Implementation and feasibility of an adapted two-stage visual inspection with acetic acid/cryotherapy-based cervical cancer screening programme for HIV-infected women in Addis Ababa, Ethiopia.

Abstract

In Ethiopia, cervical cancer screening coverage is among the lowest in the world (0.6%). While cytological screening methods rely on robust infrastructure hindering large-scale implementation, visual inspection with acetic acid (VIA) plus cryotherapy has shown promising results, specifically among women with HIV infection. Worldwide Orphan Foundation's (WWO) HIV care centre serves more than 1000 women in Addis Ababa, Ethiopia. No nation-wide screening programme existed in Ethiopia or at WWO clinic. In 2014, as a quality improvement project, we performed baseline needs assessment and feasibility analysis for screening strategy through interviews (n = 12) with key informants, providers, community health workers (CHWs), and officials at non-profit organisations and government and private hospitals, and explored patients’ (n = 61) attitudes and experience regarding cervical screening. Pap testing was offered in some hospitals in Addis Ababa but inconsistent availability, poor accessibility, lack of reproducibility and high cost were major challenges. The only ongoing screening programme with consistent supply and funding was through the Pathfinder based at two public hospitals including Zewditu Memorial (ZMH) supporting single-visit VIA plus cryotherapy. Multi-level barriers to screening described by patients, providers and stakeholders included lack of knowledge regarding cancer screening; patients’ negative perception towards screening results and its implications, and unfamiliarity with screening process; cost and time constraints associated with screening; cost of on-site cryotherapy at the WWO clinic; and systems-level barriers to accessing cervical cancer screening in health facilities. Providers were largely unaware of screening recommendations for asymptomatic patients. We scrutinised various possible options and, considering challenges and opportunities, implemented a VIA protocol based on the 2013 WHO guidelines and forged a working relationship with ZMH for cryotherapy. The project included a comprehensive education programme for staff and patients, didactic and practical VIA training for providers, a patient navigator-based referral system for cryotherapy or subsequent procedures for VIA-positive cases, and a quality assurance and continuing education strategy. Extensive research using model curricula and inputs from CHWs to incorporate community values informed the development of curriculum (World Health Organization 2006; Paul et al. 2013), which included peer-to-peer learning and mentoring. Medical providers and nurses (n = 8) received twice-weekly didactic lectures on pelvic anatomy and exam; cervical cancer epidemiology, risk factors and symptoms; performing, interpreting and managing VIA results through reviewing over 100 training VIA digital images; and patient's counselling and education. During the practical training (4 weeks), each provider performed more than 20 supervised VIA exams. VIA images were recorded digitally after consent, de-identified and logged into a database for team review, consensus building and reproducibility. We provided patient education fact sheets (World Health Organization 2006) and created an illustrated guidebook for counselling. We established a cryotherapy referral system to ZMH. A nurse navigator coordinated referrals, reminded patients of appointments, obtained results and ensured appropriate follow-up. Women's mean age (n = 61) was 34 (average of 1.6 children, 60% primary education or lower, 49% married). The average age at first sexual encounter was 17, 57% had history of STIs, and average lifetime partner was 2.5. Eight women were VIA-positive and received cryotherapy; three had VIA-indeterminate and received cervical cytology and follow-up as per our algorithm. An overwhelming number of women welcomed screening and reported satisfaction with processes, especially cancer education and navigation components. Despite multiple social, financial, logistical and health system barriers, a two-step VIA screening was feasible and could inform future small-scale efforts in East Africa, where resources are scarce and national programmes are unavailable. A decentralisation of screening away from the over-burdened referral hospitals to smaller clinics where patients have rapports with providers may improve screening coverage in resource-poor settings. JP and RA conceived the project; designed the evaluation and intervention; analysed data; and drafted and critically revised the manuscript for intellectual content. Both authors read and approved the final manuscript. RA is the guarantor of the paper. The authors thank Drs Jane Aronson and Sofia Mengistu, as well as staff at WWO in New York City and Addis Ababa, for their invaluable contribution to this project.