV-infected women. HIV-infected women should be reassured of reduced waiting time, confidentiality and optimisation of privacy by HIV clinic health workers during the provision of the integrated HIV care and CCS services. Furthermore, a nationally representative study should be conducted to assess the acceptability of integration of CCS into routine HIV care, associated factors, and perceptions among HIV-infected women enrolled in the HIV clinics in Uganda. List Of Abbreviations ART Anti - Retroviral Treatment HIV Human Immune–deficiency Virus CC Cervical Cancer CCS Cervical Cancer Screening HPV Human Papilloma Virus HDI Human Development Index VIA Visual Inspection with Acetic Acid ISS Immune Suppression Syndrome MRRH Mbarara Regional Referral Hospital MOH Ministry of Health MakSPH Makerere University School of Public Health MUST Mbarara University of Science and Technology UNCST Uganda National Council of Science and Technology PI Principal Investigator RAs Research Assistants TFA Theoretical Framework of Acceptability AWACAN African Women Awareness of CANcer WHO World Health Organization Declarations Ethics approval and consent to participate Approval was obtained from the Makerere University School of Public Health Higher Degrees, Research and Ethics Committee to conduct the study. Administrative clearance was sought from the office of the Hospital Director of Mbarara Regional Referral Hospital before conducting data collection. Individuals were informed of their right to agree to participate or withdraw from the study at any time without fear of any negative repercussions; and receipt of care was not dependent on the participation in the study. After informing them of the purpose and procedure of the study, a written informed consent was sought from the study participants before administering questionnaires or conducting focus group discussions. All methods were performed in accordance with the relevant guidelines and regulations in Ethics Approval and Consent to Participate. Consent for publication: Not applicable Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on request. Competing interests: The authors do not have any competing interests. Funding: Not applicable Authors’ contributions: MN designed the proposal, conducted quantitative and qualitative data collection, analysed the data and presented the study findings and compiled the manuscript. AN and JK provided great technical guidance through out every step of the proposal conceptualization, data collection and manuscript preparation. Acknowledgements: Exceptional applaud to Dr. Kagaayi Joseph and Ms. Nyabigambo Agnes who have been very instrumental to inspire the best of my potential in the pursuit of my research career. References Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: a cancer journal for clinicians. 2018;68(6):394–424. WHO. Human papillomavirus and cervical cancer. 2019; Accessed 5th May 2020 [Available from: https://www.who.int/en/news-room/fact-sheets/detail/human-papillomavirus-(hpv)-and-cervical-cancer . WHO. Cervical cancer common amongst African women. 2019; Accessed 5th November 2019 [Available from: https://www.afro.who.int/news/cervical-cancer-common-amongst-african-women . Viviano M, DeBeaudrap P, Tebeu P-M, Fouogue JT, Vassilakos P, Petignat P. A review of screening strategies for cervical cancer in human immunodeficiency virus-positive women in sub-Saharan Africa. International journal of women's health. 2017;9:69. Nakisige C, Schwartz M, Ndira AO. Cervical cancer screening and treatment in Uganda. Gynecologic oncology reports. 2017;20:37–40. Ghebre RG, Grover S, Xu MJ, Chuang LT, Simonds H. Cervical cancer control in HIV-infected women: Past, present and future. Gynecologic oncology reports. 2017;21:101–8. Bansil P, Lim J, Byamugisha J, Kumakech E, Nakisige C, Jeronimo JA. Performance of cervical cancer screening techniques in HIV-infected women in Uganda. Journal of lower genital tract disease. 2015;19(3):215–9. Ezechi OC, Pettersson KO, Okolo CA, Ujah IA, Ostergren PO. The association between HIV infection, antiretroviral therapy and cervical squamous intraepithelial lesions in South Western Nigerian women. PloS one. 2014;9(5):e97150. Massad LS, Xie X, D'Souza G, Darragh TM, Minkoff H, Wright R, et al. Incidence of cervical precancers among HIV-seropositive women. American journal of obstetrics and gynecology. 2015;212(5):606.e1-8. Ngabo F, Franceschi S, Baussano I, Umulisa MC, Snijders PJ, Uyterlinde AM, et al. Human papillomavirus infection in Rwanda at the moment of implementation of a national HPV vaccination programme. BMC infectious diseases. 2016;16(1):225. Thorsteinsson K, Ladelund S, Jensen-Fangel S, Katzenstein TL, Johansen IS, Pedersen G, et al. Incidence of cervical dysplasia and cervical cancer in women living with HIV in Denmark: comparison with the general population. HIV medicine. 2016;17(1):7–17. Thunga S, Andrews A, Ramapuram J, Satyamoorthy K, Kini H, Unnikrishnan B, et al. Cervical cytological abnormalities and human papilloma virus infection in women infected with HIV in Southern India. Journal of Obstetrics and Gynaecology Research. 2016;42(12):1822–8. WHO. WHO guidelines for screening and treatment of precancerous lesions for cervical cancer prevention. World Health Organization; 2013. Accessed 10th November 2019 [Available from: https://apps.who.int/iris/bitstream/handle/10665/94830/9789241548694_eng.pdf ;jsessionid=AB409201BC57FAF0983EA577366A3152?sequence=1. MOH. Consolidated Guidelines for Prevention and Treatment of HIV in Uganda. Kampala, Uganda: Republic of Uganda Ministry of Health; 2016. UNAIDS. HPV, HIV, cervical cancer: Leveraging synergies to save women's lives 2016 [Available from: https://www.unaids.org/sites/default/files/media_asset/JC2851_HPV-HIV-cervicalcancer_en.pdf . UNAIDS. The little-known links between cervical cancer and HIV 2019 [cited 2019 31st May]. Available: https://www.unaids.org/en/resources/presscentre/featurestories/2019/may/20190531 cervical-cancer-hiv . Wanyenze RK, Bwanika JB, Beyeza-Kashesya J, Mugerwa S, Arinaitwe J, Matovu JK, et al. Uptake and correlates of cervical cancer screening among HIV-infected women attending HIV care in Uganda. Global health action. 2017;10(1):1380361. Coleman JS, Cespedes MS, Cu-Uvin S, Kosgei RJ, Maloba M, Anderson J, et al. An insight into cervical cancer screening and treatment capacity in sub-Saharan Africa. Journal of lower genital tract disease. 2016;20(1):31. Denslow SA, Rositch AF, Firnhaber C, Ting J, Smith JS. Incidence and progression of cervical lesions in women with HIV: a systematic global review. International journal of STD & AIDS. 2014;25(3):163–77. Huchko MJ, Maloba M, Nakalembe M, Cohen CR. The time has come to make cervical cancer prevention an essential part of comprehensive sexual and reproductive health services for HIV-positive women in low‐income countries. Journal of the International AIDS Society. 2015;18:20282. Mapanga W, Girdler-Brown B, Feresu SA, Chipato T, Singh E. Prevention of cervical cancer in HIV-seropositive women from developing countries through cervical cancer screening: a systematic review. Systematic reviews. 2018;7(1):198. Tchounga B, Boni SP, Koffi JJ, Horo AG, Tanon A, Messou E, et al. Cervical cancer screening uptake and correlates among HIV-infected women: a cross-sectional survey in Côte d’Ivoire, West Africa. BMJ open. 2019;9(8):e029882. Kumakech E, Andersson S, Wabinga H, Berggren V. Integration of HIV and cervical cancer screening perceptions of healthcare providers and policy makers in Uganda. BMC Public Health. 2014;14(1):810. Kumakech E, Andersson S, Wabinga H, Berggren V. Integration of HIV and cervical cancer screening perceptions and preferences of communities in Uganda. BMC women's health. 2015;15(1):23. Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. BMC health services research. 2017;17(1):88. Ronald M, Andrew C, Sezalio M, John K, Hillary A, Kayondo M, et al. Cervical Cancer at Mbarara Regional Referral Hospital: Magnitude, Trends, Stages at Presentation, Impact of Acetic Acid Screening and the Need for Radiotherapy Services. Journal of Health, Medicine and Nursing. 2016;27:126–39. Aweke YH, Ayanto SY, Ersado TL. Knowledge, attitude and practice for cervical cancer prevention and control among women of childbearing age in Hossana Town, Hadiya zone, Southern Ethiopia: Community-based cross-sectional study. PloS one. 2017;12(7):e0181415. Mengesha A, Messele A, Beletew B. Knowledge and attitude towards cervical cancer among reproductive age group women in Gondar town, North West Ethiopia. BMC public health. 2020;20(1):209. Suresh K, Chandrashekara S. Sample size estimation and power analysis for clinical research studies. Journal of human reproductive sciences. 2012;5(1):7. Hajian-Tilaki K. Sample size estimation in epidemiologic studies. Caspian journal of internal medicine. 2011;2(4):289. Semeere AS, Semitala FC, Lunkuse O, Katahoire A, Sewankambo NK, Kamya MR. An assessment of implementation science research capacity in Uganda. Health research policy and systems. 2021;19(1):1–10. Huchko MJ, Bukusi EA, Cohen CR. Building capacity for cervical cancer screening in outpatient HIV clinics in the Nyanza province of western Kenya. International Journal of Gynecology & Obstetrics. 2011;114(2):106–10. Odafe S, Torpey K, Khamofu H, Oladele E, Adedokun O, Chabikuli O, et al. Integrating cervical cancer screening with HIV care in a district hospital in Abuja, Nigeria. Nigerian medical journal: journal of the Nigeria Medical Association. 2013;54(3):176. Emru K, Abebaw T-A, Abaerei AA. Role of awareness on cervical cancer screening uptake among HIV positive women in Addis Ababa, Ethiopia. A cross-sectional study. 2019. Dessalegn Mekonnen B. Cervical Cancer Screening Uptake and Associated Factors among HIV-Positive Women in Ethiopia: A Systematic Review and Meta-Analysis. Advances in Preventive Medicine. 2020; 2020. Ebu NI, Ogah JK. Predictors of cervical cancer screening intention of HIV-positive women in the central region of Ghana. BMC women's health. 2018;18(1):1–7. Bukirwa A, Mutyoba JN, Mukasa BN, Karamagi Y, Odiit M, Kawuma E, et al. Motivations and barriers to cervical cancer screening among HIV infected women in HIV care: a qualitative study. BMC women's health. 2015;15(1):82. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 03 Apr, 2023 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Major revision 05 Jan, 2023 Reviews received at journal 18 Sep, 2022 Reviewers agreed at journal 24 Aug, 2022 Reviewers agreed at journal 06 Aug, 2022 Reviewers invited by journal 05 Aug, 2022 Editor assigned by journal 01 Aug, 2022 Editor invited by journal 08 Jun, 2022 Submission checks completed at journal 08 Jun, 2022 First submitted to journal 05 Jun, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1727362","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":111951259,"identity":"eff4206a-4362-4a87-aa05-aa1f9de14bb6","order_by":0,"name":"Mackline Ninsiima","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6UlEQVRIiWNgGAWjYJACxoYCCQYG9gYQ+wCxWgyAWngOkKYFSEokEKnFXOzww48zDCzy+CVfp0n+3HGHgb/9AJvkFzxaLGenGUtuMJAolpydu02a98wzBokzCWzSMni0GNxOMGN8YCCRuOE2UAtj22EGhhsMbNISeLWkfwNr2X/z7DbJn0At8oS15JgxbgDZIsG7TYIXqMUAqEXyA34txZIzgFpmnMndbM175jCP4ZnEZms8OkAO2/ixp6Iusb/97MabP3cclpM7fvjgzR/49KAAxgYGHhDJzEOKFghNvC2jYBSMglEwAgAAmyJQFkbvcBQAAAAASUVORK5CYII=","orcid":"","institution":"Makerere University School of Public Health","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Mackline","middleName":"","lastName":"Ninsiima","suffix":""},{"id":111951261,"identity":"372e359e-d88c-4de0-9844-5129ef8b33c5","order_by":1,"name":"Agnes Nyabigambo","email":"","orcid":"","institution":"Makerere University School of Public Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Agnes","middleName":"","lastName":"Nyabigambo","suffix":""},{"id":111951262,"identity":"e4e9878d-ca23-48e2-8b3d-1b4da497b490","order_by":2,"name":"Joseph Kagaayi","email":"","orcid":"","institution":"Makerere University School of Public Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Joseph","middleName":"","lastName":"Kagaayi","suffix":""}],"badges":[],"createdAt":"2022-06-05 11:59:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1727362/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1727362/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-023-09326-6","type":"published","date":"2023-04-03T20:23:30+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":22639016,"identity":"6c5331e6-b747-4dee-baed-cfcd153d35dd","added_by":"auto","created_at":"2022-06-14 15:39:13","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":52908,"visible":true,"origin":"","legend":"\u003cp\u003ePie chart showing acceptability of integration of CCS into routine HIV care among HIV-infected women\u0026nbsp;\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1727362/v1/f8f86072e4d17881253894d3.jpg"},{"id":44724324,"identity":"bd624702-44c2-4372-b88f-f84504c75608","added_by":"auto","created_at":"2023-10-16 20:29:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1116942,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1727362/v1/602a107b-94c2-4952-b653-26f6616136af.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eAcceptability of Integration of Cervical Cancer Screening Into Routine HIV Care, Associated Factors and Perceptions Among HIV- Infected Women: a Mixed Methods Study at Mbarara Regional Referral Hospital\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eGlobally, cervical cancer (CC) is the fourth most frequently diagnosed cancer and the fourth leading cause of cancer death in women with an estimated 570, 000 incident cases and 311,000 deaths in 2018 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). World Health Organisation (WHO) reported a high mortality rate from CC globally at an age-standardized rate of 6.9/100,000 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In low and medium Human Development Index (HDI) regions, CC ranks second to breast cancer among females at world age-standardized incidence and mortality rates of 18.2/100,000 and 12.0/100,000 respectively (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In Africa, CC is the most common cause of cancer accounting for 22% of all female cancers and 12% of all newly diagnosed cancer in both men and women every year (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). 