Overcoming challenges in developing a sustainable cervical cancer screening program in Limpopo Province,

South Africa: Training of Health Workers and Sex Workers

8th SA AIDS Conference ICC Durban

Date: 13 June 2017

Presenter: Christine du Preez

MISSION

To provide quality, all-inclusive health care to everyone

in the Kruger2Canyons Biosphere Region.

VISION

A culture of caring that empowers all.

MISSION & VISION

• Hlokomela is situated in the Kruger to Canyons Area, covering commercial and game

farms in Hoedspruit, Maruleng sub-district of Mopani District in Limpopo.

• Hoedspruit is on the boundary of Mpumalanga and Limpopo. Currently operating on 74

farms;

• Hlokomela has 94 Nompilos. All receiving stipends from the Department of Health under

HBC and HTA projects. 26 Sex workers as peer educators funded by NACOSA.

• Estimated population on farms is 15 000 labour migrants and seasonal farm workers.

• Established wellness clinics provide health information, condoms, health care services and

referrals, including HTS and ART, to workers and their families.

• Mobile HIV Testing Services (HTS).

• Cervical Cancer Prevention Programme through which nurses are trained to detect early

signs of the disease and then treating malignant cells with cryotherapy.

• Breast Cancer Prevention Programme that uses ultrasound to screen for breast cancer.

PROJECT OVERVIEW

• A major challenge to successful cervical cancer screening is lack of knowledge

about the disease. To prepare for integrating screening into current HIV care, a

teaching program was designed. The objective was to close the gaps in

knowledge for HIV advocates and deliver training in “see and treat” skills to local

providers

• Poor knowledge among both health workers, HIV positive patients, key

population (women and sex workers) with regards to cervical cancer risk factors

and screening.

• Barriers to screening also include long delays in addressing abnormal results,

difficulty in referrals, and the migrant nature of the key population.

BACKGROUND TO OVERCOME THE CHALLENGESIN CERVICAL CANCER SCREENING

• Institutional review board approval was obtained from the United States and South Africa. Workshops were hosted at Hlokomela HIV clinic.

• 5 nurses underwent a 4-day workshop in cervical cancer screening using pre/post- knowledge study design.

• 13 sex worker peer educators who function as lay health workers for HIV awareness participated in a one-day cervical cancer awareness program.

• 4 modules were presented with additional visual aids and model demonstrations were used.

• Nurses were evaluated one year after initial training to assess quality and performance of cervical screening technique.

• Training completed with the Division of Global Women’s Health from the Icahn School of Medicine at Mount Sinai in New York, United States.

DESCRIPTION

• Conduct outreaches on site (taverns, shebeens, truck stops)

• Offer HTS

• Provide PrEP (Oral pre- Exposure Prophylaxis) and ARVs

• Facilitate Creative Spaces

• Provide PHC screening of STIs and non-communicable diseases (hypertension,

diabetes etc.)

• Screen for cervical and breast cancer

• Education about human rights

• Support groups

• Distribution of safe sex commodities (male and female condoms, lubricants)

ACTIVITIES IN SEX WORK PROGRAMME

• Apply acetic acid to cervix, wait 1 minute

• Check the results (normal negative / aceto white positive)

VIA (VISUAL INSPECTION WITH ACETIC ACID)

VIA NEGATIVE

VIA POSITIVE

CRYOTHERAPY

WOMEN’S HEALTH STATISTICS

Women’s Health TOTAL

Papsmears done (1 January 2015 to 31 May 2017) 927

Papsmear done using VIA (1 May 2015 to 31 May 2017) 430

Positive VIA (Visual Inspection with Acetic Acid ) 60

Negative VIA (Visual Inspection with Acetic Acid ) 370

Cryotherapy treatments done 60

Breast ultrasound scan (19 April 2017 to 31 May 2017) 68

Breast abnormalities found and referred to hospital 01

• Health education about cervical cancer for sex workers, female patients and the larger

community is very important.

• None of the 13 sex work peer educators had previous knowledge of cervical cancer and all

reported acquiring new knowledge that would benefit their community.

• Sex work peer educators reached out to co-workers and educated 4800 additional sex

workers to participate in the screening program.

• 5 nurses were successfully trained in “see and treat” to a level of competence in which they

could practice independently.

• Nurses were supervised in the care of 80 patients each on average, with adequate skills

obtained after 50 examinations supervised by the doctor.

• Evaluation by trainers after one year showed screening was being performed correctly by the

trained nurses.

LESSONS LEARNT

CONCLUSIONS

• Successful education of sex work peer educators. Increase in cervical cancer

awareness in community.

• Successful clinical training of 5 nurses to be primary providers to ensure a

sustainable screening program.

• Education and training of local HIV peer educators can increase cervical

cancer awareness in a high risk population.

• Training of local nurses in performing “see-and-treat” can result in successful

integration of screening into existing clinic services for more sustainable care.

1. Women. Current HIV/AIDS reports. 2011;8(3):192-199.

2. Hlokomela - HTT | Empowering the People. http://www.htt.org.za/. Accessed

November 12, 2014.

3. WHO guidelines for screening and treatment of precancerous lesions for cervical

cancer prevention: World Health Organization; 2013.

4. WHO guidelines: Use of cryotherapy for cervical intraepithelial neoplasia: World

Health Organization; 2011.

REFERENCES

• Ethical approval in South Africa from the University of Pretoria (protocol number 51/2015) from the Faculty of Health Sciences Research Ethics Committee. First they registered with the NHREC (South African Human Research Electronic Application System). Then they completed the UP application and provided all documentation through their online system. Because they are not associated with the university, They paid a fee of 3,192 ZAR for an independent review.

• Because they are researchers from the United States, They received dual approval from the institutional review board at the Icahn School of Medicine at Mount Sinai in New York, NY (protocol number 15-10023). They paid no fee for this review.

PROCESS OF THE APPLICATION

Thank you to

The University of Mount Sinai

NACOSA

RHI

SWEAT

North Star Alliance

Department of Health Limpopo

NPO NO. 045-804-NPO

FARM WORKERS CARE FOR EACH OTHER

PO Box 1265 Hoedspruit 1380Fax: +27 (0) 86 615 8035

Christine du Preez: +27 (0) 83 300 2933email: dupreezjc@worldonline.co.za

Also find us on

call us on 082 560 0248 for more info or visit our website at www.hlokomela.org.za