ARTICLE
The psychosocial and economic burden of genital warts among women assisted in six sexual and reproductive health clinics in Brazil

INTRODUCTION

The World Health Organization estimates that 291 million women worldwide will have a human papillomavirus (HPV) infection at any given point in their lifetime¹. Cervical cancer is related to oncogenic types of HPV infection and constitutes a public health issue in Brazil. According to the Brazilian National Cancer Institute 15.590 new cases and a rate of 15,33 cases per 100.000 women are estimated for 2014².

Although cervical cancer is the most important public health issue related to HPV infection in women, genital warts (GW), a benign condition related to non oncogenic HPV subtypes, cannot be neglected. In 2008, the Brazilian Ministry of Health published a study on sexually transmitted infections (STI) prevalence in selected populations (pregnant women, men working in industry and people seeking care in STI clinics) in five regions of the country³. Genital warts were diagnosed in 5.7% of pregnant women, and 6.5% reported previous episodes. Among women who seek STI clinics, 21% had a GW diagnosis, and 25% reported previous episodes.

Genital warts usually cause stress to the affected individuals. The treatment options bring some kind of discomfort, such as burning sensation and pain. Besides, as a sexually transmitted infection, it may be associated with feelings of shame, anxiety and problems in the relationship with the partner.

Zhu et al.⁴ developed a psychometric scale to assess the psychological burden of HPV. The self-administered questionnaire consists of 29 questions designed to capture a wide range of psychosocial consequences of HPV disease, including both cervical cancer precursors and genital warts. The results were sensitive to differences in the psychosocial impact of various HPV-related diseases.

There are studies about costs of GW treatment in many countries; some of them consider only direct costs^5,6 and others include indirect costs such as sick leave^7,8,9. Considering the importance of HPV and related diseases in Brazil and the lack of studies about both the psychosocial and the economic burden of these diseases, Bem Estar Familiar no Brasil (BEMFAM - Family Wellbeing in Brazil) carried out a study to measure the psychosocial and economic burden of genital warts among two samples of women attending its six reproductive health clinics. BEMFAM is a Brazilian non-governmental organization that provides sexual and reproductive health (SRH) services and technical support to local governments.

OBJECTIVE

There are two objectives in this paper: (i) to estimate the psychological burden of genital warts (GW); and (ii) to estimate the economic burden of GW in six reproductive health clinics in Brazil.

METHODS

The study design comprises two objectives and groups of women assisted in the six BEMFAM's SRH clinics in the Brazilian Northeast States of Maranhão, Paraíba, Rio Grande do Norte, Pernambuco, Ceará and the Southeast State of Rio de Janeiro. All the clinics are located in urban areas of the State capital cities, provide outpatient care and assist both individuals who pay out-of-pocket or with private health plans. All the individuals were assisted by gynecologists. The psychosocial burden was measured by a self-administered questionnaire at the time of the visit and the economic burden was measured with a retrospective study of medical chart review analysis.

RESULTS

Sample characteristics are displayed in Table 1.

Table 1:

Characteristics of participants in the study.

(*) Age at first genital warts diagnostic for medical records.

Mean age was similar for both samples, with a slightly younger population for the sample under medical record review (25.8 versus 27.6). Most of the sample enrolled for the psychometric part of the study was married, earning a family income of less than US 11 a day, with one living children and was revisiting BEMFAM clinics. They used modern contraception in larger proportions than women under medical record review (82.8 versus 75%). Prevalent methods among the first were pills (43%) and condoms (34%) against pill (35%), condom (29%) and sterilizations (13%), for the second. Fifty three cases were enrolled from the normal Pap smear group, 29 with CIN 1, 6 cases with CIN 2 or 3 and 34 cases with GW. For the psychometric scales, cases with CIN 1, 2 and 3 were regrouped, totaling 35 cases. The sample for medical review had the first intercourse at 17.8 years old in average, were experiencing their first GW episode for 90.2% of the total sample, with 2.0% being recurrent and 7.8% resistant cases. In average, women from the medical record sample had 0.18 normal deliveries, 0.16 cesarean sections and 0.22 abortions. Treatment payment with money out-of-pocket represented 95.1%.

The psychometric scale met with asymmetric results, with skewness above 1 for several item scales, as depicted in Chart 1. Scale items with skewness above the threshold of 1 were not retained for analysis. Overall, there were very few missing cases to observation.

Chart 1:

Scale properties and factor loads.

Four factors were regrouped during exploratory factor analysis (varimax rotation) and are displayed in Table 2.

Table 2:

Psychological burden exploratory factors

(*) Significantly different at 95% confidence interval (bootstrap)

Women with normal Pap smear presented lower scores of worries and concerns about their gynecological health (fear of test results, implications for fertility, fear of no cure for abnormal Pap smear or for cervical cancer, risks of infecting the partner or herself during sexual relations) than the group with CIN or GW. However, there was no significant difference in worries between the groups with CIN and GW. Scores of satisfaction with sexual life (feeling their bodies sexually attractive, satisfied with their sex life, relaxed after last gynecological exam and not disgusted with tests or exams) were also higher for women with normal Pap smear than for the other two groups. Again, differences in feelings about sexual life were not statistically different for women with CIN and GW. Feelings of anxiety and surprise (felt anxious or surprised with last exam or were concerned about GW) were higher for GW group than for the CIN and normal Pap smear group, in that order. All differences for the anxiety and surprise factor were statistically significant. Finally, there were no statistically significant differences in the factor of distress and shame (feeling ashamed, not in control of everyday life or of own health) among the groups.