34 out of every 100, 000 women are diagnosed with CC, and 23 out of every 100, 000 women die from CC every year (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The cervical cancer incidence and mortality rates have remained high in Sub-Saharan Africa (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In Eastern Africa, age-standardized incidence and mortality rates of CC are 40.1/100,000 and 30.0/100,000 respectively (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In Uganda, the prevalence of the human papilloma virus among women is 33.6% with one of the highest CC incidence rates in the world of 47.5 per 100,000 per year (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHuman Immunodeficiency Virus (HIV) has been associated with the high vulnerability of developing CC, a great public health challenge. Since 1989, research studies have reported an increased incidence of CC among HIV-infected women (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). HIV-infected women are at increased risk of new and persistent human papillomavirus infection hence an accelerated advancement and incidence of CC compared to HIV uninfected women (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8 CR9 CR10 CR11\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). HIV-infected women develop CC 5 to 10 years earlier compared to HIV uninfected women (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Susceptibility to HPV infection and progression to CC is highly attributed to the weakened cellular immunity among HIV-infected women (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Due to the association between HIV and CC, WHO recommended that all sexually active girls and women should undergo CCS as soon as they are diagnosed HIV positive and further emphasized regular screening and treatment of pre-cancer lesions among HIV infected women (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). With alignment to the WHO guidelines, CCS using Visual Inspection with Acetic acid and treatment of pre-cancerous cervical lesions by cryotherapy was recommended for all HIV-infected sexually active girls and women at enrolment into HIV Care and repeated annually in Uganda (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Nevertheless, reports have indicated persistent low uptake of CCS among the highly susceptible population (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). A nationally representative population-based survey carried out in Uganda reported that only 30.3% HIV-infected women had received CCS (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIntegration of CCS into routine HIV care has been endorsed as an effective strategy to increase uptake of CCS, achieve early detection and treatment of pre-cancerous lesions among HIV-infected women in Sub Saharan Africa where the cervical cancer burden parallels that of HIV (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR16 CR17 CR18 CR19 CR20 CR21\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). In Uganda, this strategy has not been implemented yet in most HIV clinics. It has been noted that published studies from Uganda explored perceptions and preferences of health care providers, policy makers, and community members including women, men, and village health teams, regarding the integration of HIV and CCS services in a single-visit approach without focussing on HIV-infected women (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). It\u0026rsquo;s difficult to utilize these findings to understand the perceptions of HIV-infected women enrolled in HIV care which would be instrumental in guiding the implementation phase. Furthermore, the acceptability of this intervention has not been assessed among HIV-infected women using the Theoretical Framework of Acceptability (TFA); the approved framework for assessing acceptability of healthcare interventions. This indicates the need to generate scientific evidence regarding acceptability of the intervention among its targeted recipients. Assessing acceptability of this proposed intervention is of great relevance to inform its implementation into comprehensive HIV programming (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHIV-infected women enrolled in the ISS clinic are either referred or voluntarily undergo CCS conducted by health workers in the CCS department at MRRH. Despite establishing the referral or client-initiated cervical cancer screening system at MRRH for the last 10 years, only 11.3% of the HIV-infected women enrolled in the ISS clinic at MRRH were reported to have undergone CCS by 30th September 2019. HIV-infected women miss CCS opportunities for early detection of pre-cancerous cervical lesions at enrolment and during the subsequent annual intervals despite their frequent visits to the HIV clinics for medical reviews, viral load monitoring, and monthly ART refills. Such missed opportunities increase the risk of presenting late with advanced cervical cancer and poor prognosis among this vulnerable population. Implementation of integration of CCS into routine HIV care is expected to increase the uptake of CCS services at enrolment and during the subsequent annual HIV clinic visits among the HIV infected women enrolled in the ISS clinic at MRRH compared to the currently practiced referral or client-initiated CCS system. It\u0026rsquo;s upon this background that this study assessed the acceptability of the integration of CCS into routine HIV care, associated factors and perceptions among HIV-infected women enrolled in the Immune Suppression Syndrome clinic at Mbarara Regional Referral Hospital.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Site\u003c/h2\u003e \u003cp\u003e The study was conducted at the Immune Suppression Syndrome Clinic (ISS) at Mbarara Regional Referral Hospital (MRRH) in Mbarara District in South Western Uganda. Cervical cancer is the leading cancer and also the leading gynaecological cancer at MRRH (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). With a proportion of 25.2%, cervical cancer is the single leading cancer; contributing to 10.1% of all diseases on the gynaecological ward and 73.9% of all gynaecological cancers at MRRH (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). The Immune Suppression Syndrome Clinic in Mbarara University of Science and Technology (MUST) and Mbarara Regional Referral Hospital has provided HIV Care since November 1998. The clinic has two sections: the adult care section, under the Department of Internal Medicine and the Paediatric and adolescents care section under the Department of Paediatrics. A total of 7212 HIV-infected women were reported to be active in HIV care by 30th September 2019. On average 168 HIV-infected women receive HIV care and treatment services on a typical clinic day. HIV-infected women enrolled in the ISS clinic are either referred or voluntarily undergo CCS conducted by health workers in the cervical cancer screening department at MRRH. It is on these grounds that the ISS clinic at MRRH was selected to study the acceptability of integration of CCS into routine HIV care, associated factors and perceptions among HIV-infected women.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eMixed methods study design utilizing the explanatory sequential approach was used to assess the acceptability of integration of CCS into routine HIV care, associated factors and perceptions among HIV-infected women. Using the explanatory sequential approach, the quantitative phase of the study was first conducted followed by analysis of the quantitative data. HIV-infected women were then selected based on the generated quantitative results of the acceptability of integration of CCS into routine HIV care; to participate in the qualitative investigations. The rationale for the explanatory sequential approach was to explain quantitative study findings in more detail using qualitative research.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy Population\u003c/h2\u003e \u003cp\u003e The study was conducted among HIV-infected women receiving HIV Care and Treatment services from the ISS Clinic at MRRH. Only HIV-infected women aged 18 and above who turned up for Anti-Retroviral Therapy (ART) refills at the ISS clinic on the interview dates were included in the study. HIV-infected women aged 18 and above who turned up for ART refills on unscheduled dates were excluded based on the electronic appointment list generated for the respective appointment date. \u003cb\u003eRationale\u003c/b\u003e: HIV-infected women who turned up on unscheduled dates were excluded because they were not on the appointment list from which study respondents were systematically selected to participate in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative phase\u003c/h2\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003eMeasurement of study variables\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section4\"\u003e \u003ch2\u003eDependent variable\u003c/h2\u003e \u003cp\u003eThe dependent variable for this study was acceptability of integration of CCS into routine HIV care. The Theoretical Framework of Acceptability (TFA) was adapted to measure the acceptability of integration of CCS into routine HIV care. The TFA was proposed as a multi-component framework and systematic approach to assess intervention acceptability across prospective, concurrent, and retrospective temporal perspectives (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Questions based on the TFA constructs namely: affective attitude, burden, perceived effectiveness, ethicality, intervention coherence, opportunity costs, and self-efficacy, were administered to eligible participants. Responses were based on a 5-point rating ordinal scale per construct. The summated score of the constructs of acceptability per study participant was computed by summing the weights assigned to construct responses; henceforth a continuous dependent variable.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eIndependent variables\u003c/h2\u003e \u003cp\u003eInformation on sociodemographic characteristics, awareness of CC, knowledge of risk factors of CC, knowledge of symptoms of CC, CCS awareness, uptake of CCS, and perceived risk of CC was obtained. Sociodemographic characteristics included age in completed years, marital status, highest education level attained, religion, area of residence, number of living biological children, and duration of HIV disease.\u003c/p\u003e \u003cp\u003eTo assess knowledge of risk factors and symptoms of CC, participants were requested to select from the response options \u0026ldquo;1. Yes\u0026rdquo; \u0026ldquo;2. No\u0026rdquo; for each item. A correct answer was awarded \u0026ldquo;1\u0026rdquo; whereas a wrong answer was awarded \u0026ldquo;0\u0026rdquo;. According to the African Women Awareness of CANcer (AWACAN) tool, the codes to the response options were assigned without any meaning. So, out of the two options, if the participant selected an appropriate answer as per the item, one received an award of \"1\" for the respective item because it was the correct answer. If the participant selected an inappropriate answer as per the item, one received an award of \"0\" for the respective item because it was the wrong answer. A summated score was obtained for variables: knowledge of risk factors and knowledge of signs and symptoms of CC.\u003c/p\u003e \u003cp\u003eKnowledge of risk factors of CC was categorised into two categories: \u0026ldquo;1. Poor Knowledge\u0026rdquo; and \u0026ldquo;2. Good Knowledge\u0026rdquo;; based on the mean score evidenced in recent published studies (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). \u0026ldquo;1. Poor Knowledge\u0026rdquo; was awarded to HIV-infected women whose summated score of the weights of the items of knowledge of risk factors of CC was less than the mean score value of 8.34. \u0026ldquo;2. Good Knowledge\u0026rdquo; was awarded to HIV-infected women whose summated score of the weights of the items of knowledge of risk factors of CC was greater than or equal to the mean score value of 8.34.\u003c/p\u003e \u003cp\u003eKnowledge of signs and symptoms of CC was also categorised into two categories: \u0026ldquo;1. Poor Knowledge\u0026rdquo; and \u0026ldquo;2. Good Knowledge\u0026rdquo;; based on the mean score demonstrated in recent published studies (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). \u0026ldquo;1. Poor Knowledge\u0026rdquo; was awarded to HIV-infected women whose summated score of the weights of the items of knowledge of signs and symptoms of CC was less than the mean score value of 7.99. \u0026ldquo;2. Good Knowledge\u0026rdquo; was awarded to HIV-infected women whose summated score of the weights of the items of Knowledge of signs and symptoms of CC was greater than or equal to the mean score value of 7.99.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSample size and sampling\u003c/h2\u003e \u003cp\u003eFor the quantitative component, sample size was calculated using the sample size estimation formula (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e):\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cimg src=\"data:image/png;base64,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\" alt=\"image\"\u003e\u003c/p\u003e\n \u003cp\u003e where Z\u003csub\u003eα/2\u003c/sub\u003e =1.96 standard normal value at 5% level of significance\u003c/p\u003e \u003cp\u003eσ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;Variance of the continuous outcome of interest or s\u003csup\u003e2\u003c/sup\u003e where s is the standard deviation\u003c/p\u003e \u003cp\u003eEstimated standard deviation\u0026thinsp;=\u0026thinsp;Range/4\u0026thinsp;=\u0026thinsp;(35\u0026thinsp;\u0026minus;\u0026thinsp;0)/4\u0026thinsp;=\u0026thinsp;8.75 (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eδ= Marginal error the researcher is willing to allow; for this study, the marginal error was considered not to exceed 1\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eOn adjusting for a 10% non-response rate, the overall sample size for this study was 327 HIV infected women. Systematic sampling method was used to select participants among HIV-infected women who had been scheduled to turn up at the ISS clinic for ART refills based on the respective appointment dates.