PLHIV have a higher risk of malignancies than the general population [19, 26, 27]. Therefore, we conducted FGD and KII with the primary objective of evaluating the knowledge, attitudes and practices of malignancies among people living with HIV. In this study, we found that most of our FGD participants had heard about cancer but had limited knowledge particularly of AIDS-associated malignancies, causes of cancer and availability of treatment. The participants expressed strong views on the association between HIV and cancer with most believing that it is not possible to develop cancer if one was already infected with HIV. Some of the participants in the study expressed preference for alternative and traditional means of diagnosis and treatment. Very few participants in our study had ever been screened for any cancer despite knowledge that screening for cancer exists.
Findings from our study suggest poor knowledge of cancer and its causes among the FGD participants. This was surprising because we expected that PLHIV would be better informed about cancers particularly those associated with HIV given their more frequent contact with the health care system. Our results suggest the need for cancer education even in cohorts with high levels of interaction with the health care system such as PLHIV.
We observed that the attitudes of PLHIV in Nigeria towards cancer were characterized by fear and low level of perceived cancer risk. Majority of our participants had heard about cancer screening, but very few had ever been screened for cancer. Similarly low levels of cancer screening had been reported in southeastern Nigeria, although in a different target population . Participants in our study identified fear of diagnosis, fear of a false positive diagnosis and cost as the primary barriers to the uptake of cancer screening among PLHIV in Nigeria.
Most FGD participants who said they or their relatives patronize alternate medical practitioners were those who had attained secondary education or less. The literature identifies poverty and lack of education as the reasons for high patronage of complementary and alternative medicine practitioners . PLHIV in our study mentioned that they patronize alternate medical practitioners because these practitioners are better at keeping patients’ diagnosis and treatment secret. This finding can be interpreted to mean that there is a level of distrust that PLHIV associate with hospitals and health care professionals. It is also possible that PLHIV are concerned about the complexity of services and personnel that they interact with in the hospital and they believe that this increases the risk of inadvertent disclosure in contrast to alternative medicine practitioners which are often one person establishments.
With the recent attention paid to HIV/AIDS in Nigeria, awareness of HIV/AIDS has substantially increased, however, cancer education and awareness remains poor . More than 70% of all cancer patients in Nigeria present with advanced disease , therefore opportunities to incorporate cancer screening into routine HIV care can play a pivotal role in reducing the cancer burden among PLHIV [21, 29, 30]. HIV clinics have expanded their operations to incorporate treatment of opportunistic infections such as tuberculosis and they can similarly incorporate cancer prevention, early diagnosis and treatment services. This model has been successfully demonstrated by programs in Zambia and other parts of Africa with resultant saving of lives [31, 32].
Health care professionals including those caring for PLHIV need to be trained to incorporate cancer prevention and education services, and recognize the early signs and symptoms of cancer, particularly those prevalent among PLHIV. When coupled with coordinated referral system, this can optimize the prevention and management of cancer among PLHIV. Such efforts are likely to be more effective if complemented by cancer education programs for the HIV/AIDS patient population so they can appreciate and take advantage of cancer prevention services. Such cancer education can be delivered through electronic and print media, mobile text messages, campaigns and other health and educational programs as suggested by our FGD participants.
Our findings are important because they show low levels of cancer awareness among PLHIV despite their high level of interaction with the health care system for HIV treatment and prevention. This is similar to findings from other studies that there is low level of cancer awareness in Nigeria . While the health care professionals who participated in our KII were fairly knowledgeable of cancer and AIDS associated cancers, the low levels of awareness in the population they serve suggest that this knowledge does not translate into screening, early detection and timely referral of cancer patients. Our results demonstrate a need for clients’ and health professionals’ education to promote early detection of cancer and increased use of cancer prevention services.
Furthermore, successful implementation of cancer prevention and control strategies among PLHIV will require a commitment by relevant government agencies to the development of appropriate policies and guidelines to support extra resources for community health education and awareness, infrastructure development, training of health care personnel on early detection and diagnosis of AIDS associated malignancies, subsidized cancer screening interventions and the evaluation of cancer prevention strategies through the promotion of research and cancer surveillance. Provision of well-equipped pathology laboratories for histologic examination of suspected cases of cancer is also important.
Our study provides valuable information about current knowledge, attitude and awareness of cancer among PLHIV in Nigeria. It is however limited by the small sample size and the use of qualitative research methods. Nevertheless, qualitative methods are appropriate where researchers need to probe for information that may be unstructured and not amenable to survey methods. It is also possible that the social interaction necessitated by the FGD methods created an atmosphere where perceived socially desirable responses had been given. Some participants’ responses may have been influenced by those of more vocal participants. However, we ensured that quieter participants in the FGD had an opportunity share their thoughts and contribute to the discussion. In order to improve the generalizability of our results, we randomly selected participants from high volume HIV/AIDS centers in Nigeria and we believe that their opinions were a true reflection of the situation among PLHIV in Nigeria.