TOGETHERFORHEALTH.ORG

CASESTUDY:PreventingcervicalcanceramongwomenlivingwithHIVinZambia

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ProjectConcernInternational(PCI)firstbeganaddressingtheconnectionbetweencervicalcancerandHIVinZambiain2011.RecognizingthatwomenlivingwithHIVareparticularlyvulnerabletocervicalcancerbecauseoftheircompromisedimmunesystems,especiallywithoutearlyaccesstoHIVtreatment,1PCIbeganitsprogrambyofferingintegratedmobilecervicalcancerscreeningandHIVtesting.Womenwithprecancerouslesionswereprovidedorlinkedtotreatment,andthosewho

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testedpositiveforHIVwerelinkedtoantiretroviraltherapy(ART)services.

Overtime,though,thecervicalcancerhealthpolicyandtechnologylandscapeinZambiachanged.Forexample,policymakersanddonorstooktheinitiativetoscaleupaccesstocervicalcancerpreventionservices—makingZambiaaleaderonthisissueamongAfricancountries—andtargetHIV-positivewomenforscreening.Thegovernmentalsolaidthegroundworkfornationalrolloutofthevaccineagainsthumanpapillomavirus(HPV),thevirusthatcausesmostcasesofcervicalcancer.Meanwhile,healthserviceprovidersgainedaccesstonewtoolsfordetectingandtreatingprecancerouslesions.

PCIsuccessfullyadaptedtothenewcircumstancesandpriorities.Today,PCIofferscervicalcancerservicesforclientsonART,contributingtoZambia’sstrategytoreducecervicalcancermortalityby25%by2025.2ThiswillhelpmoveZambiatowardtheglobalgoalofcervicalcancerelimination.3

1Rohner,Elianeetal.CervicalcancerriskinwomenlivingwithHIVacrossfourcontinents:Amulticohortstudy.InternationalJournalofCancer.19June2019.https://onlinelibrary.wiley.com/doi/full/10.1002/ijc.322602RepublicofZambiaMinistryofHealth.NationalCancerControlStrategicPlan2016-2021.https://www.iccp-portal.org/system/files/plans/NCCSP%20Final%20Version%20Zambia.pdf3AdhanomGhebreyesus,Tedros.CervicalCancer:AnNCDWeCanOvercome.SpeechatIntercontinentalHotel,Geneva.19May2018.https://www.who.int/reproductivehealth/DG_Call-to-Action.pdf?ua=1

Healthcareprovidersdiscussanimageofapatient’scervix

ByJennieAylward

CASE STUDY: PCI IN ZAMBIA 2

TOGETHERFORHEALTH.ORG

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PCI’sModel

PCIisaninnovativeglobaldevelopmentorganizationthatworkstowardmeaningfulandmeasurablechangeinthelivesofwomenandgirls,andcervicalcancerprevention,treatment,andreferralareamongPCI’slifesavinghealthinterventions.

Buildingonitsexperienceprovidingscreen-and-treatservicestoalmost22,000Zambianwomenbetween2011andOctober2018,PCIhadarunningstartforitsnewmodeltargetingwomenonHIVtreatment,startingin2019.TheworkiscurrentlyfundedbytheU.S.government’sPresident’sEmergencyFundforAIDSRelief(PEPFAR)andtheU.SDepartmentofDefenseHIVPreventionProgram(DHAPP).

ThefrontlinehealthserviceprovidersinPCI’smodelaremembersoftheZambiaDefenseForces(ZDF).PCIstrengthensthecapacityofZDFprofessionalstoprovidequalityservicesbyofferingin-servicetraining,developingtoolssuchasguidelinesandstandardoperatingprocedures,andprovidingmentoringandtechnicalsupport.

PCIdesigneditsnewmodeltoaddressthespecificneedsofitstargetpopulationofwomenlivingwithHIV,asithassince2011.Underitscurrentmodel,themobileclinictakesplaceinahealthcenter,withPCI-trainedproviderstravelingtogeographicallyisolatedARTandMaternal,Neonatal,andChildHealth(MNCH)clinicsthatotherwisearenotstaffedandequippedtoprovidecervicalcancerscreening.Attheseclinics,PCI-trainedZDFnursesprovidevisualinspectionwithaceticacid(VIA),usingavinegarsolutiontohighlightanyprecancerous

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lesionsinthecervix.4Followingtheprotocolsof“screen-and-treat,”anyprecancerouslesionsareexcisedatthetimeofdiscovery,eitheronsitebythenursesorbythemobileunit’sdoctoratanearbyhospital.PCIprioritizestheimplementationofservicesinregionswithhighincidencesofcervicalcancerandHIV,reviewingprogramtrenddataeveryquarterandupdatingitsworktoreflectchangingepidemiology.Inayear,themobileunitprovidesservicesat20clinics.