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003eQuantitative data were collected using administered questionnaires. The pre-coded questionnaire was pre-tested at Kawaala Health Centre IV to check for suitability of various aspects such as translations, skip procedures, filtering questions and modifications were made thereafter. The questionnaire was translated into Runyankole/Rukiiga. Selection and recruitment of experienced research assistants was based on competence, quantitative data collection skills and qualifications. Research assistants received training on how to administer the study questions before data collection. After meeting the selected participants to take part in the study, the researcher introduced herself and explained the purpose of the study. Eligible participants provided written informed consent before the interview was conducted. Each questionnaire was completed within 15\u0026ndash;20 minutes. During data collection, questionnaires were reviewed at the end of each interview so that corrections were made in addition to checking for completeness before departure of the participants. Supervision was conducted to ensure compliance throughout the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eData Management\u003c/h2\u003e \u003cp\u003eData capture screens with in-built checks for consistency, logical flow, range and accuracy of data was designed in Epi-data version 3.0. EPIDATA software package version 3.0 was used for data entry. Data was cleaned and stored daily. Double-entry of data was done to check for any errors. Stored data was backed up on different flash discs. The questionnaires were kept securely throughout the study and thereafter.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eLinear regression analysis is the recommended method of modelling since the dependent variable, the acceptability of the integration of CCS into routine HIV care, was a continuous variable. The summated scores of the acceptability of the integration of CCS into routine HIV care were converted into percentages. The regression modelling predicting the acceptability of the integration of CCS into routine HIV care from all the independent variables was conducted. Residuals were generated followed by testing the assumptions of linear regression: normality of residuals and homogeneity of variance. Linear regression analysis was not utilised for this study because both the assumptions of normality and homogeneity of variance of residuals were violated.\u003c/p\u003e \u003cp\u003eThe acceptability of integration of CCS into routine HIV care was dichotomized into two categories: \u0026ldquo;0. Not Accepted\u0026rdquo; and \u0026ldquo;1. Accepted\u0026rdquo; based on the value of 26.25, the 75th percentile of the highest possible summated score of 35 from the seven constructs of the Theoretical Framework of Acceptability. The 75th percentile was recommended as the cut-off value based on a published study which utilised likert - type scale responses assessing constructs to measure the composite dependent variable (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). \u0026ldquo;0. Not Accepted\u0026rdquo; was awarded to HIV-infected women whose summated score of the weights of the constructs of acceptability of integration of CCS into routine HIV care was less than the value of 26.25. \u0026ldquo;1. Accepted\u0026rdquo; was awarded to HIV-infected women whose summated score of the weights of the constructs of acceptability of integration of CCS into routine HIV car was greater than or equal to the value of 26.25. Frequencies and percentages of HIV-infected women who had accepted and those who had not accepted integration of CCS into routine HIV care were computed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eUnivariable analysis\u003c/h2\u003e \u003cp\u003eUnivariable data analysis was conducted; all variables were analysed to describe the study sample. For all independent categorical variables, data was tabulated and presented as frequencies and percentages.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eBivariable analysis\u003c/h2\u003e \u003cp\u003eCross tabulations of the outcome variable and independent variables were done to obtain the frequencies and corresponding percentages of the HIV-infected women who accepted and those who did not accept the integration of CCS into routine HIV care per independent variable. Selection of the regression model to use at bivariable analysis was conducted. Using occupation as an example, the logistic regression, log binomial and modified poisson regression models were used. It was noted that the logistic regression and log binomial models overestimated the measures of association compared to the modified poisson regression model. Given that the outcome had a higher percentage of 64.5%, modified poisson regression with robust variance was selected for the bivariable analysis to obtain crude prevalence ratios, 95% confidence interval, and the corresponding p-values.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eMultivariable analysis\u003c/h2\u003e \u003cp\u003eMulticollinearity among the independent variables was checked for using variance inflation factor. The regression modelling predicting the acceptability of the integration of CCS into routine HIV care from all the independent variables was conducted and then the vif command was issued to check for multicollinearity. The variance inflation factors for all the independent variables were less than 2.5. Ultimately, all the independent variables were included in the multivariable analysis. Modified poisson regression with robust variance using the stepwise logical model building technique was conducted to obtain adjusted prevalence ratios, 95% confidence interval and the corresponding p-values. Checking for goodness of fit of the model was done based on the Akaike Information Criteria (AIC). Significance of independent variables was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Statistical analysis was conducted using Stata/SE Version 14.0.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eQualitative phase\u003c/h2\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003eSample size and sampling\u003c/h2\u003e \u003cp\u003eWith reference to the 5 \u0026ndash; point likert - type Scale, acceptability of integration of CCS into routine HIV care was categorised into five categories; \u0026ldquo;1. Very Unacceptable\u0026rdquo;, \u0026ldquo;2. Unacceptable\u0026rdquo;, \u0026ldquo;3. Neutral\u0026rdquo;, \u0026ldquo;4. Acceptable\u0026rdquo; and \u0026ldquo;5. Very Acceptable\u0026rdquo; based on the summated score of the weights of the constructs of acceptability. \u0026ldquo;1. Very Unacceptable\u0026rdquo; was awarded to respondents whose summated score of the weights of the constructs of acceptability was 7 and below; \u0026ldquo;2. Unacceptable\u0026rdquo; was awarded to respondents whose overall score of the weights of the constructs of acceptability was 8\u0026ndash;14; \u0026ldquo;3. Neutral\u0026rdquo; was awarded to respondents whose summated score of the weights of the constructs of acceptability was 15\u0026ndash;21; \u0026ldquo;4. Acceptable\u0026rdquo; was awarded to respondents whose overall score of the weights of the constructs of acceptability was 22\u0026ndash;28; and \u0026ldquo;5. Very Acceptable\u0026rdquo; was awarded to respondents whose summated score of the weights of the constructs of acceptability was 29 and above out of the 35 criteria.\u003c/p\u003e \u003cp\u003eBased on the category of acceptability of integration of CCS into routine HIV care, 6 Focus Group Discussions (FGDs) were conducted among HIV-infected women as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The number of FGDs per level of acceptability of the integration of CCS into routine HIV care was based on the number of HIV-infected women within the respective categories. Sample size of 6 FGDs was further determined by the data saturation point; a point at which further sampling did not generate any new concepts or ideas about the phenomenon under investigation. Purposive sampling was used to select HIV-infected women from the quantitative phase to participate in the FGDs.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCriteria for selection of participants for Focus Group Discussions (FGDs)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSummated Score Range\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLevel of Acceptability\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of HIV-infected women\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNumber of Focus Group Discussions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNumber of participants per Focus Group Discussions\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVery Unacceptable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u0026ndash;14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnacceptable\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u0026ndash;21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeutral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e22\u0026ndash;28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAcceptable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e157\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e29\u0026ndash;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVery Acceptable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e142\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003eThe FGD guide was specifically developed for this study with questions aimed at eliciting HIV-infected women\u0026rsquo;s perceptions of integration of CCS into routine HIV care. The FGD guide was pre-tested and recommended changes in the questions were made to ensure that the guide captured relevant and appropriate information before use. FGD guide was translated into Runyankole/Rukiiga. Key questions in the FGD guide explored the participants\u0026rsquo; impressions, anticipated benefits, and challenges of integration of CCS into routine HIV care in a single visit approach in the HIV clinics in Uganda. An experienced research assistant at collecting qualitative data through conducting FGDs was recruited.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eData Management\u003c/h2\u003e \u003cp\u003eFocus group discussions were audio-recorded. The collected audio-recorded data was adequately and appropriately backed up. All audio recorded local language interviews were translated into English and transcribed verbatim simultaneously. The transcripts were proof-read before importing them into Atlas.ti Version 6.0, a qualitative data management software.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eThematic analysis method using inductive coding was used to analyse qualitative data. Exploration of data and synthesis of codes, subthemes and themes was done in Atlas.ti Version 6.0. Relevant verbatim quotations were selected as evidence to support the generated themes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003eSocio-demographic characteristics of study respondents\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the baseline characteristics of the study respondents. Majority of the respondents (33.0%) were aged 40\u0026ndash;49. Majority of the respondents (60.2%) resided in rural areas. Primary education was the highest level attained by majority of the respondents (45.0%) whereas only 21.4% had not attained any education. Most of the study respondents were Protestants (46.8%). Most respondents (47.4%) were self-employed in the agriculture sector. Majority of the respondents (56.0%) had delivered 1\u0026ndash;3 children. Based on self-reports, 59.0% of the respondents had lived with HIV for 10 years and above since they were diagnosed HIV positive. 95.1% and 75.8% reported that they were aware about CC and CCS programme respectively. Majority of the respondents (54.4%) had good knowledge of the risk factors of CC; whereas 63.6% had good knowledge of signs and symptoms of CC. Majority of respondents (52.0%) had \u0026ldquo;Much Above Average\u0026rdquo; perceived risk of developing CC; and 65.1% reported to have undergone CCS.