Safety, acceptability, and feasibility of a single-visit approach to cervical-cancer prevention in rural Thailand: a demonstration project

Cervical Cancer Screening Among Adult Women in China, 2010

INTRODUCTION

Cervical cancer is one of the most commonly diagnosed cancers among women in China. The World Health Organization (WHO) recommends routine screening for cervical cancer, and the WHO Global Monitoring Framework suggests that every nation monitors cervical cancer screening. However, little information is available on cervical cancer screening behavior among women in China.

METHODS

We used data from the 2010 China Chronic Disease and Risk Factor Surveillance System that included 51,989 women aged 18 years and older. We report the proportion of women who reported ever having had a Papanicolaou (Pap) test, stratified by sociodemographic characteristics and geographic region. Multivariable logistic regression modeling was performed to adjust for potential confounders.

RESULTS

Overall, 21% of 51,989 women reported having ever had a Pap test. The highest proportion was reported among women aged 30-39 years (30.1%, 95% confidence interval, 26.8%-33.4%). In all geographic regions, women in rural areas were consistently less likely than women in urban areas to report having had a Pap test. Among women who reported ever having a Pap test, 82% reported having the most recent test in the past 3 years. Factors associated with reporting ever having a test were being aged 30-49 years, higher education, being married, and having urban health insurance.

CONCLUSION

Our results indicate that screening programs need to be strengthened along with a more intense focus on specific demographic groups. National cervical cancer screening guidelines and comprehensive implementation strategies are needed to make screening services available and accessible to all women.

IMPLICATIONS FOR PRACTICE

This study is the largest nationwide and population-based assessment of self-reported history of Pap test for cervical cancer screening in China. This article describes cervical cancer screening behavior among women and examines key demographic and geographic factors. Only one fifth of Chinese women reported having ever had a Pap test for cervical cancer screening. The results highlight the urgent need to develop national cervical cancer screening guidelines and strategies that make screening services widely available, accessible, and acceptable to all women, especially to those who reside in rural areas and those with no health insurance.

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

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.

Evaluation of a single-visit approach to cervical cancer screening and treatment in Guyana: feasibility, effectiveness and lessons learned

AIM

To evaluate a cervical cancer prevention project in Guyana utilizing visual inspection with acetic acid (VIA) and immediate cryotherapy in a single-visit approach; and to identify lessons learned to inform the improvement of cervical cancer prevention programs in Guyana and other low-resource settings.

METHODS

Service records from January 2009 to June 2012 were analyzed for 18 cervical cancer prevention sites across Guyana. Records included women's HIV status, data on visual inspection with acetic acid screening and treatment status for women's initial and 1-year follow-up screenings, provider training and retention. A process evaluation was conducted in 2011 to identify programmatic strengths and interventions for integration, scale-up and sustainability.

RESULTS

During the 42-month interval, 21,597 new screenings were performed, reaching 95% of HIV(+) women enrolled in care and 17% of women aged 25-49 years in Guyana. The VIA(+) rate was 13% (n = 2806); 85% of women eligible for cryotherapy received immediate treatment. Half of VIA(+) women treated with cryotherapy or loop electrosurgical excision procedure returned for a 1-year follow-up screening (n = 1027); 95% were VIA(-) at the second screening. Non-physician providers were more likely to continue offering services than physicians. Most programmatic challenges were related to systemic rather than technical/clinical issues.

CONCLUSION

The single-visit approach-based program is feasible, effective, and when scaled up, likely to have an impact on overall incidence of cervical cancer. Services can be shifted to non-physicians for scale-up of high-quality cervical cancer prevention services nationally. To ensure sustainability and expansion, support structures should be prioritized.

Knowledge, attitudes and practices regarding cervical cancer and screening among Haitian health care workers

It is estimated that Haiti has the highest incidence of cervical cancer in the Western Hemisphere. There are currently no sustainable and affordable cervical cancer screening programs in Haiti. The current status of screening services and knowledge of health care professionals was assessed through a Knowledge, Attitudes, and Practices survey on cervical cancer screening and prevention. It was distributed to Project Medishare for Haiti health care workers (n = 27) in the Central Plateau. The majority (22/27) of participants stated pre-cancerous cells could be detected through screening, however, only four had ever performed a pap smear. All of the participants felt a screening program should be started in their area. Our data establishes that knowledge is fairly lacking among healthcare workers and there is an opportunity to train them in simple, cost effective "screen-and-treat" programs that could have a great impact on the overall health of the population.

Impact of an educational intervention on women's knowledge and acceptability of human papillomavirus self-sampling: a randomized controlled trial in Cameroon

Objective

Human papillomavirus (HPV) self-sampling (Self-HPV) may be used as a primary cervical cancer screening method in a low resource setting. Our aim was to evaluate whether an educational intervention would improve women's knowledge and confidence in the Self-HPV method.

Method

Women aged between 25 and 65 years old, eligible for cervical cancer screening, were randomly chosen to receive standard information (control group) or standard information followed by educational intervention (interventional group). Standard information included explanations about what the test detects (HPV), the link between HPV and cervical cancer and how to perform HPV self-sampling. The educational intervention consisted of a culturally tailored video about HPV, cervical cancer, Self-HPV and its relevancy as a screening test. All participants completed a questionnaire that assessed sociodemographic data, women's knowledge about cervical cancer and acceptability of Self-HPV.

Results

A total of 302 women were enrolled in 4 health care centers in Yaoundé and the surrounding countryside. 301 women (149 in the “control group” and 152 in the “intervention group”) completed the full process and were included into the analysis. Participants who received the educational intervention had a significantly higher knowledge about HPV and cervical cancer than the control group (p<0.05), but no significant difference on Self-HPV acceptability and confidence in the method was noticed between the two groups.

Conclusion

Educational intervention promotes an increase in knowledge about HPV and cervical cancer. Further investigation should be conducted to determine if this intervention can be sustained beyond the short term and influences screening behavior.

Trials Registration

International Standard Randomised Controlled Trial Number (ISRCTN) Register ISRCTN78123709

Role of print and audiovisual media in cervical cancer prevention in Bangladesh

BACKGROUND

Visual inspection of cervix with acetic acid (VIA) is offered at 252 centers in 64 districts of Bangladesh. VIA+ve women are managed at colposcopy clinics of Bangabandhu Sheikh Mujib Medical University (BSMMU) and 14 Medical College Hospitals (MCHs). This research work has been supported by 'UICC Cancer Prevention Campaign' programme.

