Abstract
BackgroundVery few efforts have been undertaken to scale-up low-cost approaches to cervical cancer prevention in low-resource countries.MethodsIn a public sector cervical cancer prevention program in Zambia, nurses provided visual-inspection with acetic acid (VIA) and cryotherapy in clinics co-housed with HIV/AIDS programs, and referred women with complex lesions for histopathologic evaluation. Low-cost technological adaptations were deployed for improving VIA detection, facilitating expert physician opinion, and ensuring quality assurance. Key process and outcome indicators were derived by analyzing electronic medical records to evaluate program expansion efforts.FindingsBetween 2006-2013, screening services were expanded from 2 to 12 clinics in Lusaka, the most-populous province in Zambia, through which 102,942 women were screened. The majority (71.7%) were in the target age-range of 25–49 years; 28% were HIV-positive. Out of 101,867 with evaluable data, 20,419 (20%) were VIA positive, of whom 11,508 (56.4%) were treated with cryotherapy, and 8,911 (43.6%) were referred for histopathologic evaluation. Most women (87%, 86,301 of 98,961 evaluable) received same-day services (including 5% undergoing same-visit cryotherapy and 82% screening VIA-negative). The proportion of women with cervical intraepithelial neoplasia grade 2 and worse (CIN2+) among those referred for histopathologic evaluation was 44.1% (1,735/3,938 with histopathology results). Detection rates for CIN2+ and invasive cervical cancer were 17 and 7 per 1,000 women screened, respectively. Women with HIV were more likely to screen positive, to be referred for histopathologic evaluation, and to have cervical precancer and cancer than HIV-negative women.InterpretationWe creatively disrupted the 'no screening' status quo prevailing in Zambia and addressed the heavy burden of cervical disease among previously unscreened women by establishing and scaling-up public-sector screening and treatment services at a population level. Key determinants for successful expansion included leveraging HIV/AIDS program investments, and context-specific information technology applications for quality assurance and filling human resource gaps.
Highlights
A high incidence of invasive cervical cancer (ICC) is observed in low- and middle-income countries (LMICs) where high quality prevention services are unavailable or inaccessible, awareness about cancer risk is low, healthcare infrastructures are fragmented and dysfunctional, lack of appropriate public health policies and competing priorities detract from making substantive improvements to the status quo [1,2,3,4]
In a public sector cervical cancer prevention program in Zambia, nurses provided visual-inspection with acetic acid (VIA) and cryotherapy in clinics co-housed with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) programs, and referred women with complex lesions for histopathologic evaluation
Local leadership was provided by the Zambian Ministry of Health while program operations were managed by the Center for Infectious Disease Research in Zambia (CIDRZ), a Zambian-US non-profit organization, in collaboration with the Department of Obstetrics and Gynecology of the University of Zambia in Zambia
Summary
A high incidence of invasive cervical cancer (ICC) is observed in low- and middle-income countries (LMICs) where high quality prevention services are unavailable or inaccessible, awareness about cancer risk is low, healthcare infrastructures are fragmented and dysfunctional, lack of appropriate public health policies and competing priorities detract from making substantive improvements to the status quo [1,2,3,4]. While cytology-based screening has been the cornerstone for secondary prevention of cervical cancer in most high-income countries, it remains unavailable or difficult to implement in most resource-constrained settings. Human papillomavirus (HPV)-based screening is more sensitive and effective than either VIA or cytology [11,12,13], low-cost and singlevisit point-of-care HPV screening assays are not yet widely available, and HPV-positive results invariably need triage by visual screening methods in LMICs [14,15], underscoring the importance of VIA-based cervical cancer screening platforms. Very few efforts have been undertaken to scale-up low-cost approaches to cervical cancer prevention in low-resource countries
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