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of study respondents\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequencies (n\u0026thinsp;=\u0026thinsp;327)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentages (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCompleted Age\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e50 and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e197\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHighest Education Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e147\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary or Higher Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot Married\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e205\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReligion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnglican\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e153\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCatholic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuslim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers (Pentecostal \u0026amp; SDA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOccupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot working\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed (Paid)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf Employed (Businesswoman)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf Employed (Agriculture)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of Children\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e183\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4 and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHIV Duration (Number of years since diagnosed HIV positive)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10 and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e193\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAwareness of Cervical Cancer (CC)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e311\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKnowledge of risk factors of Cervical Cancer (CC)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor Knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood Knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e178\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKnowledge of signs and symptoms of Cervical Cancer (CC)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor Knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e119\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood Knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e208\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived risk of developing cervical cancer\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuch Below Average\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBelow Average\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbove Average\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuch Above Average\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAwareness of Cervical Cancer Screening (CCS)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e248\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEver screened for Cervical Cancer\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e213\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eAcceptability of integration of Cervical Cancer Screening into routine HIV care\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the frequencies and percentages of acceptability of integration of CCS into routine HIV care. Majority of the respondents (64.5%) accepted the integration of CCS into routine HIV care as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAcceptability of integration of CCS into routine HIV care among HIV-infected women\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy variable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequencies (n\u0026thinsp;=\u0026thinsp;327)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentages (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcceptability of integration of cervical cancer screening into routine HIV care\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot Accepted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccepted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e211\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eFactors associated with acceptability of integration of Cervical Cancer Screening into routine HIV care among HIV infected women\u003c/b\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows unadjusted and adjusted prevalence ratios with their respective corresponding confidence intervals. At bivariable analysis, religion, awareness of CC, knowledge of signs and symptoms of CC, perceived risk of developing CC, awareness of CCS, and ever screened for CC were associated with the acceptability of integration of CCS into routine HIV care among HIV-infected women at MRRH.\u003c/p\u003e \u003cp\u003eAt multivariable analysis, based on 95% confidence intervals and p \u0026ndash; values, religion, perceived risk of developing CC and ever screened for CC were statistically significantly associated with the acceptability of integration of CCS into routine HIV care among HIV-infected women at MRRH. On adjusting for other independent variables, the prevalence of the acceptability of integration of CCS into routine HIV care among Muslims was 1.47 [95% CI\u0026thinsp;=\u0026thinsp;1.21\u0026ndash;1.78] times the prevalence of the acceptability of integration of CCS into routine HIV care among Protestants. Muslims were 47% more likely to accept the integration of CCS into routine HIV care compared to Protestants.\u003c/p\u003e \u003cp\u003eThe prevalence of the acceptability of integration of CCS into routine HIV care among HIV-infected women with \u0026ldquo;Much Above Average\u0026rdquo; perceived risk of developing CC was 1.43 [95% CI\u0026thinsp;=\u0026thinsp;1.11\u0026ndash;1.85] times the prevalence of the acceptability of integration of CCS into routine HIV care among HIV-infected women with \u0026ldquo;Much Below Average\u0026rdquo; perceived risk of developing CC. HIV-infected women with \u0026ldquo;Much Above Average\u0026rdquo; perceived risk of developing CC were 43% more likely to accept the integration of CCS into routine HIV care compared to HIV-infected women with \u0026ldquo;Much Below Average\u0026rdquo; perceived risk of developing CC.\u003c/p\u003e \u003cp\u003eThe prevalence of the acceptability of integration of CCS into routine HIV care among HIV-infected women who had not undergone CCS was 0.71 [95% CI\u0026thinsp;=\u0026thinsp;0.58\u0026ndash;0.86] times the prevalence of the acceptability of integration of CCS into routine HIV care among HIV-infected women who had undergone CCS. HIV-infected women who had not undergone CCS were 29% less likely to accept the integration of CCS into routine HIV care compared to HIV-infected women who had undergone CCS.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFactors associated with acceptability of integration of CCS into routine HIV care among HIV-infected women\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eIndependent variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eAcceptability of integration of CCS into routine HIV care\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eUnadjusted Prevalence Ratios\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e95% Confidence Intervals\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAdjusted Prevalence Ratios\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e95%\u003c/p\u003e \u003cp\u003eConfidence Intervals\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNot Accepted\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eAccepted\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCompleted Age\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (44.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (55.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (33.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61 (67.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.89\u0026ndash;1.63]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.83\u0026ndash;1.49]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (34.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71 (65.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.87\u0026ndash;1.59]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.86\u0026ndash;1.56]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e50 and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (35.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (64.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.85\u0026ndash;1.58]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.86\u0026ndash;1.55]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77 (39.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e120 (60.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91 (70.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.98\u0026ndash;1.35]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.97\u0026ndash;1.31]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHighest Education Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58 (39.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89 (60.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.80\u0026ndash;1.27]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.70\u0026ndash;1.11]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary or Higher Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80 (72.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.97\u0026ndash;1.52]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.78\u0026ndash;1.26]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot Married\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (36.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e130 (63.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (33.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81 (66.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.89\u0026ndash;1.23]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.82\u0026ndash;1.15]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReligion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProtestant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66 (43.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87 (56.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCatholic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (31.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 (68.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.99\u0026ndash;1.45]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.96\u0026ndash;1.39]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuslim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (14.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (85.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[1.23\u0026ndash;1.83]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e[1.21\u0026ndash;1.78] ***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers (Pentecostal \u0026amp; SDA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.89\u0026ndash;1.55]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.88\u0026ndash;1.48]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOccupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed (Paid)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (24.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (75.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.75\u0026ndash;1.36]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.80\u0026ndash;1.33]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf Employed (Business)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (33.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77 (67.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.70\u0026ndash;1.15]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.73\u0026ndash;1.14]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf Employed (Agriculture)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64 (41.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91 (58.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.61\u0026ndash;1.01]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.64\u0026ndash;1.03]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of Children\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e133 (72.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.98\u0026ndash;2.16]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.86\u0026ndash;1.83]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4 and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (44.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65 (55.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.73\u0026ndash;1.67]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.63\u0026ndash;1.43]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHIV Duration (Number of years since diagnosed HIV positive)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (48.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (52.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (31.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 (69.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.98\u0026ndash;1.80]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.89\u0026ndash;1.58]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10 and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66 (34.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e127 (65.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.95\u0026ndash;1.68]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.81\u0026ndash;1.44]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAwareness of Cervical Cancer (CC)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e104 (33.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e207 (66.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.16\u0026ndash;0.88]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.20\u0026ndash;1.02]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKnowledge of risk factors of Cervical Cancer (CC)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor Knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (40.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88 (59.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood Knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (30.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e123 (69.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.99\u0026ndash;1.38]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.85\u0026ndash;1.20]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKnowledge of signs and symptoms of Cervical Cancer (CC)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor Knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52 (43.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67 (56.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood Knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64 (30.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e144 (69.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[1.02\u0026ndash;1.48]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.96\u0026ndash;1.35]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived risk of developing Cervical Cancer (CC)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuch Below Average\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (49.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (50.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBelow Average\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (35.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (64.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.88\u0026ndash;1.82]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.91\u0026ndash;1.78]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (48.