Reducing Health Inequities in the Prevention of Cervical Cancer The Cervical Cancer Prevention and Care Cascade for Women Living with HIV
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KEY MESSAGES The availability of country-specific data on cervical cancer control among women living with HIV in countries with high HIV prevalence is essential for the development of targeted strategies and the achievement of the WHO global cervical cancer elimination targets.
The availability of high-quality data and indicators to measure the performance of cervical cancer control services offered to women living with HIV is crucial to strengthen prevention efforts, ensure early detection and provide appropriate care. The application of machine learning can help overcome the problem of lacking an integrated data system by combining the data sources for HIV care and cervical cancer prevention and care.
Intensifying community sensitisation on cervical cancer can address misinformation and alleviate concerns related to stigma, screening procedures, and results. This increased awareness and knowledge has the potential to increase the uptake of cervical cancer services.
CONTENT AT A GLANCE
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KEY FACTS
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INTRODUCTION
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PROJECT FEATURES
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RESULTS
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Current Situation
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The Cervical Cancer Preventation and Care Cascade
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Improving Data for Cervival Cancer in Zambia
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Cervival Cancer Care Barriers and Facilitators in Zambia
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IMPLICATIONS AND CONCLUSION
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AT A GLANCE Cervical cancer is the leading cause of cancer related deaths
Further information on the project and
among women in sub-Saharan Africa. Women living with the
related peer-reviewed publications can
human immunodeficiency virus (HIV) are six times more likely
be found on the website.
to develop cervical cancer than those who are HIV negative. To tackle this issue, the Cervical Cancer Prevention and Care Cascade (The CCPC Cascade) framework has been developed to enhance cervical cancer screening programmes for women living with HIV in sub-Saharan Africa. This project was realised between 2018 and 2023 in totally 17 countries in sub-Saharan Africa. In Zambia, a comprehensive analysis of the uptake of cervical cancer services was conducted in communities and health facilities. It identified both barriers and facilitators, and the crucial steps in tailoring strategies for optimal effectiveness. This real-world application allowed experts to identify gaps in cervical cancer care, providing valuable insights to enhance services. Tunisia Morocco Algeria
Libya
Egypt
Western Sahara Mauritania
Mali
Senegal Gambia GuineaGuinea Bissau Sierra Leone
B.Faso Benin Togo Ghana Liberia Côte d’Ivoire
Niger
Djibouti Nigeria Cameroon Uganda Kenya Democratic Rwanda Republic Burundi of Congo Tanzania
Congo
Namibia
Somalia
Malawi
Angola Zambia
Mozambique
Zimbabwe Botswana Lesotho
South Africa
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Ethiopia
Central African Republic
Gabon
Geographic scope of the project
Eritrea
Sudan
Chad
Madagascar
KEY FACTS Women with HIV are
85%
of women with cervical cancer and HIV live in sub-Saharan Africa.
Cervical cancer is the top cause of cancer deaths among women in sub-Saharan Africa.
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times more likely to develop cervical cancer.
Pre-cancerous lesions and cervical cancer can be cured if diagnosed and treated promptly.
Challenges in sub-Saharan Africa include limited access to cervical cancer prevention and treatment, and late diagnosis.
The majority of cervical cancers is caused by the human papillomavirus (HPV).
Comprehensive cervical cancer elimination measures include:
HPV
is mainly transmitted through sexual contact.
*Source: World Health Organization (WHO)
systematic implementation of evidencebased interventions for primary prevention (e.g. health education and vaccination secondary prevention against HPV), (screening and treatment of pre-cancerous lesions), and tertiary prevention (diagnosis and treatment of invasive cervical cancer).*
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INTRODUCTION Substantial disparities in cervical cancer-related incidence
grammes in family planning or antiretroviral therapy (ART) pro-
and mortality persist between high- and low-income coun-
grammes. In these settings, few studies report health out-
tries. In sub-Saharan Africa, cervical cancer continues to be
comes of all women who were screened for cervical cancer,
the leading cause of cancer-related death among women.
including those who were treated and those who were not. This
This overlaps with a high prevalence of HIV in the region. Wom-
highlights the lack of comprehensive patient and data man-
en living with HIV are at higher risk of an HPV infection, which
agement systems, which hinders the systematic implementa-
is responsible for most cervical cancers. While HPV infections
tion, monitoring and evaluation of cervical cancer screening
are also very common in the general population and most
programmes for women living with HIV.
women with healthy immune systems will clear these infections over time, women with compromised immune systems (such as women living with HIV) are far less likely to clear an HPV infection. This means that once they have been infected with HPV, women living with HIV are more likely to develop pre-invasive lesions, which, if left untreated, can progress to invasive, life-threatening cervical cancer. Although the introduction of antiretroviral treatment has reduced the risk of some cancers in those living with HIV, the incidence of cervical cancer has not yet decreased. Prevention strategies remain the most effective intervention for reducing cervical cancer-related morbidity and mortality.
