Description
Introduction
Studies have shown disparities in cancer incidence and mortality by individual and area-level socioeconomic positions (SEP). Individuals in low SEP areas have been observed to be at a higher risk of infection-related cancers such as cervical cancer whilst breast and uterine cancer has been observed to be higher in high compared to low SEP areas. However, cancer screening services and uptake has been observed to be higher in high municipal SEPs. In this study, we aimed to determine the effect of municipal SEP on cancer incidence in women living with HIV (WLHIV) in South Africa between 2004 and 2014.
Methodology
We included women aged 15+ years from the South African cancer match (SAM) study for the period 2004 to 2014. The SAM study involves an HIV cohort created through probabilistic record linkage of HIV-related laboratory record and subsequently linked to cancer data form the National Cancer Registry. Data on individual level SEP was lacking but information on the facility of HIV-related test was available. Since HIV care facilities are largely decentralised, we assumed that the municipality of HIV testing was the same as the municipality of residence. This municipal information was then linked to the South African Index of Multiple deprivation (SAIMD) to determine the SEP at municipal level. The SAIMD in a combination of four measures of deprivation, namely education, material, employment and living environment. Cox proportional hazard models were used to determine the association between cancer incidence and municipal SEP adjusting for age, settlement type, calendar period and CD4 cell counts.
Results and Discussions
From our cohort of 3.4 million women and 10.5 million years of follow-up, 12,605 incident cancers where diagnosed between 2004-2014. The overall cancer incidence was 120/100,000 person-years (pyrs) (interquartile range (IQR): 118-122). Overall, the crude incidence of cancer increased from 80/100000 pyrs (IQR: 76-83) in the low SEP municipalities to 174/100,000 pyrs (IQR: 169-179) in high SEP municipalities. Adjusting for settlement type and age, there was an elevated risk of overall cancer (Hazard Ratio (HR): 1.61; 95% Confidence Interval (CI) [1.50-1.72]; infection-related cancer (HR: 1.53; 95% CI [1.41-1.68] and infection-unrelated cancer (HR: 2.21; 95% CI [1.74-2.81] in high SEP municipalities compared to low SEP municipalities. Similarly, adjusting for age, CD4 cell count, calendar period and settlement type, we observed an elevated risk of cervical cancer and breast cancer in high SEP municipalities compared to low SEP municipalities. Our results show an elevated incidence and risk of cancer in high municipal areas. This may reflect better accessibility of diagnostic and pre-cancer screening services in high municipal areas compared to low SEP municipalities leading to higher cancer diagnosis rates in areas of high SEP.
Conclusions
Our results reflect a potential unequal distribution of cancer diagnostic services in low municipal SEPs compared to high municipal SEP. More efforts should be made to provide better and equal access to cancer diagnostic services amongst WLHIV in South Africa.
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