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (51.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.67\u0026ndash;1.54]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.75\u0026ndash;1.70]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbove Average\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (35.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (64.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.89\u0026ndash;1.81]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.87\u0026ndash;1.73]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuch Above Average\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (27.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e123 (72.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[1.11\u0026ndash;1.84]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e[1.11\u0026ndash;1.85] **\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAwareness of Cervical Cancer Screening (CCS)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76 (30.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e172 (69.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (50.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (49.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.56\u0026ndash;0.90]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.74\u0026ndash;1.45]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEver screened for Cervical Cancer (CC)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59 (27.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e154 (72.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.57\u0026ndash;0.85]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e[0.58\u0026ndash;0.86] **\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e* p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 ** p\u0026thinsp;\u0026lt;\u0026thinsp;0.01 *** p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cb\u003ePerceptions of HIV infected women regarding the integration of Cervical Cancer Screening into routine HIV care\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of Focus Group Discussion (FGD) participants\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e shows the characteristics of Focus Group Discussion (FGD) participants. The mean age of the FGD participants was 40.0 (9.8). Majority of the participants (33.3%) were aged 40\u0026ndash;49. Majority of the respondents (55.6%) resided in rural areas. Primary education was the highest level attained by majority of the respondents (47.2%) whereas only 16.7% had not attained any education. Most of the FGD participants (36.1%) were self-employed in the agriculture sector. Only 5.6% and 11.1% of the Focus Group Discussion participants were selected from the \u0026ldquo;Very Unacceptable\u0026rdquo; and \u0026ldquo;Unacceptable\u0026rdquo; levels of acceptability respectively. Of the FGD participants, 16.7% were selected from the \u0026ldquo;Neutral\u0026rdquo; level of acceptability; whereas 33.3% were selected from each of the \u0026ldquo;Acceptable\u0026rdquo; and \u0026ldquo;Very Acceptable\u0026rdquo; levels of acceptability.\u003c/p\u003e \u003cp\u003eThe FGD participants were grouped into 6 groups based on the level of acceptability to ensure homogeneity of the groups. FGD 1 comprised of 2 and 4 participants from the \u0026ldquo;Very Unacceptable\u0026rdquo; and \u0026ldquo;Unacceptable\u0026rdquo; levels of acceptability respectively. FGD 2 comprised of 6 participants from the \u0026ldquo;Neutral\u0026rdquo; level of acceptability. FGD 3 comprised of 6 participants from the \u0026ldquo;Acceptable\u0026rdquo; level of acceptability. FGD 4 comprised of 6 participants from the \u0026ldquo;Acceptable\u0026rdquo; level of acceptability. FGD 5 comprised of 6 participants from the \u0026ldquo;Very Acceptable\u0026rdquo; level of acceptability. FGD 6 comprised of 6 participants from the \u0026ldquo;Very Acceptable\u0026rdquo; level of acceptability.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of Focus Group Discussion (FGD) participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequencies (n\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentages (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCompleted Age\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge [Mean Age (SD)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e40.0 (9.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e50 and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHighest Education Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary or Higher Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOccupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot working\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed (Paid)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf Employed (Businesswoman)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf Employed (Agriculture)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLevel of acceptability of integration of CCS into routine HIV care\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery Unacceptable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnacceptable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeutral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcceptable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery Acceptable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e shows the codes, sub-themes and themes of the perceptions of HIV-infected women regarding the integration of CCS into routine HIV care. The perceptions of HIV-infected women were presented in two thematic areas: i) Perceived benefits of the integration of CCS into routine HIV care and ii) Perceived challenges of the integration of CCS into routine HIV care.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCodes, sub-themes and themes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCodes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSub -Themes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Receiving HIV drugs and CCS services at the same scheduled date\u003c/p\u003e \u003cp\u003e- Cost saving\u003c/p\u003e \u003cp\u003e- Receiving HIV care and CCS services from the same place\u003c/p\u003e \u003cp\u003e- Prior preparation to undergo CCS on the scheduled date\u003c/p\u003e \u003cp\u003e- Time saving\u003c/p\u003e \u003cp\u003e- Reduced disturbance and movements seeking for HIV care and CCS services from different clinics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConvenience to seek Cervical Cancer Screening services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003ePerceived benefits of the integration of CCS into routine HIV care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- HIV-infected women will be encouraged to receive CCS services\u003c/p\u003e \u003cp\u003e- Increased awareness about cervical cancer and the rationale to undergo CCS services\u003c/p\u003e\u003cp\u003e- Easier to remember the next appointment for undergoing CCS annually\u003c/p\u003e\u003cp\u003e- Health workers will easily remind HIV-infected women about their next scheduled check-up for CCS\u003c/p\u003e\u003cp\u003e- Reduces the fear to receive CCS services\u003c/p\u003e\u003cp\u003e- Early treatment of precancerous lesions\u003c/p\u003e\u003cp\u003e- Early detection of Cervical Cancer\u003c/p\u003e\u003cp\u003e- Compliance and adherence to undergo CCS services annually\u003c/p\u003e\u003cp\u003e- Increased opportunities to undergo CCS services\u003c/p\u003e\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMotivation to undergo Cervical Cancer Screening\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Record keeping of CCS results and HIV related information in the one HIV patient\u0026rsquo;s file\u003c/p\u003e \u003cp\u003e- Easy follow-up of CCS results\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImproved archiving of Cervical Cancer Screening results\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- HIV-infected women don\u0026rsquo;t want to interact with HIV uninfected women at the CCS unit\u003c/p\u003e \u003cp\u003e- Reduction in HIV stigma from the HIV uninfected women and non-ISS health workers at the CCS unit\u003c/p\u003e \u003cp\u003e- Privacy of the HIV positive status\u003c/p\u003e \u003cp\u003e- HIV-infected women will be interacting with ISS health workers and fellow HIV-infected women who know their HIV status without stigma\u003c/p\u003e\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConfidentiality of HIV patient information\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Free interaction and opening up to ISS health workers whom the HIV-infected women are used to\u003c/p\u003e \u003cp\u003e- ISS health workers do not neglect the HIV infected women\u003c/p\u003e \u003cp\u003e- Fear to disclose the HIV status to non-ISS health workers\u003c/p\u003e \u003cp\u003e- Some non-ISS health workers fear to conduct CCS procedure on the HIV-infected women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreference to interact with ISS clinic health workers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Ashamed to expose private parts to health workers who have known the HIV-infected women\u003c/p\u003e \u003cp\u003e- Preference to open up and share experiences to health workers who don\u0026rsquo;t know them\u003c/p\u003e\u003cp\u003e- Fear and shame to continue interacting with the same health workers to whom they have exposed their private parts for any other HIV related services\u003c/p\u003e\u003cp\u003e- Shyness to expose private parts to health workers who have known the HIV-infected women\u003c/p\u003e\u003cp\u003e- Fear to receive HIV related services from the health workers to whom HIV- infected women have exposed to their private parts\u003c/p\u003e\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShame to expose their privacy to the ISS clinic health workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePerceived challenges of the integration of CCS into routine HIV care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Increase on the time spent at the ISS clinic to undergo CCS\u003c/p\u003e \u003cp\u003e- Delay at the ISS clinic to receive both HIV and CCS services\u003c/p\u003e \u003cp\u003e- Very many women to undergo CCS since the women are more than the men enrolled in the ISS clinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIncreased waiting time\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003ePerceived benefits of integration of Cervical Cancer Screening into routine HIV care\u003c/h2\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eConvenience to seek Cervical Cancer Screening services\u003c/h2\u003e \u003cp\u003eConvenience to seek cervical cancer screening (CCS) services was the most predicted advantage of the integration of CCS into routine HIV care. In all FGDs, HIV-infected women acknowledged that the integration of CCS into routine HIV care would grant them an opportunity to receive both CCS in addition to HIV Care and Treatment services from the ISS Clinic compared to the currently practiced referral or client \u0026ndash; initiated CCS conducted at the CCS unit at MRRH. Furthermore, HIV-infected women claimed that the proposed strategy of delivering CCS would reduce the disruption and movement from one clinic to another since all the CCS and HIV related services would be available and received under one roof in a single HIV clinic visit comprehensively.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Sending you down there wouldn\u0026rsquo;t have a problem but it can somehow disturb you \u0026hellip;, but if they are here, you can know that I am going to pick drugs and then test so I get all services from one place...\u0026rdquo; (Respondent 1, FGD 6 _ Very Acceptable)\u003c/p\u003e \u003cp\u003e\u0026ldquo;But when you bring it here, you will have helped us truthfully, you examine us from here, we go there and get medicine \u0026hellip;, I would prefer that they examine me from here and everything gets done from here\u0026hellip;\u0026rdquo; (Respondent 1, FGD 5 _ Very Acceptable)\u003c/p\u003e \u003cp\u003eHIV-infected women in majority of the FGDs revealed that the referral or client \u0026ndash; initiated CCS services have been quite hectic and inconveniencing to an extent that some of them have missed several opportunities to undergo the CCS procedure; hence supporting the integrated mode of delivery of CCS and HIV related services.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I say that it is right because of a reason. When you come for treatment, to pick drugs, even when you are in pain, it will be hard for you to tell the doctor because you know that he will send you down there ... But if it is here and you know that I will just do like this, reach here, they test me for cancer of the cervix and I go home, there is no problem in that.\u0026rdquo; (Respondent 4, FGD 5 _ Very Acceptable)\u003c/p\u003e \u003cp\u003eHIV-infected women in most FGDs affirmed that the convenience attributed to the integration of CCS into routine HIV care would eventually save the time spent at the health facility compared to the currently delivered stand-alone CCS and HIV services.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u0026hellip; because when she comes here, she has to pick drugs and then slope down there or first slope there and hurry back to get drugs and in this she may be caught by time, or even by the time she gets down, she may find that they have already closed but if those services are here, she can get drugs and later enter the room and they test for cancer of the cervix.\u0026rdquo; (Respondent 1, FGD 3 _ Acceptable)\u003c/p\u003e \u003cp\u003e\u0026ldquo;If these services are brought here inside, it will be faster for us \u0026hellip;, you can even put your paper at the window and you say that let me go to the cancer room and they test me meanwhile. When I am coming from the cancer clinic, I find when they are working on my drugs, get them and go. So, if you bring these services here, it will be faster for us.