WHO Global Strategy to eliminate cervical cancer In 2020, the World Health Organization (WHO) launched the Global strategy to accelerate the elimination of cervical cancer as a public health problem. It proposed the “90-70-90” targets to be achieved by 2030: 90% coverage of HPV vaccination in girls, 70% coverage of cervical cancer screening, and 90% treatment and management of both pre-cancerous lesions and invasive cancer cases. To achieve the WHO’s goal to eliminate cervical cancer, countries in sub-Saharan Africa must scale up access to primary,
Importance of prevention and early treatment
secondary, and tertiary prevention measures, especially for
Differences in availability and quality of prevention strategies
toring and evaluation tools, which can help to increase pro-
are likely to contribute to disparities in cervical cancer mortal-
gramme performance and ultimately reduce cervical cancer
ity. Although vaccination against HPV programmes have
morbidity and mortality. Such tools can contribute to achiev-
gained momentum in sub-Saharan Africa, they are not yet
ing the WHO threshold of cervical cancer incidence rate below
widely implemented and their positive effects will not emerge
4 per 100,000 women per year.
girls and women living with HIV. To improve effectiveness of cervical screening programmes, it is critical to develop moni-
for decades. Screening programmes for early detection and treatment of pre-cancerous cervical lesions remain funda-
The ultimate aim of this project was to contribute to reducing
mental to the prevention of cervical cancer in this region.
inequities in morbidity and mortality from cervical cancer by de-
Screening programmes in high-income countries have effec-
veloping a Cervical Cancer Prevention and Care Cascade frame-
tively reduced cervical cancer incidence and mortality by up
work and monitoring tool for cervical screening programmes in
to 80%. However, these models are far from being replicable
sub-Saharan Africa offered to women living with HIV.
in low- and middle-income settings where financial and human resources are scarce amidst competing health priorities. Despite the challenges, many countries in sub-Saharan Africa have initiated the integration of cervical cancer screening pro-
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PROJECT FEATURES The Cervical Cancer Prevention and Care Cascade was developed within the Advancing Cervical Cancer Screening in HIV-positive women (ACCHIVe) project. The project was led by the Swiss Tropical and Public Health Institute (Swiss TPH) in a consortium with the A peer educator is conducting cervical cancer sensitisation in the Kanyama community in Lusaka, Zambia.
Centre for Infectious Disease Research in Zambia (CIDRZ) and the Ministry of Health of Zambia. It was implemented between 2018 and 2023. Other partners included the International epidemiology Databases to Evaluate AIDS (IeDEA) regional research programmes in Southern Africa, Central Africa, East Africa and West Africa as well as the International Agency for Research on Cancer (IARC). The project was funded through the Swiss Programme for Research on Global Issues for Development (r4d programme), a joint programme of the Swiss National Science Foundation (SNSF) and the Swiss Agency for Development and Cooperation (SDC), and by the National Cancer Institute (NCI), USA.
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RESULTS Current Situation of Cervical Cancer Screening among Women Living with HIV in Sub-Saharan Africa Policy landscape To understand the existing challenges and gaps, the current policy landscape for cervical cancer prevention and control in sub-Saharan African countries with the highest HIV burden (prevalence ≥10% in 2018) was assessed. The policies from nine countries have been analysed according to aspects related to cervical cancer prevention, diagnosis and treatment, as which could be potential barriers to women seeking care.
Prevention and treatment of cervical cancer in health facilities
Results of this assessment have shown that all nine countries
To assess the implementation of cervical cancer prevention
had policies on cervical cancer prevention and control either
services at facility and patient level, a survey was conducted
as a standalone document (77.8%), or as part of a cancer or
in 30 sites across 14 countries. The survey found that screen-
non-communicable diseases policy (22.2%) or both (66.7%).
ing services were available as routine care on- or off-site in
Specific recommendations for cervical cancer prevention in
two thirds of the HIV clinics (74%), using mainly visual inspec-
women living with HIV were often lacking in these countries.
tion with acetic acid (83%). HPV testing was used in few sites
There were largely homogeneous recommendations for most
(40%) in all regions except Central Africa. Referral for pre-cancer
aspects of primary prevention (sex education, condom use,
(40%) and invasive cancer (70%) treatment was common.