OBJECTIVES

This study explored the role of print materials and electronic media to improve cervical cancer screening in the present socio-cultural context of Bangladesh.

METHODS

This study was performed from January to August 2011 at two upazilas of Bangladesh (Singair with screening facility and Sonargaon without screening facility). Data were collected by focus group discussion (FGD) with women, husbands and community people before and after intervention. Information on cervical cancer screening and VIA camps was disseminated using advertisement through local cable line of the television, microphone announcement, service providers and leaflet throughout the week prior to a VIA camp. Three-day VIA camps were organized at the upazila health complex (UHC) of both upazilas. Quantitative data was gathered from women at the camps on source of information on VIA and the best method of awareness creation.

RESULTS

The population was aware of "cancer" and a notable number knew about cervical cancer. Baseline awareness on prevention and VIA was low and it was negligible where screening services were unavailable. Awareness was increased fourfold in both upazilas after interventions and half of the women and the majority of the community people became aware of screening and available facilities. Cable line advertisement (25.5%), microphone announcement (21.4%), and discussion sessions (20.4%) were effective for awareness creation on VIA. Television was mentioned as the best method (37.4%) of awareness creation.

CONCLUSION

Television should be used for nation-wide awareness creation. For local awareness creation, cable line advertisement, microphone announcements and health education at Uthan Baithaks/ EPI sessions can easily be adopted by the government.

Integrating HIV testing into cervical cancer screening in Tanzania: an analysis of routine service delivery statistics

BACKGROUND

While the lifetime risk of developing cervical cancer (CaCx) and acquiring HIV is high for women in Tanzania, most women have not tested for HIV in the past year and most have never been screened for CaCx. Good management of both diseases, which have a synergistic relationship, requires integrated screening, prevention, and treatment services. The aim of this analysis is to assess the acceptability, feasibility and effectiveness of integrating HIV testing into CaCx prevention services in Tanzania, so as to inform scale-up strategies.

METHODS

We analysed 2010-2013 service delivery data from 21 government health facilities in four regions of the country, to examine integration of HIV testing within newly introduced CaCx screening and treatment services, located in the reproductive and child health (RCH) section of the facility. Analysis included the proportion of clients offered and accepting the HIV test, reasons why testing was not offered or was declined, and HIV status of CaCx screening clients.

RESULTS

A total of 24,966 women were screened for CaCx; of these, approximately one-quarter (26%) were referred in from HIV care and treatment clinics. Among the women of unknown HIV status (n = 18,539), 60% were offered an HIV test. The proportion of women offered an HIV test varied over time, but showed a trend of decline as the program expanded. Unavailability of HIV test kits at the facility was the most common reason for a CaCx screening client not to be offered an HIV test (71% of 6,321 cases). Almost all women offered (94%) accepted testing, and 5% of those tested (582 women) learned for the first time that they were HIV-positive.

CONCLUSION

Integrating HIV testing into CaCx screening services was highly acceptable to clients and was an effective means of reaching HIV-positive women who did not know their status; effectiveness was limited, however, by shortages of HIV test kits at facilities. Integration of HIV testing into CaCx screening services should be prioritized in HIV-endemic settings, but more work is needed to eliminate logistical barriers. The coverage of CaCx screening among HIV care and treatment-enrolled women in Tanzania may be low and should be examined.

Impact of health education intervention on knowledge and perception of cervical cancer and cervical screening uptake among adult women in rural communities in Nigeria

BACKGROUND

Cervical cancer is a disease of public health importance affecting many women and contributing to avoidably high levels of cancer deaths in Nigeria. In spite of the relative ease of prevention, the incidence is on the increase. This study aimed to determine the effect of health education on the awareness, knowledge and perception of cervical cancer and screening among women in rural Nigerian communities.

METHODS

The study design was quasi-experimental. The study was carried out among adult women in Odogbolu (intervention) and Ikenne (control) local government areas (LGA) of Ogun state. Three hundred and fifty (350) women were selected per group by multistage random sampling technique. Data was collected by semi structured interviews with the aid of questionnaire. The intervention consisted of structured health education based on a movie.

RESULT

The intervention raised the level of awareness of cervical cancer and screening to 100% (p < 0.0001). The proportion of women with very good knowledge of cervical cancer and screening rose from 2% to 70.5% (χ(2) = 503.7, p < 0.0001) while the proportion of those with good perception rose from 5.1% to 95.1% (p < 0.0001). The mean knowledge and mean perception scores were also increased (p < 0.0001). There was increase in the proportion of women who had undertaken cervical screening from 4.3% to 8.3% (p = 0.038). The major reason stated by the women for not having had cervical screening done was lack of awareness about cervical cancer and screening. There was statistically significant difference between the intervention and control groups concerning their knowledge attitude and practice towards cervical and screening (p < 0.05) after the intervention.

CONCLUSION

Multiple media health education based on a movie is effective in creating awareness for and improving the knowledge and perception of adult women about cervical cancer and screening. It also improves the uptake of cervical cancer screening. The creation of awareness is very crucial to the success of a cervical cancer prevention programme.

Infrastructure requirements for human papillomavirus vaccination and cervical cancer screening in sub-Saharan Africa

The availability of both human papillomavirus (HPV) vaccination and alternative screening tests has greatly improved the prospects of cervical cancer prevention in sub-Saharan African (SSA) countries. The inclusion of HPV vaccine in the portfolio of new vaccines offered by the Gobal Alliance for Vaccines and Immunization (GAVI) to GAVI-eligible countries has vastly improved the chances of introducing HPV vaccination. Further investments to improve vaccine storage, distribution and delivery infrastructure and human resources of the Extended Programme of Immunization will substantially contribute to the faster introduction of HPV vaccination in SSA countries through both school- and campaign-based approaches. Alternative methods to cytology for the prevention of cervical cancer through the early detection and treatment of cervical cancer precursors have been extensively evaluated in the past 15 years, in Africa as well as in other low-resource settings. Visual inspection with 3-5% dilute acetic acid (VIA) and HPV testing are the two alternative screening methods that have been most studied, in both cross-sectional and randomised clinical trials. VIA is particularly suitable to low-resource settings; however, its efficacy in reducing cervical cancer is likely to be significantly lower than HPV testing. The introduction of VIA screening programmes will help develop the infrastructure that will, in turn, facilitate the introduction of affordable HPV testing in future. Links with the existing HIV/AIDS control programmes is another strategy to improve the infrastructure and screening services in SSA. Infrastructural requirements for an integrated approach aiming to vaccinate single-year cohorts of girls in the 9-13 years age-range and to screen women over 30 years of age using VIA or affordable rapid HPV tests are outlined in this manuscript. This article forms part of a regional report entitled "Comprehensive Control of HPV Infections and Related Diseases in the Sub-Saharan Africa Region" Vaccine Volume 31, Supplement 5, 2013. Updates of the progress in the field are presented in a separate monograph entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.