\u0026rdquo; (Respondent 1, FGD 2 _ Neutral)\u003c/p\u003e \u003cp\u003eHIV-infected women in some FGDs who had endeavoured to undergo the CCS procedure reported that they missed receiving ART refills due to having spent quite many hours seeking for the CCS services from the CCS unit at MRRH.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u0026hellip;the day I tested from down there, I didn\u0026rsquo;t get the drugs because I found that health workers here had left and so I had to come back the following day\u0026rdquo; (Respondent 5, FGD 5 _ Very Acceptable)\u003c/p\u003e \u003cp\u003eHIV-infected women in most FGDs believe that such scenarios of missing HIV Care and Treatment services due to the disruption of seeking CCS services from the CCS unit at MRRH would be minimised by implementation of the integrated mode of delivery of CCS and HIV related services.\u003c/p\u003e \u003cp\u003e\u0026ldquo;The problem is going there and you find there very many people or sometimes you fail to get treatment and they tell you to come back the following day. You come early in the morning but you fail to get treatment but if they are here, you can be sure that at least today, I will go back when I have gotten treatment. And remember, you won\u0026rsquo;t jump the whole of that line that you are going in front. You will go behind and by the time they finish that line, and remember you have to get HIV drugs from up. And you might find when the health workers at the ISS clinic have closed. And now imagine having to come back the next day\u0026rdquo; (Respondent 3, FGD 6 _ Very Acceptable)\u003c/p\u003e \u003cp\u003eFurthermore, HIV-infected women in \u0026ldquo;Very Acceptable\u0026rdquo; FGDs stated that integrated services would save time since a client would easily receive both HIV and CCS services in a single HIV clinic compared to spending a lot of time while travelling to the health facility twice; to seek for CCS and HIV related services from two separate clinics on different days which would in due course reduce the travel costs.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Sending you down there wouldn\u0026rsquo;t have a problem but it can somehow disturb you because sometimes you can be home without money waiting to use the one you have the time you are coming to pick drugs, and there still, they want you to go and test. It can disturb you a bit if you go down there to get tested and then by the time you come back, you find the health workers here have closed. And you have to come back the next day to pick drugs\u0026hellip; but if they are here, you can know that I am going to pick drugs and then test so I get all services from one place, I test for cancer of the cervix and at the same time, pick my drugs on the same day.\u0026rdquo; (Respondent 1, FGD 5 _ Very Acceptable)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eMotivation to undergo Cervical Cancer Screening\u003c/h2\u003e \u003cp\u003eHIV-infected women in all FGDs reported that integration of CCS into routine HIV care would motivate HIV infected women to undergo CCS services. This would ultimately increase the uptake of CCS among HIV infected women; hence achieving the primary goal of implementing the integration of CCS into routine HIV care.\u003c/p\u003e \u003cp\u003e\u0026ldquo;What I think about is that when they bring those services here so that when we have come for treatment and we find them here, we would get inspired to go and test...\u0026rdquo; (Respondent 3, FGD 6 _ Very Acceptable)\u003c/p\u003e \u003cp\u003e\u0026ldquo;When you find that they have brought that clinic here, it will be really so good for it will give us morale to access it.\u0026rdquo; (Respondent 2, FGD 2 _ Neutral)\u003c/p\u003e \u003cp\u003e\u0026ldquo;I think that when those services come here, even those who fear themselves will no longer do so because we have been with our doctors, and they know how our lives are and how they handle us. So, I think that everyone will be encouraged to participate in it.\u0026rdquo; (Respondent 2, FGD 3 _ Acceptable)\u003c/p\u003e \u003cp\u003eFurthermore, HIV-infected women in majority of the FGDs alleged that integration of CCS into routine HIV care would inspire HIV-infected women, the targeted recipients to comply and adhere to recommended annual CCS services. Since documentation about when one last conducted CCS would be captured in the same file with all the other HIV related information, it would be easier for the health worker to remind the client about the appointment date for conducting the next CCS procedure.\u003c/p\u003e \u003cp\u003e\u0026ldquo;That that you have decided that when you are coming to pick drugs, they also test you from here is really so good because I went down there and they tested me \u0026hellip; They also gave me a card but unfortunately, the card got lost but I was negative. They told me to go back \u0026hellip; but like how you said it at the beginning, I have never gone back. But if it is here and I have come to pick drugs or I have come for treatment, they can check in my file and remind me that on such a date, you are supposed to come and they test you.\u0026rdquo; (Respondent 1, FGD 4 _ Acceptable)\u003c/p\u003e \u003cp\u003e\u0026ldquo;If we are receiving services from here in our clinic, it will be helping us so much because if they have given you the date for treatment as that of testing for cancer of the cervix, it will be helping us so much to find that you cannot be disturbed a lot because you know the dates for treatment and testing for cancer of the uterus. \u0026hellip;if I have tested this year, I have another date next year when I will come back! It being the same date for treatment\u0026rdquo; (Respondent 2, FGD 3 _ Acceptable)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eImproved archiving of Cervical Cancer Screening results\u003c/h2\u003e \u003cp\u003eHIV-infected women in some FGDs acknowledged that integration of CCS into routine HIV care would enhance improved record keeping of CCS results. This was highly attributed to the fact that documentation about when the client last conducted CCS would be captured in the same file with all the other HIV related information.\u003c/p\u003e \u003cp\u003e\u0026ldquo;For me I see that the beauty about testing me from here is that everything will be done from here and all will be put in one file and anyone who gets your file will have to see all the diseases that you have.\u0026rdquo; (Respondent 5, FGD 5 _ Very Acceptable)\u003c/p\u003e \u003cp\u003eHIV-infected women in few of the FGDs anticipated that undergoing CCS from the ISS Clinic would make it quite easier for follow up of CCS results.\u003c/p\u003e \u003cp\u003e\u0026ldquo;You see when we are examined from this our clinic, even when results don\u0026rsquo;t come there and then, \u0026hellip;, when you come back, you know that you will find your results in your file and still the health worker will have the responsibility of telling you what the outcome of the results was, \u0026hellip;, even when you may forget, your health worker will definitely remind you.\u0026rdquo; (Respondent 3, FGD 5 _ Very Acceptable)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec30\" class=\"Section2\"\u003e \u003ch2\u003eConfidentiality of HIV patient information\u003c/h2\u003e \u003cp\u003eHIV-infected women in majority of the FGDs claimed that the proposed intervention of integrating CCS into routine HIV care would promote confidentiality of the HIV status and any other health related information due to interaction with only health workers and fellow HIV infected women; as opposed to the current situation where HIV-infected women are forced to interact with other health workers and HIV uninfected women while undergoing CCS at the CCS unit of MRRH. Confidentiality was very much appreciated as a great attribute of the integrated delivery of CCS comprehensively with all other routine HIV care services due to reduced stigma.\u003c/p\u003e \u003cp\u003e\u0026ldquo;You see when they are sending us down there; they send us with our files and remember there are people who have come so early to test for cancer of the cervix. \u0026hellip;, they see people bombarding them and then they start to ask, where are these ones coming from? Ahh they are HIV/AIDS victims. You see them pointing fingers because they have isolated us. But if it has come to our clinic and you know that if I have come to test for cancer of the cervix I will find services at the ISS clinic, I will also be confident wherever I will be seated because I will know that the people I am seated with are my fellows. ...and even when they say that, you should start with the ones from the ISS clinic, you see them start to grumble\u0026hellip; eh we are going to rest from such at least. The thing of grumbling at us, pin pointing us, isolating us\u0026hellip;\u0026rdquo; (Respondent 2, FGD 6 _ Very Acceptable)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u0026hellip; there are women who don\u0026rsquo;t want others to know that they are sick. So she will go down there, and meet a friend whom she has been keeping it away from, and this person is going to see her in the line of those with HIV virus. That will bring an effect because she has found there her friend who has not been knowing her stand and now she\u0026rsquo;s going to know. But if they bring the services for cancer of the cervix, I think it will help all of us and those who don\u0026rsquo;t want their stand to be known\u0026hellip;\u0026rdquo; (Respondent 4, FGD 5 _ Very Acceptable)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003ePreference to interact with ISS clinic health workers\u003c/h2\u003e \u003cp\u003eHIV-infected women in most FGDs appreciated the integrated strategy whereby health workers from the ISS Clinic will perform the CCS procedure in addition to other HIV related services. HIV-infected women preferred receiving CCS conducted by the ISS clinic health workers to the currently practiced system where the CCS procedure is conducted by the health workers at the ISS unit of MRRH. HIV-infected women revealed that they can freely share their experiences or any health-related issues with the health workers at the ISS Clinic due to the strong relationship built over time as opposed to health workers at the CCS Unit of MRRH.\u003c/p\u003e \u003cp\u003e\u0026ldquo;me I think that if they bring them here, it will be easy for us because let\u0026rsquo;s say they put a particular person to carry out the tests, it will be easier for one to explain to her how someone is, not like the one down there because you find in most cases, when they would send us there, the health workers would look at you as if there is something on you, they would all be neglecting to attend to you, because the people down there may not be as free to you as this one who can be here, you can explain everything to her and another thing it becomes easier for you because after picking the drugs, you can go and test.\u0026rdquo; (Respondent 3, FGD 3 _ Acceptable)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003ePerceived challenges of integration of Cervical Cancer Screening into routine HIV care\u003c/h2\u003e \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e \u003ch2\u003eShame to expose their privacy to the ISS clinic health workers\u003c/h2\u003e \u003cp\u003eHIV-infected women in the \u0026ldquo;Very Unacceptable and Unacceptable\u0026rdquo; FGD reported that they would prefer receiving CCS conducted by the health workers at the CCS Unit of MRRH as opposed to the health workers at the ISS Clinic. They argued that due to having interacted for quite a very long time, they would always be overwhelmed with fear and shame to continue interacting with the same health workers to whom they have exposed their private parts for any other HIV related services. They confessed that they would honestly prefer undergoing the CCS conducted by the health workers at the CCS Unit of MRRH because they rarely interact with them; hence no fear and shame to expose their private parts.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u0026hellip; ever since l started picking drugs from here, the nurse I found here is the one still there, the doctor I found there is the one still there, but there is a way we are created in our private parts, if someone has ever seen you, you feel ashamed as if she knows how you are exactly, as if she will tell others that so and so is like this and that, but down there where we go, sometimes you find they have changed them, you find that those who are always there are very different. And even by the time you go there, they can\u0026rsquo;t be remembering you because you go there once, but here, we come every month, every after two months, someone knows how you are created down, but down there, someone cannot even be remembering that you are the one but here they know us as patients in and out \u0026hellip; you say that now that he has seen me, he has remembered how I look like down there in my private parts...\u0026rdquo; (Respondent 5, FGD 1 _ Very Unacceptable and Acceptable)\u003c/p\u003e \u003cp\u003eHIV-infected women in only the \u0026ldquo;Very Unacceptable\u0026rdquo; and \u0026ldquo;Unacceptable\u0026rdquo; FGD anticipated that the fear and shame to undergo CCS conducted by the health workers at the ISS Clinic would even generate non-adherence to scheduled HIV clinic visits.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Sometimes, those people will start irregular treatment. The day they gave her, if she knows that she is going to be tested for cancer of the cervix, she won\u0026rsquo;t come or that day when she is to come, she will come when she is in her periods.\u0026rdquo; (Respondent 4, FGD 2 _ Neutral)\u003c/p\u003e \u003cp\u003e\u0026ldquo;Testing us from here\u0026hellip; No\u0026hellip; I too don\u0026rsquo;t like that. Me too I can\u0026rsquo;t like that because I can know that all these people seated here know what I am from doing. Now he himself will be looking at me as if he knows exactly how I was created. As if he sees me naked. No No. They should put us there where others have been because personally you will put me here, when you look at me, I look down, you do like this, I look down, now my CD4s will go down or even my thoughts be low because of that thing.