warnings against tobacco use, school-based HPV vaccination
Women paid a fee for these services in about half of the sites
strategy) but recommendations on voluntary male circumci-
(53%). Among sites doing laboratory testing for screening and
sion and vaccination dose schedules for girls living with HIV
diagnosis, the majority had results turnaround times varying
were rarely reported. Age at screening commencement and
between 1 to 4 weeks (65%). About half of the sites received
screening intervals for women living with HIV varied across
funding for cervical cancer prevention from the government
countries. The most common recommended screening meth-
(43%) and NGOs (43%). Almost all sites (90%) used electronic
ods were visual inspection with acetic acid (88.9%) and pap
systems for data collection, and half of them (50%) collected
smear (77.8%), and treatment methods included cryotherapy
cervical cancer data, including WHO global indicators for cer-
(100%) and loop electrosurgical procedure (88.9%).
vical cancer monitoring. About a third of the sites (37%) spe-
well as monitoring mechanisms and the cost of services,
cifically linked the HIV status to existing indicators. Routinely Considerations for cervical cancer treatment in women living
collected data to populate the WHO global cervical cancer
with HIV, indicators disaggregated by HIV status for monitoring
elimination targets for girls and women livening with HIV was
cervical cancer programmes and service costs for women
available only in few sites in the countries that were analysed.
were also rarely reported. Due to the increased susceptibility of women living with HIV to developing cervical cancer and recurrent lesions, this data is particularly important to inform governments on existing gaps to better define and tailor prevention strategies to meet the needs for this population and global targets for cervical cancer elimination.
Estimates of screening and pre-cancer treatment rate for women living with HIV Screening Southern Africa
Western Africa
Target
70% 45.7%
69.2%
4.3%
12.7%
Hospital 1
Hospital 2
Hospital 3
Hospital 4
Treatment Southern Africa
Western Africa
Target
90%
46.8%
13.8%
50.0%
76.6%
Hospital 1
Hospital 2
Hospital 3
Hospital 4
Selected examples from data based on a survey conducted in 2020 in different hospitals in sub-Saharan Africa
There is often a wide gap between the WHO target of 70% of women screened and 90% of women treated for cervical pre-cancer and actual screening and treatment rates in sub-Saharan Africa. 9
The Cervical Cancer Prevention and Care Cascade Indicators
To support existing cervical cancer control and monitoring ef-
These indicators are tailored to HIV clinics that offer on- or
forts to achieve the WHO’s 90-70-90 targets, a Cervical Cancer
off-site cervical cancer prevention and care services. In col-
Prevention and Care Cascade was developed, tailored to girls
laboration with the IeDEA consortium, the aim is to implement
and women living with HIV in sub-Saharan Africa.
the data elements needed to inform the indicators within the IeDEA Data Exchange Standard. This will help ART clinics in
This Cascade is an innovative framework to monitor and scale-
sub-Saharan Africa that are collaborating with the IeDEA to
up cervical screening services offered at ART clinics in sub-
collect data needed to inform the indicators and to manage
Saharan Africa. It describes the steps along the cervical cancer
cervical cancer control services. The indicators can be imple-
prevention and care continuum for women living with HIV at
mented gradually and adapted to context in other countries.
facility level.
This will facilitate standardised data collection and reporting and inform decision-making processes to improve or scale-up
Key indicators to inform decision-makers
cervical cancer screening and care services for women living with HIV in sub-Saharan Africa.
Indicators were developed through a Delphi consensus process with 72 stakeholders from 15 sub-Saharan African coun-
Ultimately, the aim is to strengthen capacities for cervical
tries that are part of the International epidemiology Databases
cancer data analysis, interpretation, and dissemination, and
to Evaluate AIDS (IeDEA) consortium. As a result, stakeholders
to support existing efforts to reach the goals of the WHO Cer-
reached consensus on 5 core and 12 optional indicators for
vical Cancer Elimination Strategy.
routine patient-level data collection at ART clinics that offer cervical cancer prevention and care services to women living with HIV. These indicators measure the performance of cervical cancer prevention across the Cascade. To inform these indicators, a minimum set of data elements were defined that need to be collected and reported. These indicators should support programme and data managers, health professionals and other stakeholders to better measure and understand the performance of each step along the cervical cancer prevention and care continuum for girls and women living with HIV and lead them towards evidence-based decision-making.