Screen-and-treat approach to cervical cancer prevention using visual inspection with acetic acid and cryotherapy: experiences, perceptions, and beliefs from demonstration projects in Peru, Uganda, and Vietnam

Cervical cancer is preventable but continues to cause the deaths of more than 270,000 women worldwide each year, most of them in developing countries where programs to detect and treat precancerous lesions are not affordable or available. Studies have demonstrated that screening by visual inspection of the cervix using acetic acid (VIA) is a simple, affordable, and sensitive test that can identify precancerous changes of the cervix so that treatment such as cryotherapy can be provided. Government partners implemented screening and treatment using VIA and cryotherapy at demonstration sites in Peru, Uganda, and Vietnam. Evaluations were conducted in the three countries to explore the barriers and facilitating factors for the use of services and for incorporation of screen-and-treat programs using VIA and cryotherapy into routine services. Results showed that use of VIA and cryotherapy in these settings is a feasible approach to providing cervical cancer prevention services. Activities that can help ensure successful programs include mobilizing and educating communities, organizing services to meet women's schedules and needs, and strengthening systems to track clients for follow-up. Sustainability also depends on having an adequate number of trained providers and reducing staff turnover. Although some challenges were found across all sites, others varied from country to country, suggesting that careful assessments before beginning new secondary prevention programs will optimize the probability of success.

Accuracy of visual inspection with acetic acid to detect cervical cancer precursors among HIV-infected women in Kenya

Visual inspection with acetic acid (VIA) is becoming a more widely recommended and implemented screening tool for cervical cancer prevention programs in low-resource settings. Many of these settings have a high prevalence of HIV-infected women. We carried out a cross-sectional validation study to define the sensitivity, specificity and predictive values of VIA among HIV-infected women. Women enrolled in HIV care at the Family AIDS Care and Education Services clinic in Kisumu, Kenya, were recruited for participation. All participants underwent VIA followed by colposcopy performed by a second blinded clinician. At colposcopy, lesions suspicious for cervical intraepithelial neoplasia 2 or greater (CIN2+) were biopsied. Disease status was determined by final histopathologic diagnosis in women who underwent biopsies. A satisfactory colposcopy with no lesions was considered a negative result. From October 2010 to June 2012, 1,432 women underwent VIA and colposcopy. A total of 514 (35.7%) women had a positive VIA, and 179 (12.2%) had CIN2+ confirmed by colposcopically directed biopsy. Sensitivity, specificity, positive and negative predictive values of VIA for CIN2+ were 86.6, 71.6, 30.3 and 97.4%, respectively. Specificity, but not sensitivity, increased with older age. Among older women, sensitivity was affected by CD4+ count and use of antiretroviral therapy. Although they are impacted by age and immune status, test characteristics for VIA among HIV-infected women are similar to what has been reported for general populations. Recommendations to use VIA as a screening tool should not vary by HIV status.

Innovative approaches to cervical cancer screening for sex trade workers: an international scoping review

OBJECTIVE

Female sex trade workers are among those at highest risk for developing and dying of cervical cancer, and yet many-particularly the most marginalized-are less likely than other women to be screened. This review summarizes global findings on innovative approaches to cervical cancer screening for female sex trade workers, highlights current gaps in the delivery of cervical cancer screening for female sex trade workers globally, and suggests areas for future research and policy development.

DATA SOURCES

A scoping review of peer-reviewed publications and grey literature was conducted. Medline (OVID), PubMed, EMBASE, and SCOPUS were searched for relevant studies written in English. There were no limitations placed on dates. Grey literature was identified by hand searching and through discussion with health care providers and community outreach workers currently working with sex trade workers.

STUDY SELECTION

Twenty-five articles were deemed suitable for review. Articles detailing innovative ways for female sex trade workers to access cervical cancer screening were included. Articles about screening for sexually transmitted infections were also included if the findings could be generalized to screening for cervical cancer. Articles limited to exploring risk factors, knowledge, awareness, education, prevalence, and incidence of cervical cancer among sex trade workers were excluded from the review.

DATA EXTRACTION AND SYNTHESIS

Successful screening initiatives identified in the studies reviewed had unconventional hours of operation, understood the difference between street-based and venue-based sex trade workers, and/or used peers for outreach.

CONCLUSION

Two significant gaps in health care service delivery were highlighted in this review: the limited use of unorthodox hours and the nearly exclusive practice of providing sexually transmitted infection screening for female sex trade workers without cervical cancer screening. In addition, although street-based (as opposed to venue-based) sex trade workers are likely at higher risk for developing cervical cancer, they are much less likely than other eligible women to participate in screening programs, meaning traditional outreach methods are unlikely to be successful.

Predictors of default from follow-up care in a cervical cancer screening program using direct visual inspection in south-western Nigeria

Background

Increasingly evidence is emerging from south East Asia, southern and east Africa on the burden of default to follow up care after a positive cervical cancer screening/diagnosis, which impacts negatively on cervical cancer prevention and control. Unfortunately little or no information exists on the subject in the West Africa sub region. This study was designed to determine the proportion of and predictors and reasons for default from follow up care after positive cervical cancer screen.

Method

Women who screen positive at community cervical cancer screening using direct visual inspection were followed up to determine the proportion of default and associated factors. Multivariate logistic regression was used to determine independent predictors of default.