\u0026rdquo; (Respondent 3, FGD 1 _ Very Unacceptable and Unacceptable)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec34\" class=\"Section2\"\u003e \u003ch2\u003eIncreased waiting time\u003c/h2\u003e \u003cp\u003eHIV-infected women in majority of the FGDs argued that delivering CCS comprehensively with other routine HIV care services during the scheduled HIV clinic visits would be very time consuming hence increasing the waiting time at the ISS clinic. With the increased numbers of HIV-infected women enrolled into HIV care at the ISS Clinic, the participants were worried of the potential delay at the ISS clinic attributed to the integration of CCS into routine HIV care.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u0026hellip;you come when you have put your attention on the health worker to explain to him how you are feeling and where you are paining. By the time you get to the line of picking drugs, in fact you be already tired. And now imagine, you will also have to go the cancer room\u0026hellip; don\u0026rsquo;t you think women will go back at night or even the next day [laughs] \u0026hellip;\u0026rdquo; (Respondent 5, FGD 1 _ Very Unacceptable and Unacceptable)\u003c/p\u003e \u003cp\u003e\u0026ldquo;The problem \u0026hellip; the one of time because there is when you see someone who came very early in the morning sitting there up to around 11am. She has not yet seen the doctor so that she can ask the nurse for the file, so it is always that they have not yet reached her. So, you see her start to complain that I came here in the morning and up to now I am still there. So, by the time she finishes all that to come back to test for cancer of the cervix, I see that that is the only problem we are going to find\u0026hellip;\u0026rdquo; (Respondent 6, FGD 6 _ Very Acceptable)\u003c/p\u003e \u003cp\u003eDue to the time-consuming challenge, HIV-infected women in very few FGDs expressed concern on how the integrated approach of CCS and HIV services in a single HIV clinic visit would be delivered since some of the recipients travel from very far to seek for HIV treatment services from the ISS clinic.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u0026hellip; so I don\u0026rsquo;t know, like how I told you that women are more than men in this clinic, l don\u0026rsquo;t know, shall we be making a line like this here, shall we be having numbers, shall we be having 4 rooms, how will that thing be done \u0026hellip;? Some of us come from far. Not that this clinic covers only the Mbarara people, we even have those from Fortportal, Kamwenje, generally people come from far. So, let\u0026rsquo;s say I have come from Kamwenje, to pick drugs because l know that l have to get drugs. Yet I also have to test for cancer from our clinic. Which arrangement do you have that the time I have here doesn\u0026rsquo;t be increased?\u0026rdquo; (Respondent 4, FGD 4 _ Acceptable)\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e This study aimed at assessing the acceptability of integration of Cervical Cancer Screening (CCS) into routine HIV care, associated factors and perceptions among HIV-infected women enrolled in the Immune Suppression Syndrome (ISS) clinic at Mbarara Regional Referral Hospital (MRRH). Analysis of data showed that 64.5% of the HIV-infected women enrolled in the ISS clinic at MRRH accepted the integration of CCS into routine HIV care. This study finding is lower than the acceptance among HIV-infected women to undergo the CCS procedure reported at 87.6% after incorporating Visual Inspection with Acetic acid (VIA) into the routine clinical services offered at Family AIDS Care and Education Services (FACES) clinics in Kisumu, Kenya (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe acceptability of the proposed intervention at 64.5% is lower than the CCS acceptance of 79.8% among HIV-infected women at the HIV treatment centre, Nigerian Institute of Medical Research (NIMR), Lagos, Nigeria who participated in the study assessing the acceptability of the integration of CCS into HIV care (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). In addition, the reported finding of 64.5% is lower than the 96.5% acceptability to undergo Visual Inspection with Acetic acid (VIA) after integrating CCS and HIV care and treatment services in a district hospital in Abuja, Nigeria (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). This could be attributed to the perceived challenges of the integration of CCS into routine HIV care among HIV-infected women enrolled at the ISS clinic.\u003c/p\u003e \u003cp\u003eResults of the multivariable regression analysis indicated that religion, perceived risk of developing Cervical Cancer (CC) and ever screened for Cervical Cancer (CC) were statistically significantly associated with the acceptability of integration of CCS into routine HIV care among HIV-infected women. Despite the fact that Muslims accepted the integration of CCS into routine HIV care compared to protestants, a study conducted among HIV-infected women at the HIV treatment centre, Nigerian Institute of Medical Research (NIMR), Lagos, Nigeria reported that religion was not significantly associated with the acceptability of the integration of CCS into routine HIV care (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Additionally, a study conducted in Ethiopia reported that religion differences were not significantly associated with acceptability and uptake of CCS among HIV-infected women at St. Paul's and Zewditu Hospitals where CCS had been integrated into HIV care and treatment services (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Despite the fact that this was a surprising finding, it is unclear why most Christians inclusive of protestants regard fatal illnesses like CC to be a punishment from God and believe that the prevalence of CC is very low among children of God; hence the need for involvement of religious stakeholders in the advocacy for integration of CCS into routine HIV care.\u003c/p\u003e \u003cp\u003eIn this study, HIV-infected women with \u0026ldquo;Much Above Average\u0026rdquo; perceived risk of developing CC accepted the integration of CCS into routine HIV care. This study finding highly correlates with the finding from the systematic review conducted in Ethiopia where perceived susceptibility to acquiring CC (AOR\u0026thinsp;=\u0026thinsp;3.26; 95% CI : 2.26, 4.26) was significantly associated with CCS acceptability among HIV-positive women (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). However, a study conducted among HIV-infected women at the HIV treatment centre, Nigerian Institute of Medical Research (NIMR), Lagos, Nigeria reported that perceived risk of acquiring CC was not significantly associated with the acceptability of the integration of CCS into routine HIV care (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Nonetheless, a study conducted in Ghana reported that perceived susceptibility to acquiring CC was not significantly associated with willingness and acceptability to undergo CCS among HIV-infected women (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). The discrepancies in the influence of perceived risk of CC to the acceptability of integration of CCS into routine HIV care could be explained by the gap of lack of awareness that HIV infected women are more at risk of developing CC compared to their counterparts, the HIV negative women.\u003c/p\u003e \u003cp\u003eIt was also found out HIV-infected women who had not undergone CCS were less likely to accept the integration of CCS into routine HIV care compared to HIV-infected women who had undergone CCS. A study conducted among HIV-infected women at the HIV treatment centre, Nigerian Institute of Medical Research (NIMR), Lagos, Nigeria reported that ever screened for CC was not significantly associated with the acceptability of the integration of CCS into routine HIV care (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). HIV-infected women who have previously undergone CCS applaud the integration of CCS into routine HIV care due to the perceived benefits most especially convenience of the integrated CCS and HIV services. Despite the fact that HIV-infected women who had not undergone CCS are highly expected to support the integration of CCS into routine HIV services, this might not necessarily be true because they could be ashamed of exposing their private parts to health workers whom they occasionally interact with in the HIV clinics.\u003c/p\u003e \u003cp\u003ePerceived benefits of the proposed intervention were: convenience to seek for CCS, motivation to undergo CCS, improved archiving of CCS results, confidentiality of HIV patient information, and preference to interact with ISS clinic health workers. In all FGDs, HIV-infected women acknowledged that the integration of CCS into routine HIV care would grant them an opportunity to receive both CCS in addition to HIV services conveniently from the ISS Clinic compared to the currently practiced referral or client-initiated CCS conducted at the CCS unit at MRRH. This study finding is in agreement with findings from other studies which reported that the convenience of seeking for integrated HIV and CCS services from one point without forgetting an added advantage of one off relief of anxiety was attributed to the integration strategy compared to stand alone screening services (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The intervention was regarded as a time saving strategy attributed to the convenience through reducing the frequency of health facility visits, necessity of several return journeys, travel time and return transportation costs (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). HIV-infected women anticipated that implementation of the proposed strategy of delivering CCS would reduce the disruption and movement from one clinic to another since all the CCS and HIV related services would be available and received under one roof in a single HIV clinic visit comprehensively.\u003c/p\u003e \u003cp\u003eHIV-infected women in all FGDs reported that the integration of CCS would motivate HIV infected women to undergo CCS services. Furthermore, HIV-infected women in majority of the FGDs alleged that the integration of CCS into routine HIV care would inspire HIV-infected women, the targeted recipients for the proposed intervention, to comply and adhere to the recommended annual CCS services. Researchers, community members, health care providers and policy makers were also optimistic that the intervention would improve the uptake of initial and annual CCS among HIV-infected women (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Integration of CCS into routine HIV services would reduce the missed opportunities for HIV-infected women to undergo the CCS procedure; hence increasing the uptake of CCS among the targeted recipients.\u003c/p\u003e \u003cp\u003eHIV-infected women in majority of the FGDs claimed that the proposed intervention would promote confidentiality of the HIV status and any other health related information due to interaction with only health workers and fellow HIV-infected women. This study finding was also reported in a study conducted in Uganda where women reported that the integrated screening model would promote confidentiality of HIV and any other health related information due to being accessed and confined to limited teams of health care practitioners at the HIV clinics (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). In most instances, HIV-infected women prefer confidentiality of their HIV status through interacting with only health workers in HIV clinics and archiving of the CCS information in the same file with all the other HIV related information; due to fear of being stigmatised.\u003c/p\u003e \u003cp\u003eShame to expose their privacy to the ISS clinic health workers and increased waiting time were the only perceived challenges of the integration of CCS into routine HIV care among HIV-infected women. HIV-infected women in only the \u0026ldquo;Very Unacceptable and Unacceptable\u0026rdquo; FGD reported that they would prefer undergoing CCS conducted by the health workers at the CCS Unit of MRRH as opposed to the ISS clinic health workers. Based on the study findings from a study conducted in Uganda, discomfort and invasion of privacy expressed by HIV-infected women due to genital illnesses, menstrual periods, and fear to expose their private parts was one of the challenges to undergo CCS integrated into routine HIV services at Mildmay Uganda (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). HIV-infected women argued that they would be uncomfortable and ashamed to continue interacting with the same health workers to whom they have exposed their private parts for any other HIV related services.\u003c/p\u003e \u003cp\u003eHIV-infected women in majority of the FGDs argued that delivering CCS comprehensively with other routine HIV care services during scheduled HIV clinic visits would be very time consuming hence increasing the waiting time at the ISS clinic. This study finding was consistent with findings from other studies where long waiting time was cited as one of the potential challenges HIV-infected women would have to endure through to undergo the CCS procedure integrated into comprehensive HIV services (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). HIV-infected women in some of the FGDs expressed concern on how the integrated approach of CCS and HIV treatment services in a single HIV clinic visit would be delivered to the ever-increasing numbers of recipients within the shortest time possible.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe mixed methods study design using the explanatory sequential approach increased the rigor and internal validity of the study. Utilisation of the systematic sampling method for selection of HIV-infected women to participate in the quantitative phase of the study was an added strength to the conduct of the study. However, the theoretical Framework of Acceptability (TFA) adapted to measure acceptability of the integration of CCS into routine HIV care has not yet been validated among the Ugandan populations. HIV-infected women who turned up on unscheduled dates were excluded from participating in the study; increasing potential for information bias. Furthermore, this study was conducted in only one HIV clinic in the entire country due to limited funding; hence affecting the generalisability of study findings to all HIV-infected women in Uganda.