Medical records analysis showed that each GW episode last in average 132 days (Table 1) and cost US$ 139 with private health plan and US$ 105 with BEMFAM's clinics subsidized tariffs. Cost figures per episode of GW, number of encounters (visits) and cost per procedure are depicted in Table 3. Regarding the medical procedures, in 95 episodes, the provider applied trichloroacetic acid as the only treatment. It was also associated with electrosurgery in one episode, with excision and imiquimod in six episodes each. Excision was the only treatment in four episodes. Other procedures described were consultations, Pap smear and colposcopy.

Table 3:

Costs of genital warts treatment at BEMFAM clinics.

DISCUSSION

The results of this research are consistent with findings from other studies showing a high psychological and economic burden of the disease. However, the average number of visits per episode is higher than reported elsewhere^8,9,10,11,12. According to the analysis of medical records, home treatment with imiquimod was also ­prescribed less often than reported by other studies^{7,8,9,10,11,11}. Most cases of GW were treated with provider-applied trichloroacetic acid that is cheaper than patient applied imiquimod, which is neither provided by public sector nor by private health plans. This probably explains the higher number of mean visits in our study.

Average costs per episode (US$ 105) might also appear low when compared to other countries but it is not when compared with an average monthly income for 91.2% of women enrolled in our study, that is under US$ 480. For this population, about one-week wages is necessary to provide for treatment, indirect and social costs not included.

Woodhall et al.¹³⁾ wrote that concerns over future recurrence and transmission to new partners could impair the quality of life of subjects after completion of an episode. In our study the results from the psychosocial scale suggest that the psychological burden of GW is at least as distressful and heavy as for the CIN diagnosis and much heavier than for the normal Pap smear group. All the negative feelings associated to GW may lead to sexual dysfunction, low self-steem, risky behavior and the need to use additional health services, increasing the GW related costs.

Those results prompt for practical implications and future research directions. Free access to public healthcare is a constitutional right for all Brazilian citizens. Nevertheless, there are 50.7 million users of private health plans in the country¹⁴, which means that almost 25% of the population is resorting to complementary or substitute sources of healthcare. Low income citizens constitute the majority of users of public primary health care services. Those who cannot afford a private health plan but prefer private assistance pay for low fee private health services, as the clients enrolled in this study did.

HPV is the most common viral reproductive tract infection. Primary prevention includes vaccination, sexuality education and condom promotion¹⁵. According to the International Federation of Gynecology and Obstetrics¹⁶, all randomized controlled clinical trials provide evidence of a safety profile for the two vaccines against HPV: the bivalent Cervarix (GlaxoSmithKline) and the quadrivalent Gardasil (Merck, Co., Inc.). In Brazil both vaccines are available in the private market and the Ministry of Health included the quadrivalent vaccine in the national vaccination programme since March 2014, for 11-13 year-old girls.

A national study about knowledge, attitudes and practice in the Brazilian population¹⁷, revealed that 26.8% of those who reported at least one sexual intercourse in the last twelve months had had sexual debut before the age of 15. This national study also revealed that only 24.6% of women had free access to condoms in the past year. A survey on adolescent sexual behavior in a public Brazilian high school showed that at the age of 14, 39% boys and 8,5% girls declared being sexually active¹⁸. Advocacy efforts for the scaling up of the government vaccination program in order to include boys and to expand the age range for the target population of the public vaccination campaigns should be considered. Promoting condom access and use and sexual education cannot be neglected. In addition, the use of imiquimod for treatment should be encouraged and provided through public sector channels. Besides, as the private health plans serve almost 25% of Brazilian population, their contribution to vaccine access should be encouraged.

Despite the relevant results of our study, which shows an excessive psychological and economic burden of GW among the clinics surveyed, there are some limitations to the study that open venues for new research. The main limitations of this study are the analysis of only part of the economic burden of the disease, from the payers' perspective and the fact that the sample is not representative of the country but of BEMFAM's clinics. A comprehensive cost analysis should also include social costs that emerge from the conflict between sexual partners and domestic violence¹⁹. Finally, the asymmetry in the scales prevented us from analyzing different psychological burdens of the disease due to the non-validation of some scale items in this study. The expansion of the sample for confirmatory factor analysis is also suggested.

CONCLUSION

Our study shows that the economic burden of GW is closely related to psychosocial burden of disease, and health service use after a GW episode should be considered in next studies. The study of indirect costs is also important, considering the mean number of visits per episode of GW. Additional studies about both the psychological and the economic burden of GW are needed and can help the advocacy efforts for a comprehensive primary prevention program in Brazil, with the participation of the private health sector.