Results

One hundred and eight (16.1%) women who screened positive to direct visual inspection out of 673 were enrolled into the study. Fifty one (47.2%) out of the 108 women that screened positive defaulted from follow-up appointment. Women who were poorly educated (OR: 3.1, CI: 2.0 – 5.2), or lived more than 10 km from the clinic (OR: 2.0, CI: 1.0 – 4.1), or never screened for cervical cancer before (OR: 3.5, CI:3:1–8.4) were more likely to default from follow-up after screening positive for precancerous lesion of cervix . The main reasons for default were cost of transportation (48.6%) and time constraints (25.7%).

Conclusion

The rate of default was high (47.2%) as a result of unaffordable transportation cost and limited time to keep the scheduled appointment. A change from the present strategy that involves multiple visits to a “see and treat” strategy in which both testing and treatment are performed at a single visit is recommended.

Cervical cancer screening: knowledge, attitude and practices among nursing staff in a tertiary level teaching institution of rural India

BACKGROUND

Assessment of the nursing staff knowledge, attitude and practices about cervical cancer screening in a tertiary care teaching institute of rural India.

MATERIALS AND METHODS

A cross sectional, descriptive, interview- based survey was conducted with a pretested questionnaire among 262 staff nurses of a tertiary care teaching and research institute.

RESULTS

In this study 77% respondents knew that Pap smear is used for detection of cervical cancer, but less than half knew that Pap smear can detect even precancerous lesions of cervix. Only 23.4% knew human papilloma virus infection as a risk factor. Only 26.7% of the respondents were judged as having adequate knowledge based on scores allotted for questions evaluating knowledge about cervical cancer and screening. Only 17 (7%) of the staff nurses had themselves been screened by Pap smear, while 85% had never taken a Pap smear of a patient. Adequate knowledge of cervical cancer and screening, higher parity and age >30 years were significantly associated with self screening for cervical cancer. Most nurses held a view that Pap test is a doctor procedure, and nearly 90% of nurses had never referred a patient for Pap testing.

CONCLUSIONS

The majority of nursing staff in rural India may have inadequate knowledge about cervical cancer screening, and their attitude and practices towards cervical cancer screening could not be termed positive.

Managing the changing burden of cancer in Asia

Asia accounts for 60% of the world population and half the global burden of cancer. The incidence of cancer cases is estimated to increase from 6.1 million in 2008 to 10.6 million in 2030, due to ageing and growing populations, lifestyle and socioeconomic changes. Striking variations in ethnicity, sociocultural practices, human development index, habits and dietary patterns are reflected in the burden and pattern of cancer in different regions. The existing and emerging cancer patterns and burden in different regions of Asia call for political recognition of cancer as an important public health problem and for balanced investments in public and professional awareness. Prevention as well as early detection of cancers leads to both better health outcomes and considerable savings in treatment costs. Cancer health services are still evolving, and require substantial investment to ensure equitable access to cancer care for all sections of the population. In this review, we discuss the changing burden of cancer in Asia, along with appropriate management strategies. Strategies should promote healthy ageing via healthy lifestyles, tobacco and alcohol control measures, hepatitis B virus (HBV) and human papillomavirus (HPV) vaccination, cancer screening services, and vertical investments in strengthening cancer healthcare infrastructure to improve equitable access to services.

The prevalence of precancerous cervical cancer lesion among HIV-infected women in southern Ethiopia: a cross-sectional study

Introduction

The magnitude of precancerous cervical cancer lesions as well as invasive cervical cancer is higher in HIV-infected women than non HIV-infected women. Thus, screening targeting HIV-infected women is being undertaken in developing countries, including Ethiopia. However, data on the prevalence and determinants of precancerous cervical cancer lesion among HIV-infected women in southern Ethiopia is lacking. Thus, this study aimed to assess the prevalence of and factors associated with precancerous cervical cancer lesion among HIV- infected women in southern Ethiopia.

Methods

A hospital-based cross-sectional study was conducted from October 2012 to February 2013 among HIV-infected women in Southern Ethiopia. Four hundred forty eight HIV-infected women who had been screened and treated for precancerous cervical cancer lesion were included in the study. Data were collected by using structured and pretested questionnaire. Visual inspection with acetic acid was applied for screening and treatment. SPSS version 16.0 was used for data entry and analysis. Logistic regression analysis was fitted and odds ratios with 95% Confidence intervals and p-values were computed to identify factors associated with precancerous cervical cancer lesion.

Results

Out of 448 study participants, 99 (22.1%) were found to be positive for precancerous cervical cancer. Being currently on highly active antiretroviral treatment (AOR=0.52, 95%CI: 0.35, 0.92), history of sexually transmitted disease (AOR=2.30, 95%CI: 1.23, 4.29) and having only one lifetime sexual partner (AOR=0.33, 95%CI: 0.20, 0.56) were factors associated with precancerous cervical cancer lesion.

Conclusions

The prevalence of precancerous cervical cancer lesion among HIV-infected women in southern Ethiopia was found to be high. Intervention to access all HIV-infected women like scaling up the limited services and awareness creation should be undertaken. Measures aimed at preventing the acquisition and transmission of sexually transmitted diseases and reducing the number of sexual partners are required. Besides, early initiation of highly active antiretroviral treatment is important.

Screen-and-treat approach to cervical cancer prevention using visual inspection with acetic acid and cryotherapy: experiences, perceptions, and beliefs from demonstration projects in Peru, Uganda, and Vietnam

Cervical cancer is preventable but continues to cause the deaths of more than 270,000 women worldwide each year, most of them in developing countries where programs to detect and treat precancerous lesions are not affordable or available. Studies have demonstrated that screening by visual inspection of the cervix using acetic acid (VIA) is a simple, affordable, and sensitive test that can identify precancerous changes of the cervix so that treatment such as cryotherapy can be provided. Government partners implemented screening and treatment using VIA and cryotherapy at demonstration sites in Peru, Uganda, and Vietnam. Evaluations were conducted in the three countries to explore the barriers and facilitating factors for the use of services and for incorporation of screen-and-treat programs using VIA and cryotherapy into routine services. Results showed that use of VIA and cryotherapy in these settings is a feasible approach to providing cervical cancer prevention services. Activities that can help ensure successful programs include mobilizing and educating communities, organizing services to meet women's schedules and needs, and strengthening systems to track clients for follow-up. Sustainability also depends on having an adequate number of trained providers and reducing staff turnover. Although some challenges were found across all sites, others varied from country to country, suggesting that careful assessments before beginning new secondary prevention programs will optimize the probability of success.