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eStudy findings highlight the need to take advantage of this acceptability to prioritize implementation of integration of CCS into routine HIV care. Ministry of Health should prioritise of the implementation of the integration of CCS into routine HIV care to increase uptake of CCS among HIV-infected women along the continuum of HIV care and treatment services. Health workers delivering HIV care and treatment services should endeavour to conduct intensified health education and awareness about the increased risk of developing CC among HIV-infected women. HIV-infected women should be reassured of reduced waiting time, confidentiality and optimisation of privacy by HIV clinic health workers during the provision of the integrated HIV care and CCS services. Furthermore, a nationally representative study should be conducted to assess the acceptability of integration of CCS into routine HIV care, associated factors, and perceptions among HIV-infected women enrolled in the HIV clinics in Uganda.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"List Of Abbreviations","content":"\u003cp\u003eART \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Anti -\u0026nbsp;Retroviral Treatment\u003c/p\u003e\n\u003cp\u003eHIV \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Human\u0026nbsp;Immune\u0026ndash;deficiency\u0026nbsp;Virus\u003c/p\u003e\n\u003cp\u003eCC \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Cervical Cancer\u003c/p\u003e\n\u003cp\u003eCCS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Cervical Cancer Screening\u003c/p\u003e\n\u003cp\u003eHPV \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Human Papilloma\u0026nbsp;Virus\u003c/p\u003e\n\u003cp\u003eHDI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Human Development Index\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVIA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Visual\u0026nbsp;Inspection with Acetic\u0026nbsp;Acid\u003c/p\u003e\n\u003cp\u003eISS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Immune Suppression Syndrome\u003c/p\u003e\n\u003cp\u003eMRRH\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Mbarara Regional Referral Hospital\u003c/p\u003e\n\u003cp\u003eMOH \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Ministry\u0026nbsp;of Health\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMakSPH \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Makerere\u0026nbsp;University\u0026nbsp;School of Public Health\u003c/p\u003e\n\u003cp\u003eMUST\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Mbarara University of Science and Technology\u003c/p\u003e\n\u003cp\u003eUNCST \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Uganda National Council of Science and Technology\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Principal\u0026nbsp;Investigator\u003c/p\u003e\n\u003cp\u003eRAs \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Research Assistants\u003c/p\u003e\n\u003cp\u003eTFA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Theoretical Framework of Acceptability\u003c/p\u003e\n\u003cp\u003eAWACAN\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp;African Women Awareness of CANcer\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWHO \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproval was obtained from the Makerere University School of Public Health Higher Degrees, Research and Ethics Committee to conduct the study. Administrative clearance was sought from the office of the Hospital Director of Mbarara Regional Referral Hospital before conducting data collection. Individuals were informed of their right to agree to participate or withdraw from the study at any time without fear of any negative repercussions; and receipt of care was not dependent on the participation in the study. After informing them of the purpose and procedure of the study, a written informed consent was sought from the study participants before administering questionnaires or conducting focus group discussions.\u003c/p\u003e\n\u003cp\u003eAll methods were performed in accordance with the relevant guidelines and regulations in Ethics Approval and Consent to Participate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors do not have any competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u003c/strong\u003e MN designed the proposal, conducted quantitative and qualitative data collection, analysed the data and presented the study findings and compiled the manuscript. AN and JK provided great technical guidance through out every step of the proposal conceptualization, data collection and manuscript preparation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eExceptional applaud to Dr. Kagaayi Joseph and Ms. Nyabigambo Agnes who have been very instrumental to inspire the best of my potential in the pursuit of my research career.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: a cancer journal for clinicians. 2018;68(6):394\u0026ndash;424.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. 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Journal of lower genital tract disease. 2016;20(1):31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDenslow SA, Rositch AF, Firnhaber C, Ting J, Smith JS. Incidence and progression of cervical lesions in women with HIV: a systematic global review. International journal of STD \u0026amp; AIDS. 2014;25(3):163\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuchko MJ, Maloba M, Nakalembe M, Cohen CR. The time has come to make cervical cancer prevention an essential part of comprehensive sexual and reproductive health services for HIV-positive women in low‐income countries. Journal of the International AIDS Society. 2015;18:20282.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMapanga W, Girdler-Brown B, Feresu SA, Chipato T, Singh E. Prevention of cervical cancer in HIV-seropositive women from developing countries through cervical cancer screening: a systematic review. 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Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. BMC health services research. 2017;17(1):88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRonald M, Andrew C, Sezalio M, John K, Hillary A, Kayondo M, et al. Cervical Cancer at Mbarara Regional Referral Hospital: Magnitude, Trends, Stages at Presentation, Impact of Acetic Acid Screening and the Need for Radiotherapy Services. Journal of Health, Medicine and Nursing. 2016;27:126\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAweke YH, Ayanto SY, Ersado TL. Knowledge, attitude and practice for cervical cancer prevention and control among women of childbearing age in Hossana Town, Hadiya zone, Southern Ethiopia: Community-based cross-sectional study. PloS one. 2017;12(7):e0181415.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMengesha A, Messele A, Beletew B. Knowledge and attitude towards cervical cancer among reproductive age group women in Gondar town, North West Ethiopia. BMC public health. 2020;20(1):209.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSuresh K, Chandrashekara S. Sample size estimation and power analysis for clinical research studies. Journal of human reproductive sciences. 2012;5(1):7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHajian-Tilaki K. Sample size estimation in epidemiologic studies. Caspian journal of internal medicine. 2011;2(4):289.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSemeere AS, Semitala FC, Lunkuse O, Katahoire A, Sewankambo NK, Kamya MR. An assessment of implementation science research capacity in Uganda. Health research policy and systems. 2021;19(1):1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuchko MJ, Bukusi EA, Cohen CR. Building capacity for cervical cancer screening in outpatient HIV clinics in the Nyanza province of western Kenya. International Journal of Gynecology \u0026amp; Obstetrics. 2011;114(2):106\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOdafe S, Torpey K, Khamofu H, Oladele E, Adedokun O, Chabikuli O, et al. Integrating cervical cancer screening with HIV care in a district hospital in Abuja, Nigeria. Nigerian medical journal: journal of the Nigeria Medical Association. 2013;54(3):176.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEmru K, Abebaw T-A, Abaerei AA. Role of awareness on cervical cancer screening uptake among HIV positive women in Addis Ababa, Ethiopia. A cross-sectional study. 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDessalegn Mekonnen B. Cervical Cancer Screening Uptake and Associated Factors among HIV-Positive Women in Ethiopia: A Systematic Review and Meta-Analysis. Advances in Preventive Medicine. 2020; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEbu NI, Ogah JK. Predictors of cervical cancer screening intention of HIV-positive women in the central region of Ghana. BMC women's health. 2018;18(1):1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBukirwa A, Mutyoba JN, Mukasa BN, Karamagi Y, Odiit M, Kawuma E, et al. Motivations and barriers to cervical cancer screening among HIV infected women in HIV care: a qualitative study. BMC women's health. 2015;15(1):82.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Acceptability, Integration, Cervical Cancer Screening, HIV","lastPublishedDoi":"10.21203/rs.3.rs-1727362/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1727362/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIntegrating Cervical Cancer Screening (CCS) into routine HIV care has been endorsed as an effective strategy for increasing uptake of CCS, and facilitating early detection and treatment of pre-cancerous lesions among HIV-infected women. In Uganda, this strategy has not been implemented yet in most HIV clinics. Assessing the acceptability of this intervention among HIV-infected women is of great relevance to inform its implementation. This study assessed acceptability of integration of CCS into routine HIV care, associated factors and perceptions among HIV-infected women enrolled in the Immune Suppression Syndrome clinic at Mbarara Regional Referral Hospital (MRRH).\u003c/p\u003e\u003ch2\u003eMethodology:\u003c/h2\u003e \u003cp\u003eA mixed methods study utilizing the explanatory sequential approach was conducted among 327 eligible HIV-infected women. Acceptability of integration of CCS into routine HIV care was measured using the Theoretical Framework of acceptability (TFA). A pre-tested questionnaire was used to collect quantitative data. Focus group discussions to explore perceptions regarding the intervention were conducted among purposively selected HIV-infected women. Modified poisson regression with robust variance analysis was utilized to determine factors associated with the acceptability of the intervention. Statistical significance was determined at p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Thematic analysis utilizing inductive coding was used to analyze qualitative data.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMajority of the HIV-infected women (64.5%) accepted the integration of CCS into routine HIV care. Religion, perceived risk of developing CC and ever screened for CC were statistically significantly associated with the acceptability of integration of CCS into routine HIV care. Perceived benefits of the proposed intervention were: convenience to seek for CCS, motivation to undergo CCS, improved archiving of CCS results, confidentiality of HIV patient information, and preference to interact with ISS clinic health workers. Shame to expose their privacy to the ISS clinic health workers and increased waiting time were the only perceived challenges of the intervention.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eStudy findings highlight the need to take advantage of this acceptability to prioritize implementation of the integration of CCS into routine HIV care. HIV-infected women should be reassured of confidentiality and reduced waiting time to increase uptake of the integrated CCS and HIV services among HIV-infected women along the continuum of HIV care and treatment services.\u003c/p\u003e","manuscriptTitle":"Acceptability of Integration of Cervical Cancer Screening Into Routine HIV Care, Associated Factors and Perceptions Among HIV- Infected Women: a Mixed Methods Study at Mbarara Regional Referral Hospital","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-06-14 15:39:11","doi":"10.21203/rs.3.rs-1727362/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-01-05T06:32:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-09-18T10:46:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2e419ec5-8126-4e90-be8b-55a875c14040","date":"2022-08-24T18:29:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"8a4e9194-b4b2-4d65-b38e-39cbecac4b26","date":"2022-08-06T07:09:19+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-08-05T21:42:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-08-01T06:10:36+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-06-08T06:32:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-06-08T06:10:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2022-06-05T11:45:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"405d992a-d8a9-47ef-bbb5-d80f083c75e8","owner":[],"postedDate":"June 14th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T20:26:21+00:00","versionOfRecord":{"articleIdentity":"rs-1727362","link":"https://doi.org/10.1186/s12913-023-09326-6","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2023-04-03 20:23:30","publishedOnDateReadable":"April 3rd, 2023"},"versionCreatedAt":"2022-06-14 15:39:11","video":"","vorDoi":"10.1186/s12913-023-09326-6","vorDoiUrl":"https://doi.org/10.1186/s12913-023-09326-6","workflowStages":[]},"version":"v1","identity":"rs-1727362","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1727362","identity":"rs-1727362","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}