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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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Program process and outcome indicators of the Cervical Cancer Prevention Program in Zambia (CCPPZ).Panel A (Top, left): Trends in HIV status of screened women over the calendar years 2006–2013. Panel B (Bottom, left): Rates of screening positivity, cryotherapy eligibility and cryotherapy-ineligiblity by age categories and overall. Panel C (Bottom, right): Trends in rates of screening positivity and cryotherapy rates over calendar years 2006–2013. Panel D (Top, right): Trends in rates of ‘same day-services’ and rates of ‘appropriate referral’ over calender years 2006–2013.
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pone.0122169.g005: Program process and outcome indicators of the Cervical Cancer Prevention Program in Zambia (CCPPZ).Panel A (Top, left): Trends in HIV status of screened women over the calendar years 2006–2013. Panel B (Bottom, left): Rates of screening positivity, cryotherapy eligibility and cryotherapy-ineligiblity by age categories and overall. Panel C (Bottom, right): Trends in rates of screening positivity and cryotherapy rates over calendar years 2006–2013. Panel D (Top, right): Trends in rates of ‘same day-services’ and rates of ‘appropriate referral’ over calender years 2006–2013.

Mentions: Overall, just over a quarter of women screened were HIV-positive (28%; 28,529/102,942), about half were HIV-negative (48%; 49,483) and the HIV status was unknown in about a quarter of the women (24%; 24,930). The proportion of HIV-positive women among the total screened population declined from 55% in 2006 to 26% in 2013, while the proportion of women who were HIV-negative increased during the same period from 23% to 56% (Fig 5-Panel A). The proportion of women whose HIV status was unknown initially increased from 22% in 2006 to 35% in 2007, but as HIV testing services began being offered in the cervical cancer screening clinics, this proportion steadily fell, and was 19% in 2013.


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)

Program process and outcome indicators of the Cervical Cancer Prevention Program in Zambia (CCPPZ).Panel A (Top, left): Trends in HIV status of screened women over the calendar years 2006–2013. Panel B (Bottom, left): Rates of screening positivity, cryotherapy eligibility and cryotherapy-ineligiblity by age categories and overall. Panel C (Bottom, right): Trends in rates of screening positivity and cryotherapy rates over calendar years 2006–2013. Panel D (Top, right): Trends in rates of ‘same day-services’ and rates of ‘appropriate referral’ over calender years 2006–2013.
© Copyright Policy
Related In: Results  -  Collection

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

pone.0122169.g005: Program process and outcome indicators of the Cervical Cancer Prevention Program in Zambia (CCPPZ).Panel A (Top, left): Trends in HIV status of screened women over the calendar years 2006–2013. Panel B (Bottom, left): Rates of screening positivity, cryotherapy eligibility and cryotherapy-ineligiblity by age categories and overall. Panel C (Bottom, right): Trends in rates of screening positivity and cryotherapy rates over calendar years 2006–2013. Panel D (Top, right): Trends in rates of ‘same day-services’ and rates of ‘appropriate referral’ over calender years 2006–2013.
Mentions: Overall, just over a quarter of women screened were HIV-positive (28%; 28,529/102,942), about half were HIV-negative (48%; 49,483) and the HIV status was unknown in about a quarter of the women (24%; 24,930). The proportion of HIV-positive women among the total screened population declined from 55% in 2006 to 26% in 2013, while the proportion of women who were HIV-negative increased during the same period from 23% to 56% (Fig 5-Panel A). The proportion of women whose HIV status was unknown initially increased from 22% in 2006 to 35% in 2007, but as HIV testing services began being offered in the cervical cancer screening clinics, this proportion steadily fell, and was 19% in 2013.

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