Health systems and noncommunicable diseases in the Asia-Pacific region: a review of the published literature

Addressing the growing burden of noncommunicable diseases (NCDs) in countries of the Asia-Pacific region requires well-functioning health systems. In low- and middle-income countries (LMICs), however, health systems are generally characterized by inadequate financial and human resources, unsuitable service delivery models, and weak information systems. The aims of this review were to identify (a) health systems interventions being implemented to deliver NCD programs and services and their outcomes and (b) the health systems bottlenecks impeding access to or delivery of these programs and services in LMICs of the Asia-Pacific region. A search of 4 databases for literature published between 1990 and 2010 retrieved 36 relevant studies. For each study, information on basic characteristics, type of health systems bottleneck/intervention, and outcome was extracted, and methodological quality appraised. Health systems interventions and bottlenecks were classified as per the World Health Organization health systems building blocks framework. The review identified interventions and bottlenecks in the building blocks of service delivery, health workforce, financing, health information systems, and medical products, vaccines, and technologies. Studies, however, were heterogeneous in methodologies used, and the overall quality was generally low. There are several gaps in the evidence base around NCDs in the Asia-Pacific region that require further investigation.

Utilization of cervical cancer screening services and trends in screening positivity rates in a 'screen-and-treat' program integrated with HIV/AIDS care in Zambia

Background

In the absence of stand-alone infrastructures for delivering cervical cancer screening services, efforts are underway in sub-Saharan Africa to dovetail screening with ongoing vertical health initiatives like HIV/AIDS care programs. Yet, evidence demonstrating the utilization of cervical cancer prevention services in such integrated programs by women of the general population is lacking.

Methods

We analyzed program operations data from the Cervical Cancer Prevention Program in Zambia (CCPPZ), the largest public sector programs of its kind in sub-Saharan Africa. We evaluated patterns of utilization of screening services by HIV serostatus, examined contemporaneous trends in screening outcomes, and used multivariable modeling to identify factors associated with screening test positivity.

Results

Between January 2006 and April 2011, CCPPZ services were utilized by 56,247 women who underwent cervical cancer screening with visual inspection with acetic acid (VIA), aided by digital cervicography. The proportion of women accessing these services who were HIV-seropositive declined from 54% to 23% between 2006–2010, which coincided with increasing proportions of HIV-seronegative women (from 22% to 38%) and women whose HIV serostatus was unknown (from 24% to 39%) (all p-for trend<0.001). The rates of VIA screening positivity declined from 47% to 17% during the same period (p-for trend <0.001), and this decline was consistent across all HIV serostatus categories. After adjusting for demographic and sexual/reproductive factors, HIV-seropositive women were more than twice as likely (Odds ratio 2.62, 95% CI 2.49, 2.76) to screen VIA-positive than HIV-seronegative women.

Conclusions

This is the first ‘real world’ demonstration in a public sector implementation program in a sub-Saharan African setting that with successful program scale-up efforts, nurse-led cervical cancer screening programs targeting women with HIV can expand and serve all women, regardless of HIV serostatus. Screening program performance can improve with adequate emphasis on training, quality control, and telemedicine-support for nurse-providers in clinical decision making.

Cervical cancer screening and prevention in low-resource settings

Cervical cancer is both preventable and curable, yet it remains one of the leading causes of mortality in women worldwide. Approximately 88% of cervical cancer cases are diagnosed in low-resource countries, yet very few resources are allocated to prevention and treatment programs. In fact, it is estimated that only 5% of women in low-resources countries are screened appropriately for cervical cancer. Cytology-based programs are not feasible because of lack of healthcare infrastructure and cost, thus alternative methods of cancer screening, such as visual inspection with acetic acid and HPV-DNA testing, have been intensively studied and are reviewed in this article.

Integrating cervical cancer screening with HIV care in a district hospital in Abuja, Nigeria

BACKGROUND

Human immunodeficiency virus positive (HIV+) women have a higher risk of developing invasive cervical cancer compared with uninfected women. This study aims to document programmatic experience of integrating cervical cancer screening using Visual Inspection and Acetic Acid (VIA) into HIV care as well as to describe patients' characteristics associated with positive VIA findings amongst HIV+ women.

MATERIALS AND METHODS

A cross-sectional study analysed routine service data collected at the antiretroviral therapy (ART) and cervical cancer screening services. Our program integrated screening for cervical cancer using VIA technique to HIV care and treatment services through a combination of stakeholder engagement, capacity building for health workers, creating a bi-directional referral between HIV and reproductive health (RH) services and provider initiated counselling and screening for cervical cancer. Information on patients' baseline and clinical characteristics were captured using an electronic medical records system and then exported to Statistical Package for the Social Sciences (SPSS). Logistic regression model was used to estimate factors that influence VIA results.

RESULTS

A total of 834 HIV+ women were offered VIA screening between April 2010 and April 2011, and 805 (96.5%) accepted it. Complete data was available for 802 (96.2%) women. The mean age at screening and first sexual contact were 32.0 (SD 6.6) and 18.8 (SD 3.5) years, respectively. VIA was positive in 52 (6.5%) women while 199 (24.8%) had a sexually transmitted infection (STI). Of the 199 who had a STI, eight (4.0%) had genital ulcer syndrome, 30 (15.1%) had lower abdominal pain syndrome and 161 (80.9%) had vaginal discharge syndrome. Presence of lower abdominal pain syndrome was found to be a significant predictor of a positive VIA result (P = 0.001). Women with lower abdominal pain syndrome appeared to be more likely (OR 47.9, 95% CI: 4.8-480.4, P = 0.001) to have a positive VIA result.

CONCLUSION

The high burden of both HIV and cervical cancer in developing countries makes it a necessity for integrating services that offer early detection and treatment for both diseases. The findings from our study suggest that integrating VIA screening into the package of care offered to HIV+ women is feasible and acceptable.

Evaluation of a 5-year cervical cancer prevention project in Indonesia: opportunities, issues, and challenges

AIM

The Cervical and Breast Cancer Prevention (CECAP) Project sought to develop a national model for cervical cancer prevention in Indonesia based on visual inspection with acetic acid (VIA) to detect abnormal changes in the cervix. The purpose of this study was to evaluate a pilot project introducing VIA and cryotherapy in Indonesia and to identify lessons learned that could be applied to the national scale-up of cervical cancer prevention services.

