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Population-level scale-up of cervical cancer prevention services in a low-resource setting: development, implementation, and evaluation of the cervical cancer prevention program in Zambia.

Parham GP, Mwanahamuntu MH, Kapambwe S, Muwonge R, Bateman AC, Blevins M, Chibwesha CJ, Pfaendler KS, Mudenda V, Shibemba AL, Chisele S, Mkumba G, Vwalika B, Hicks ML, Vermund SH, Chi BH, Stringer JS, Sankaranarayanan R, Sahasrabuddhe VV - PLoS ONE (2015)

Bottom Line: 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.We 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.

View Article: PubMed Central - PubMed

Affiliation: Center for Infectious Disease Research in Zambia, Lusaka, Zambia; University of Zambia, Lusaka, Zambia; University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America; International Agency for Research on Cancer, Lyon, France.

ABSTRACT

Background: Very few efforts have been undertaken to scale-up low-cost approaches to cervical cancer prevention in low-resource countries.

Methods: 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 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.

Findings: Between 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.

Interpretation: We 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.

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Related in: MedlinePlus

District-level expansion across provinces in Zambia (2006–2014) and projected (in 2016) of the Cervical Cancer Prevention Program in Zambia (CCPPZ).
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pone.0122169.g001: District-level expansion across provinces in Zambia (2006–2014) and projected (in 2016) of the Cervical Cancer Prevention Program in Zambia (CCPPZ).

Mentions: Prompted by pilot research that demonstrated a very high burden of ICC and high-grade cervical precursors among HIV-infected Zambian women newly accessing antiretroviral therapy [18], we began an innovative Zambian-US partnership to initiate CCPPZ in 2006. PEPFAR, through the U.S. Centers for Disease Control and Prevention (CDC), funded CCPPZ as its first-ever cervical cancer prevention initiative focused on HIV-infected women. 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. PEPFAR funding allowed us to initially offer services to the highest-risk HIV-infected women, but the development of the infrastructure and human resources through this funding allowed the program to offer these services to all women in the catchment area, regardless of their HIV status, with low marginal costs. Starting with two public sector clinics in the country’s most populated province (Lusaka) in 2006, CCPPZ now operates in 33 government-run health facilities across all of Zambia’s 10 provinces [19–25]. (Fig 1) (Fig 2).


Population-level scale-up of cervical cancer prevention services in a low-resource setting: development, implementation, and evaluation of the cervical cancer prevention program in Zambia.

Parham GP, Mwanahamuntu MH, Kapambwe S, Muwonge R, Bateman AC, Blevins M, Chibwesha CJ, Pfaendler KS, Mudenda V, Shibemba AL, Chisele S, Mkumba G, Vwalika B, Hicks ML, Vermund SH, Chi BH, Stringer JS, Sankaranarayanan R, Sahasrabuddhe VV - PLoS ONE (2015)

District-level expansion across provinces in Zambia (2006–2014) and projected (in 2016) of the Cervical Cancer Prevention Program in Zambia (CCPPZ).
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4401717&req=5

pone.0122169.g001: District-level expansion across provinces in Zambia (2006–2014) and projected (in 2016) of the Cervical Cancer Prevention Program in Zambia (CCPPZ).
Mentions: Prompted by pilot research that demonstrated a very high burden of ICC and high-grade cervical precursors among HIV-infected Zambian women newly accessing antiretroviral therapy [18], we began an innovative Zambian-US partnership to initiate CCPPZ in 2006. PEPFAR, through the U.S. Centers for Disease Control and Prevention (CDC), funded CCPPZ as its first-ever cervical cancer prevention initiative focused on HIV-infected women. 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. PEPFAR funding allowed us to initially offer services to the highest-risk HIV-infected women, but the development of the infrastructure and human resources through this funding allowed the program to offer these services to all women in the catchment area, regardless of their HIV status, with low marginal costs. Starting with two public sector clinics in the country’s most populated province (Lusaka) in 2006, CCPPZ now operates in 33 government-run health facilities across all of Zambia’s 10 provinces [19–25]. (Fig 1) (Fig 2).

Bottom Line: 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.We 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.

View Article: PubMed Central - PubMed

Affiliation: Center for Infectious Disease Research in Zambia, Lusaka, Zambia; University of Zambia, Lusaka, Zambia; University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America; International Agency for Research on Cancer, Lyon, France.

ABSTRACT

Background: Very few efforts have been undertaken to scale-up low-cost approaches to cervical cancer prevention in low-resource countries.

Methods: 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 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.

Findings: Between 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.

Interpretation: We 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.

Show MeSH
Related in: MedlinePlus