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The cervical cancer control continuum at facility level PRIMARY PREVENTION
Domain title and description
SECONDARY PREVENTION
TERTIARY PREVENTION
IMPACT & LINKAGE
HPV prevention
Screening
Triage
Treatment of pre-cancerous lesions
Cervical cancer diagnosis and care
Programme impact & linkage to services
HPV vaccination and HPV incidence
Screening efforts for early detection a nd diagnosis of pre-cancerous lesions
All steps between primary screening and treatment
Treatment efforts of pre-cancerous lesions
Cervical cancer diagnosis and care efforts
Long-term impact and linkage of cervical cancer prevention and care services
Cervical screening rate Number of women screened Core indicators
Treatment rate of pre-cancerous lesions
Screening test positivity rate Screening test positivity rate for first time screened women
Optional indicators
1st ranked indicators
HPV vaccination rate High-risk HPV incidence rate
HPV vaccination rate
Received screening test results Re-screened within target interval
Number of women screened
Triage examination positivity rate Received triage examination rate
Pre-cancerous lesions post-treatment follow-up rate
Triage examination provision rate Received triage examination rate
Treatment rate of pre-cancerous lesions
Suspected cervical cancer cases rate Confirmed cervical cancer
Suspected cervical cancer cases rate
Cervical cancer incidence rate HIV testing and counselling service provision
Cervical cancer incidence rate
The cervical cancer control continuum at facility level: the overview of domains, core, optional and first ranked indicators per each domain that reached consensus. Source: Davidović M et al, on behalf of IeDEA. Facility-based indicators to manage and scale up cervical cancer prevention and care services for women living with HIV in sub-Saharan Africa: three-round online Delphi consensus method. JAIDS.
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Improving Data for Cervical Cancer Care in Zambia One of the challenges facing cervical cancer care in Zambia is the lack of interoperable data systems across health facility service areas. Clinical services have historically been provisioned in silos, established with data systems that are without common unique identifiers for patients. Cervical cancer related data is primarily collected in tools parallel to the nationally adopted electronic health record system, SmartCare. This presents a barrier to ascertaining the uptake of cervical cancer screening services among women living with HIV.
Using machine learning for data analysis To overcome this problem, a machine learning technique was used to link patient records belonging to the same patient across cervical cancer databases and SmartCare. A nurse conducting a visual inspection with acetic acid at a government health facility in Lusaka, Zambia.
To conduct the linkage, the following common variables were used: first name, middle name, maiden name, last name, age or birth year, date of cervical cancer screening. Upon completion of the linkage, all patient data was anonymised. The study was conducted at the Kanyama First Level Hospital in Lusaka, Zambia, using data of patients starting ART between 2010 to 2020.
In the absence of integrated and interoperable data systems, data linkages offer a solution to create service cascades, useful in identifying gaps in service delivery. The use of machine learning techniques like in this instance, offers an efficient solution with minimal resource requirements. This makes it feasible to integrate into existing information systems, data warehouses, and routine data management process for data consolidation.
Low screening coverage The results showed that 10% of patients in the priority age group of 35 to 49 years old had been screened. One limitation of the linkage is the few variables used, which may lead to under-estimation of this screening uptake. Notwithstanding, the coverage is concerning and threatens the attainment of the WHO target, which aims to have 70% women screened by 2030.
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To reach the WHO targets requires strengthening electronic data systems, improving data completeness and quality, and having systems that have inherent interoperability functions.
Cervical Cancer Care Barriers and Facilitators in Zambia In 2006, Zambia established the Cervical Cancer Prevention
The results show that interventions are needed at different
Programme (CCPPZ) in Lusaka, which was subsequently ex-
levels. For instance, free histopathology services at the gov-
tended to the rest of the country. However, uptake of services
ernment laboratory in the Eastern province and strengthening
by women living with HIV in Zambia remains low. To under-
the laboratory courier system can provide more efficient lab-
stand why, the barriers and facilitators to cervical cancer ser-
oratory diagnostic services. Training more medical doctors
vice uptake in Zambia were investigated. Interviews and sur-
and other lower-level cadres such as clinical officers and
veys were conducted with women in communities and health
medical licentiates to conduct biopsies, perform ablative and
facilities, including women accessing ART services, women
excision treatment, and simple hysterectomies can reduce
diagnosed with pre-cancerous cervical lesions, and with
wait time and delays in client’s receiving further diagnosis and
health care workers providing ART and cervical cancer servic-
treatment. Establishing additional cervical cancer screening
es in the three districts of Lusaka, Chipata and Lundazi.
sites and training more nurses can reduce queues. Though cervical cancer sensitisations are conducted daily at cervical
Fear of stigma and screening results
cancer and ART clinics, the findings highlight the need to intensify community sensitisations on basic knowledge of cer-
Results showed that while generally knowledgeable, women
vical cancer including signs and symptoms while addressing
had low awareness of cervical cancer services and there was
specific fears and misinformation.