MATERIAL AND METHODS

Fifty-four months (July 2007 to December 2011) of service records at 17 health centers were abstracted and analyzed. The data were used to calculate the proportion of all women aged 30-50 who received VIA screening, the VIA-positive rate, the treatment rate, and the interval between screening and treatment.

RESULTS

The 45 050 women screened during the project included 24.4% of the total female population in the target age group in the catchment area. Throughout the 5-year project, 83.1% of VIA-positive women sought cryotherapy. During the last 18 months of the project, after data collection tools were revised to more accurately reflect when cryotherapy was received, 13% of women were treated on the same day that they were screened. Among the 74% of women treated within 1 month of screening, the mean interval between screening and treatment was 7.2 days.

CONCLUSION

As cervical cancer prevention services are scaled up throughout Indonesia, changes in the service delivery model and program management are needed to increase screening coverage, promote a single-visit approach, and ensure the quality of services.

Influencing women's actions on cervical cancer screening and treatment in Karawang District, Indonesia

INTRODUCTION

The impact of cervical cancer prevention programs depends on persuading women to go for screening and, if needed, treatment. As part of an evaluation of a pilot project in Indonesia, qualitative research was conducted to explore the factors that influence women's decisions regarding screening and treatment and to generate practical recommendations to increase service coverage and reduce loss to follow up.

METHODS

Research was conducted at 7 of the 17 public health centers in Karawang District that implemented the pilot project. Interviews and focus group discussions were held with 20 women, 20 husbands, 10 doctors, 18 midwives, 3 district health officials, and 16 advocacy team members.

RESULTS

Free services and mobile outreach events encouraged women to go for screening, along with promotional efforts by community health workers, advocacy teams, and the mass media. Knowledge and perceptions were the most important barriers to screening: women were not aware of cervical cancer risks, did not know the disease was treatable, and were fatalistic. Factors facilitating treatment were social support from husbands, relatives, and friends and the encouragement and role modeling of health workers. Barriers to prompt treatment included limited access to services and the requirement for husband's consent for cryotherapy.

CONCLUSION

As cervical cancer prevention services are scaled up throughout Indonesia, the findings suggest three strategies to expand screening coverage and ensure prompt treatment: strengthening community mobilization and advocacy activities, modifying the service delivery model to encourage a single visit approach to screening and treatment, and working to gain men's support.

Evidence-based screening, early diagnosis and treatment strategy of cervical cancer for national policy in low- resource countries: example of India

Cervical cancer remains the most frequent cancer in women from the developing world. More than 88% of deaths occur in low-income countries, and it is predicted to climb to 91.5% by 2030. Although Pap-based screening programmes have shown to be effective in reducing the disease burden in high-resource countries, implementation and sustention of cytology-based programmes is quite challenging in low-resource settings. The present paper reviews evidence-based alternatives of screening methods, triaging algorithm, treatment of cervical precancerous lesions, and age-group at screening appropriate for low-income countries. Evidence shows that visual inspection methods using diluted acid acetic or Lugol's iodine, and HPV-DNA testing are more sensitive tests than the Pap-smear screening test. Visual inspection allows an immediate result and, when appropriate, may be immediately followed by cryotherapy, the so called "screen-and-treat" approach, achieved in a single visit, by trained nurses and midwives. Examples of cervical cancer prevention programmes in India and selected low-income countries are given.

Low cost versus other screening tests to detect cervical cancer or precancer in developing countries

This is a protocol for a Cochrane Review (diagnostic). The objectives are as follows:

To assess the accuracy of low cost screening tests (visual inspection of the cervix with VIA, VILI or VIAM and care HPV test) to detect underlying CIN2+, CIN3+ or cervical cancer among adult women in developing countries To assess the accuracy of comparator tests (cervical cytology and other HPV tests requiring established laboratory infrastructure) to detect underlying CIN2+, CIN3+ or cervical cancer among adult women in developing countries To assess the relative sensitivity and specificity of the low cost index tests compared to each other and to the comparator tests to detect CIN2+, CIN3+ or cervical cancer among adult women in developing countries

Factors affecting uptake of cervical cancer early detection measures among women in Thika, Kenya

In this study, 50 in-depth interviews were carried out with women from the general population in Thika, Kenya. We explored awareness, attitudes, and behavior toward cervical cancer and screening measures among the women. The concept of the health belief model (HBM) was used to develop the topics for the in-depth interviews. Our findings highlight the lack of awareness of cervical cancer and the benefits of early detection measures as critical barriers that affect women's participation in screening programs. We provide a basis for designing programs that will be acceptable and accessible to a larger population, resulting in a reduced cervical cancer burden.

Single-visit approach of cervical cancer screening: see and treat in Indonesia

Background:

We performed a cross-sectional study in Indonesia to evaluate the performance of a single-visit approach of cervical cancer screening, using visual inspection with acetic acid (VIA), histology and cryotherapy in low-resource settings.

Methods:

Women having limited access to health-care facilities were screened by trained doctors using VIA. If the test was positive, biopsies were taken and when eligible, women were directly treated with cryotherapy. Follow-up was performed with VIA and cytology after 6 months. When cervical cancer was suspected or diagnosed, women were referred. The positivity rate, positive predictive value (PPV) and approximate specificity of the VIA test were calculated. The detection rate for cervical lesions was given.

Results:

Screening results were completed in 22 040 women, of whom 92.7% had never been screened. Visual inspection with acetic acid was positive in 4.4%. The PPV of VIA to detect CIN I or greater and CIN II or greater was 58.7% and 29.7%, respectively. The approximate specificity was 98.1%, and the detection rate for CIN I or greater was 2.6%.

Conclusion:

The single-visit approach cervical cancer screening performed well, showing See and Treat is a promising way to reduce cervical cancer in Indonesia.

Comparison of conventional cervical cytology versus visual inspection with acetic acid among human immunodeficiency virus-infected women in Western Kenya

OBJECTIVE

This study aimed to determine the accuracy of visual inspection with acetic acid (VIA) versus conventional Pap smear as a screening tool for cervical intraepithelial neoplasia/cancer among human immunodeficiency virus (HIV)-infected women.