DespitesignificantprogressagainstHIVandAIDSoverthepasttwodecades,anestimated630,000ZambianwomenarecurrentlylivingwithHIV.5AndPCIhasfoundthattheprevalenceofcervicalprecancerouslesionsinHIV-positivewomenismorethanthreetimeshigherthanintheirHIV-negativepeersinZambia,6soitisunsurprisingthatcervicalcanceristhemostcommonanddeadlyformofcancerinZambia.Anestimated2,994Zambianwomen

AZambiaDefenseForcesnursestaffsPCI’smobileserviceunit

4InlinewithrecentlyadoptednationalHPVtestingguidelines,PCIwillintegrateHPVtestingwithVIAtriageintoitsscreeningprograminFY2020.5JointUnitedNationsProgrammeonHIV/AIDS(UNAIDS).UNAIDSData2018.https://www.unaids.org/sites/default/files/media_asset/unaids-data-2018_en.pdf6GrulichAE,vanLeeuwenMT,FalsterMO,VajdicCM.IncidenceofCancersinPeoplewithHIV/AIDSComparedwithImmunosuppressedTransplantRecipients:AMeta-Analysis.TheLancet.2007;370(9581):59-67.http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)61050-2/abstract7InternationalAgencyforResearchonCancer.GLOBOCAN2018.http://gco.iarc.fr/today/data/factsheets/populations/894-zambia-fact-sheets.pdf

CASE STUDY: PCI IN ZAMBIA 3

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werediagnosedwithcervicalcancerin2018,andthediseasecaused1,839deaths.7

PCI’seffortstoaddressthisdualdiseaseburden,acrossallthe10provincesofZambia,havebeensuccessfulbecausetheyreflecttheconstraintsandopportunitiesinherentinthelow-resource,high-disease-burdensetting,andbecausePCIworkscloselywithgovernmentrepresentativesatmultiplelevels,tosupportnationalandprovincialpriorities.

GiventheshortageofphysiciansinZambia,thePCImodelusestrainednursemidwivestoperformscreen-and-treat,and“cervicography”telemedicinetechnologytosupplementtheirexpertise.Duringscreenings,PCI’sserviceproviderscancaptureimagesofthecervixusingaspecializeddigitalcamera,andsharethemwithremotelylocatedphysicians,inrealtime,tosupportdiagnosesandtreatmentrecommendations.Cervicographyalsoallowsforcontinuedqualityassurance(QA),asimagestakenbythemobileunitprovidersaresharedlaterwithphysicianconsultantsinQAmeetingscoordinatedbyPCI.Theconsultantsofferongoingmentorship,training,andsupportivesupervisionbasedontheimagespresented.

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EvenbeforetheWorldHealthOrganizationissuedguidelinesinJuly2019fortheuseofthermalablationforprecancerouscervicallesions,PCIofferedthermalablationasascreen-and-treatinnovation.Thermalablationovercomessomeofthebarrierstothealternativeprocedure—cryotherapy—inresource-constrainedsettings.

Conclusion:TailoringServicestoFittheCircumstances

PCI’ssuccessinprovidingcervicalcancerpreventionservicesinZambiaisbasedonitsstrongandevolvingunderstandingofbothwomen’shealthneedsandtheimpact-maximizingstrategiesofdonorsandpolicymakers.Bytargetingthemostvulnerablewomen,offeringthemservicesinawaythatmeetstheirneeds,andgivinglow-levelhealthcareworkersthetoolsandtrainingtoprovidehigh-qualityservices,PCIisakeyplayerinmovingtowardeventualcervicalcancereliminationinZambia–acountrythatissettinganexampleforotherAfricannationsonscalingupaccesstocervicalcancerinterventions.

ChallengesTheZambiangovernmenthasprioritizedcervicalcancerandisworkingtoscaleupcervicalcancerpreventionviabothHPVvaccinationandscreen-and-treatservices.PCI’sscreen-and-treatservicesforwomenonARTareaddressingaparticularlyvulnerablepopulation,andconsequentlyhavingalargehealthimpact.

However,PCIfoundthatalmost3%ofitsHIV-negativeclientsfrom2011-18hadcervicalprecancer,meaningthatadditionalfundingisneededtoscaleupservicesforZambianwomenwhodonothaveHIV.Theneedisespeciallygreatinperi-urbanandruralareas,whereprimaryhealthcareprovidersfrequentlylacktheresourcestooffercervicalcancerservices.Insomelocations,PCIcanreferHIV-negativewomentofacilitieswheretheGlobalFundsupportscervicalcancerservicesforallwomen,regardlessoftheirHIVstatus.

Anotherchallenge,notuniquetoZambia,isthatmythsandmisconceptionsaboutcervicalcancerscreeningdiminishuptakeofservices.Therearepervasive,inaccuratemythsaboutpelvicexamsandcervicalcancerthatmakewomenafraidtocomeforwardforscreening.PCIcontributestodispellingmythsandmisconceptionswithstrongandextensivecommunitymobilizationcampaignstoeducatethepopulationandaddressconcerns.

TolearnmoreaboutPCI’swork,visitwww.pciglobal.org