Implementation of 'see-and-treat' cervical cancer prevention services linked to HIV care in Zambia

University Teaching Hospital, Ministry of Health, Lusaka, Zambia.
AIDS (London, England) (Impact Factor: 5.55). 04/2009; 23(6):N1-5. DOI: 10.1097/QAD.0b013e3283236e11
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Available from: Sten H Vermund
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    • "Qualitative studies as to the acceptability of VIA screening as well as basic gynaecologic health knowledge are currently underway in Zambézia Province to quantitate this gap. In countries such as Zambia, relatively low cost digital cervicography has been introduced with success into VIA screening programs [27]. This technology projects an image of the cervix to a bedside monitor or television screen and allows for immediate education of patients about examination results. "
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    ABSTRACT: In order to maximize the benefits of HIV care and treatment investments in sub-Saharan Africa, programs can broaden to target other diseases amenable to screening and efficient management. We nested cervical cancer screening into family planning clinics at select sites also receiving PEPFAR support for antiretroviral therapy (ART) rollout. This was done using visual inspection with acetic acid (VIA) by maternal child health nurses. We report on achievements and obstacles in the first year of the program in rural Mozambique. VIA was taught to clinic nurses and hospital physicians, with a regular clinical feedback loop for quality evaluation and retraining. Cryotherapy using carbon dioxide as the refrigerant was provided at clinics; loop electrosurgical excision procedure (LEEP) and surgery were provided at the provincial hospital for serious cases. No pathology services were available. Nurses screened 4651 women using VIA in Zambézia Province in year one of the program, more than double the Ministry of Health service target. VIA was judged positive for squamous intraepithelial lesions in 8% (n=380) of the women (9% if age ≥ 30 years (n=3154) and 7% if age <30 years (n=1497); p=0.02). Of the 380 VIA-positive women, 4% (n=16) had lesions (0.3% of 4651 total screened) requiring referral to Quelimane Provincial Hospital. Fourteen (88%) of these 16 women were seen at the hospital, but records were inadequate to judge outcomes. Of women screened, 2714 (58%) either had knowledge of their HIV status prior to VIA or were subsequently sent for HIV testing, of which 583 (21%) were HIV positive. Screening and clinical services were successfully provided on a large scale for the first time ever in these rural clinics. However, health manpower shortages, equipment problems, poor paper record systems and a limited ability to follow-up patients inhibited the quality of the cervical cancer screening services. Using prior HIV investments, chronic disease screening and management for cervical cancer is feasible even in severely resource-constrained rural Africa.
    Full-text · Article · Jun 2012 · Journal of the International AIDS Society
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    • "Although having a lower sensitivity and specificity than HPV tests, they have shown an equal validity compared to cytology in HIV-negative as well as HIV-positive women in resource-limited settings [13,14]. A successful experience with the implementation of such a cervical screening procedure targeting HIV-infected women has been recently reported in Zambia but experiences from other parts of sub-Saharan Africa are limited [15,16]. We therefore sought to compare some of the critical operational and clinical outcomes of a cervical cancer screening based on VI methods among HIV-negative and HIV-positive women in Abidjan, Côte d'Ivoire. "
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    ABSTRACT: Cervical cancer screening is not yet standard of care of women attending HIV care clinics in Africa and presents operational challenges that need to be addressed. A cervical cancer screening program based on visual inspection methods was conducted in clinics providing antiretroviral treatment (ART) in Abidjan, Côte d'Ivoire. An itinerant team of midwives was in charge of proposing cervical cancer screening to all HIV-positive women enrolled in ART clinics as well as to HIV-negative women who were attending the Abidjan national blood donor clinic. Positively screened women were systematically referred to a colposcopic examination. A phone-based tracking procedure was implemented to reach positively screened women who did not attend the medical consultation. The association between HIV status and cervical cancer screening outcomes was estimated using a multivariate logistic model. The frequency of positive visual inspection was 9.0% (95% CI 8.0-10.0) in the 2,998 HIV-positive women and 3.9% (95% CI 2.7-5.1) in the 1,047 HIV-negative ones (p < 10-4). In multivariate analysis, HIV infection was associated with a higher risk of positive visual inspection [OR = 2.28 (95% CI 1.61-3.23)] as well as more extensive lesions involving the endocervical canal [OR = 2.42 (95% CI 1.15-5.08)]. The use of a phone-based tracking procedure enabled a significant reduction of women not attending medical consultation after initial positive screening from 36.5% to 19.8% (p < 10-4). The higher frequency of positive visual inspection among HIV-positive women supports the need to extend cervical cancer screening program to all HIV clinics in West Africa. Women loss to follow-up after being positively screened is a major concern in cervical screening programs but yet, partly amenable to a phone tracking procedure.
    Full-text · Article · Mar 2012 · BMC Public Health
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    • "HIV prevalence among women 15–49 years is extremely high, at 16.1% nationally and 23.1% in the capital of Lusaka (Joint United Nations Programme on HIV/AIDS, 2010). In response to this crisis, the Zambian Ministry of Health, in collaboration with the University of Alabama at Birmingham-Center for Infectious Disease Research in Zambia, launched a cervical cancer prevention program in 2006 that introduced VIA-based " see and treat " prevention services within twelve existing primary health care facilities in Lusaka and linked them with concurrent HIV treatment and prevention services (Mwanahamuntu et al., 2009). As of 2011, a total of 58,000 women had been evaluated using VIA see and treat methods in clinics where cervical screening was offered (Mwanahamuntu et al., 2011). "
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    ABSTRACT: Invasive cervical cancer is the second most common cancer among women worldwide, with approximately 85% of the disease burden occurring in developing countries. To date, there have been few systematic efforts to document African women's conceptualization of cervical cancer after participation in a visual inspection with acetic acid (VIA)-based "see and treat" cervical cancer prevention program. In this study, conducted between September, 2009-July, 2010, focus groups and in-depth interviews were conducted with 60 women who had recently undergone cervical cancer screening at a government-operated primary health care clinic in Lusaka, Zambia. Interviewers elicited participants' causal representations of cervical cancer, associated physical signs and symptoms, perceived physical and psychological effects, and social norms regarding the disease. The lay model of illness causation portrayed by participants after recent exposure to program promotion messages departed in several ways from causal models described in other parts of the world. However, causal conceptualizations included both lay and biomedical elements, suggesting a possible shift from a purely traditional causal model to one that incorporates both traditional concepts and recently promoted biomedical concepts. Most, but not all, women still equated cervical cancer with death, and perceived it to be a highly stigmatized disease in Zambia because of its anatomic location, dire natural course, connections to socially-condemned behaviors, and association with HIV/AIDS. No substantive differences of disease conceptualization existed according to HIV serostatus, though HIV positive women acknowledged that their immune status makes them more aware of their health and more likely to seek medical attention. Further attention should be dedicated to the processes by which women incorporate new knowledge into their representations of cervical cancer.
    Full-text · Article · Mar 2012 · Social Science [?] Medicine
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