MATERIALS AND METHODS

A total of 150 HIV-infected women attending the Moi Teaching and Referral Hospital HIV clinic in Eldoret underwent conventional Pap smear, VIA, colposcopy, and biopsy. Both VIA and Pap smears were done by nurses, whereas colposcopy and biopsy were done by a physician. Receiver operating characteristic analysis was conducted to compare the accuracies between VIA and Pap smear in sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

Among the study participants: VIA was abnormal in 55.3% (83/150, 95% confidence interval [CI] = 47.0%-63.5%); Pap smear showed atypical squamous cells of undetermined significance or worse in 43.7% (59/135, 95% CI = 35.2%-52.5%) and 10% (15/150) of the Pap smears were unsatisfactory. Of the abnormal Pap smears, 3% (2/59) had atypical squamous cells of undetermined significance, 7% (4/59) had high-grade atypical squamous cells, 60% (35/59) had low-grade squamous intraepithelial lesions, 29% (17/59) had high-grade squamous intraepithelial lesions, and 2% (1/59) was suspicious for cervical cancer. Using cervical intraepithelial neoplasia 2 or higher disease on biopsy as an end point, VIA has a sensitivity of 69.6% (95% CI = 55.1%-81.0%), specificity of 51.0% (95% CI = 41.5%-60.4%), PPV of 38.6% (95% CI = 28.8%-49.3%), and NPV of 79.1% (95% CI = 67.8%-87.2%). For conventional Pap smear, sensitivity was 52.5% (95% CI = 42.1%-71.5%), specificity was 66.3% (95% CI = 52.0%-71.2%), PPV was 39.7% (95% CI = 27.6%-51.8%), and NPV was 76.8% (95% CI = 67.0%-85.6%).

CONCLUSIONS

Visual inspection with acetic acid is comparable to Pap smear and acceptable for screening HIV-infected women in resource-limited settings such as Western Kenya.

Alternative approaches to cervical cancer screening for developing countries

Cervical cancer remains the most common cancer among women living in developing countries, largely because of the failure either to initiate or sustain effective cervical-cancer screening programmes. This potentially preventable and curable cancer continues to cause high mortality among relatively young women residing in low-resource countries. Cytology as a screening test, linked with a robust healthcare infrastructure, has significantly affected cervical cancer prevention in countries that have had sufficient resources to establish and sustain well-conducted programmes. The failure to establish such programmes has stimulated a large body of research into alternative screening tests and approaches to cervical-cancer prevention. Two of the most recent research methods have been visual inspection with acetic acid and molecular testing for high-risk types of human papillomavirus deoxyribonucleic acid. Visual inspection with acetic acid has shown a great deal of promise in cross-sectional studies; however, in randomised-controlled trials, it has been shown to be significantly less effective in reducing cervical cancer or its precursors. The development of point-of-care human papillomavirus or other highly sensitive tests for the prevention of cervical cancer is imperative. It has also been clearly shown that linking testing or screening to treatment (so-called 'screen and treat') without the intervention of colposcopy or the need for sophisticated laboratories may potentially prevent cervical cancer in large numbers of women.

Issues and challenges in implementing cervical cancer screenings in the emergence of HPV vaccination in Thailand

The discovery of the HPV vaccine has been a major breakthrough in preventing cervical cancer and other HPV-related diseases around the globe. Cervical cancer is a significant public health problem in Thailand. Despite the long-time availability of cervical cancer screening programs in Thailand, the uptake among the target female population remains low. HPV vaccines were approved by the Food and Drug Administration of Thailand in 2007. As of March 2011, due to financial limitations, HPV vaccines have still not been included in the national immunization program under the public health benefit plans although individuals has the option to pay privately for the vaccine. This paper discusses the issues and challenges in implementing cervical cancer screening programs in the era of HPV vaccination in Thailand. Recommendations to increase the uptake of cervical cancer screening and further research to inform a policy regarding the cervical cancer screening measures are proposed.

Cervical cancer screening by visual inspection in Côte d'Ivoire, operational and clinical aspects according to HIV status

Background

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.

Methods

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.

Results

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).

Conclusion

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.

Visual inspection methods for cervical cancer prevention

The need for simple, cost-effective screening approaches for cervical cancer prevention in low-resource countries has led to the evaluation of visual screening with 3-5% acetic acid. The low reproducibility and wide variation in accuracy reflect the subjective nature of the test. Pooled sensitivity, specificity, positive and negative predictive values were 80%, 92%, 10% and 99%, respectively, for detecting cervical intraepithelial neoplasia grade 2 or worse lesions. Realistic sensitivity of a quality- assured single visual inspection with acetic acid is around 50%. A single round of visual inspection with acetic acid screening has been associated with a 25-35% reduction in cervical cancer incidence and the frequency of cervical intraepithelial neoplasia grade 2 or worse lesions in randomised-controlled trials. Despite all its limitations, implementing visual inspection with acetic acid screening in low-resource countries may provide a pragmatic approach to building up human resources and infrastructure that may facilitate the highly anticipated low-cost, rapid human papilloma virus testing in the near future.

Visual inspection with acetic acid for detection of high grade lesion in atypical squamous cells and low grade squamous intraepithelial lesions from cervical Pap smear

Objective

To evaluate the value of visual inspection with acetic acid (VIA) test to detect high grade lesion in women with atypical squamous cells or low grade squamous intraepithelial lesions cervical cytology.

Methods

Women with atypical squamous cells or low grade squamous intraepithelial lesions who were scheduled to undergo colposcopy at Vajira Hospital and met inclusion criteria were included. All participants underwent VIA test prior to usual steps of colposcopy. The VIA results were interpreted as positive or negative using the criteria by the International Agency for Cancer Research. The standard colposcopic examination and appropriate investigations for cervical pathology were then continued. The diagnostic values of VIA test including sensitivity, specificity, positive predictive value, and negative predictive value were determined using high grade lesion including cervical intraepithelial neoplasia 2-3 and squamous cell carcinoma as a threshold.

Results

Total of 106 women was included. The VIA test was positive in 33 women (31.1%) and negative in 73 women (68.9%). Among the women with VIA test positive, 14 had high grade lesion (42.4%) while 19 had no significant lesions. Only 2/73 (2.7%) cases with negative VIA test had high grade lesion (both had cervical intraepithelial neoplasia 2). The sensitivity, specificity, positive predictive value and negative predictive value with 95% confidence interval were 87.5% (81.2 to 93.8%), 78.8% (71.1 to 86.7%), 42.4% (33.0 to 51.8%), and 97.2% (94.2 to 1.0%) respectively.