misinformation regarding causation and screening procedures particularly among women who had never been
As a first step, the project conducted street drama using a
screened. Fear of stigma, procedures, and results were prom-
drama troupe trained on cervical cancer, which incorporated
inent barriers across all categories of women. Women with
key findings and recommendations from the qualitative study.
lesions particularly from the Eastern districts in Lundazi and
Secondly, the project created a radio drama show that was
Chipata were most affected by structural and health system
scripted based on the key themes from the transcripts. Addi-
barriers. Structural barriers include the cost of transport to
tionally, the project hosted dissemination meetings with key
screening sites and the cost of sample testing. Health system
cervical cancer stakeholders from Chipata and Lundazi Pro-
barriers include long queues at the screening clinics, long wait
vincial and District Offices where they shared study findings
time to see a doctor, and the lack of histopathology services
and discussed a roadmap to implement recommendations.
at the laboratory in the Eastern province. This led to delayed or lost test results, affecting women’s access to treatment.
From individual to health systems factors: barriers and facilitators Individual-level facilitators for screening uptake were perceived benefits of knowing one’s cervical cancer status and experiencing signs and symptoms of cervical cancer. Social factors included encouragement from friends, family, husbands, and peers while health system factors included trust in the healthcare system, positive interaction with healthcare workers, and sensitisation. Financial support in the form of transport reimbursement to access services at health facilities was the most prominent structural facilitator.
Health education to address knowledge gaps on cervical cancer prevention and screening in Zambia.
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Use of Cervical Cancer Services in Zambia: Barriers and Facilitators
INDIVIDUAL / Perceived benefit of knowing status Participant, Lusaka “I was worried with the stomach pains that I had, at least my worries have been addressed and I found out that I’m free”
SOCIAL / Encouragement from husband Participant, Lusaka “I was scared to go for cervical cancer screening but my husband was with me all the way”
INDIVIDUAL / Misinformation about screening procedures Participant, Lusaka “I used to hear stories that the cervix is moved in a different position, and you will not give birth”
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HEALTH SYSTEM / Trust in health system Participant, Lundazi
STRUCTURAL / Transport
“It is at the hospital where there is help. Yes that is where there are medicines for cancer”
reimbursement Participant, Lusaka “They gave me money, they told me that it was my transport reimbursement that I used to get to the clinic”
HEALTH SYSTEM / Long queues Participant, Lundazi “At the screening center, there is a queue, maybe the whole day you are just there”
STRUCTURAL / Financial constraints Participant, Lundazi SOCIAL / Fear of stigma and results Participant, Chipata
“The only problem is financial because like what I have gone through, it is very expensive”
“Some are afraid, others, maybe its stigma that if I go there, I will be found with HIV or cancer itself, I’ll die early and leave my children behind”
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IMPLICATIONS AND CONCLUSION This project contributes to understanding the state of cervical cancer prevention and care in contexts with a high HIV burden, which is essential for scaling up programmes and catalysing the elimination process. As countries in sub-Saharan Africa revise their cervical cancer prevention policies and adapt implementation practices to better meet the needs of girls and women living with HIV, monitoring strategies should be strengthened. The Cervical Cancer Prevention and Care Cascade with indicators tailored to girls and women living with HIV in sub-Saharan Africa could be considered for programme monitoring permitting for comparability across and within countries as we track progress towards the 2030 WHO targets on cervical cancer elimination. In addition, understanding the barriers and facilitators to cervical cancer service uptake in Zambia helps to address identified infrastructure, capacity building and community awareness issues to improve cervical cancer prevention and care, and ultimately contribute to the WHO strategy towards cervical cancer elimination.
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Authors
Concept and edits
Maša Davidović
Layla Hasler
Mwansa Lumpa
Photos
Serra Asangbeh
Centre for Infectious Disease
Anjali Sharma
Research in Zambia, Olivier
Albert Manasyan
Brandenberg, Andrey Popo and
Misinzo Moono
Riccardo Niels Mayer - Adobe Stock
Mwanahamuntu Mulindi
Cover picture
Samuel Bosomprah
Olivier Brandenberg
Herbert Kapesa
Design
Chanda Mwamba
BÜRO SPRENG
Kabwe Mwamba
Grafik und Kommunikation | Basel
Mwati Chipungu
Copyright
Julia Bohlius
Swiss TPH, 2023
Consortium partners
Funders
International Epidemiology Databases to Evaluate AIDS
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