Conclusion

VIA as the intermediate test in atypical squamous cells and low grade squamous intraepithelial lesions cytology may reduce the necessity to refer some women for colposcopy.

Cervical HIV-1 RNA shedding after cryotherapy among HIV-positive women with cervical intraepithelial neoplasia stage 2 or 3

OBJECTIVE

To determine the effect of cryotherapy on HIV-1 cervical shedding.

DESIGN

Prospective cohort study.

METHODS

Five hundred HIV-positive women enrolled at an HIV treatment clinic in Nairobi, Kenya were screened for cervical cancer. Women diagnosed with cervical intraepithelial neoplasia stage 2 or 3 (CIN 2/3) by histology were offered cryotherapy treatment. The first 50 women had cervical swabs taken at baseline and at 2 and 4 weeks following treatment. Swabs were analyzed for HIV-1 RNA and compared using General Estimating Equation (GEE) with binomial or Gaussian links.

RESULTS

Of the 50 women enrolled, 40 were receiving antiretroviral therapy (ART) and 10 were not receiving ART at the time of cryotherapy and during study follow-up. Among all women, the odds of detectable cervical HIV-1 RNA did not increase at 2 weeks [odds ratio (OR) 1.18; 95% confidence interval (CI) 0.65-2.13] or 4 weeks (OR 1.29; 95% CI 0.71-2.33) following cryotherapy. Among 10 women not receiving ART, the OR of detectable shedding at 2 weeks was higher, but not statistically significant (OR 4.02; 95% CI 0.53-30.79; P = 0.2), and at 4 weeks remained unchanged (OR 1.00; 95% CI 0.27-3.74).

CONCLUSION

There was no increase in detectable cervical HIV-1 RNA among HIV-positive women after cryotherapy. The risk of HIV-1 transmission after cryotherapy may not be significant, particularly among women already on ART at the time of cervical treatment. However, further investigation is needed among women not receiving ART.

Economic evaluation of policy options for prevention and control of cervical cancer in Thailand

BACKGROUND

The Thai healthcare setting has seen patients with cervical cancer experience an increasing burden of morbidity and mortality, a stagnation in the performance of cervical screening programmes and the introduction of a vaccine for the prevention of human papillomavirus (HPV) infection.

OBJECTIVE

This study aims to identify the optimum mix of interventions that are cost effective, from societal and healthcare provider perspectives, for the prevention and control of cervical cancer.

METHODS

A computer-based Markov model of the natural history of cervical cancer was used to simulate an age-stratified cohort of women in Thailand. The strategy comparators, including both control and prevention programmes, were (i) conventional cytology screening (Pap smears); (ii) screening by visual inspection with acetic acid (VIA); and (iii) HPV-16, -18 vaccination. Input parameters (e.g. age-specific incidence of HPV infection, progression and regression of the infection, test performance of screening methods and efficacy of vaccine) were synthesized from a systematic review and meta-analysis. Costs (year 2007 values) and outcomes were evaluated separately, and compared for each combination. The screening strategies were started from the age of 30-40 years and repeated at 5- and 10-year intervals. In addition, HPV vaccines were introduced at age 15-60 years.

RESULTS

All of the screening strategies showed certain benefits due to a decreased number of women developing cervical cancer versus 'no intervention'. Moreover, the most cost-effective strategy from the societal perspective was the combination of VIA and sequential Pap smear (i.e., VIA every 5 years for women aged 30-45 years, followed by Pap smear every 5 years for women aged 50-60 years). This strategy was dominant, with a QALY gain of 0.01 and a total cost saving of Baht (Bt) 800, compared with doing nothing. From the societal perspective, universal HPV vaccination for girls aged 15 years without screening resulted in a QALY gain of 0.06 at an additional cost of Bt 8,800, based on the cost of Bt 15,000 for a full immunization schedule. The incremental cost-effectiveness ratio, comparing HPV vaccinations for girls aged 15 years with the current national policy of Pap smears for women aged 35-60 years every 5 years, was approximately Bt 18,1000 per QALY gained. This figure was relatively high for the Thai setting.

CONCLUSIONS

The results suggest that controlling cervical cancer by increasing the numbers of women accepting the VIA and Pap smear screening as routine and by improving the performance of the existing screening programmes is the most cost-effective policy option in Thailand.

SOGC–GOC–SCC Joint Policy Statement. No. 255, March 2011. Cervical cancer prevention in low-resource settings

OBJECTIVE

To help care providers understand the current status of cervical cancer in low-resource countries.

OPTIONS

The most effective and practical options for cervical screening and treatment in low-resource countries are evaluated.

OUTCOMES

Improvement in rates of prevention and early detection of cervical cancer in low-resource countries.

EVIDENCE

PubMed or Medline, CINAHL, and The Cochrane Library were searched for studies published in English between January 2006 and December 2009. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table). RECOMMENDATIONS 1. All girls 9 years old or over should have access to the cervical cancer vaccine before they become sexually active. (I-A) 2. Cervical cancer screening by visual inspection with acetic acid is suggested for low-resource settings acceptable. Cervical cytology or human papillomavirus testing may also be used when practical. (II-2B) 3. Cryotherapy is a safe, effective, and low-cost therapy that should be included in pre-invasive cervical cancer treatment. (III-B) 4. All countries should have a documented cervical cancer prevention strategy that includes public education built on existing outreach programs. (III-C) 5. Countries should define a centre or centres of excellence for the management of cervical cancer. (III-C) Because these units would serve a larger population, they would be able to identify leaders and develop their skills, and would be able to invest in costly radiation equipment. 6. All women with cervical cancer should have access to pain management. (III-C).

Effectiveness of cervical cancer screening using visual inspection with acetic acid in Peru

OBJECTIVE

To evaluate the effectiveness of screening using visual inspection with acetic acid (VIA).

METHODS

In a low-resource area of Peru in 2005-2008, a randomly selected sample of women who had previously screened negative by VIA and Pap (intervention group), and a group of eligible women previously unscreened by VIA (comparison group) were screened by VIA. The outcome measures were histologically confirmed cervical intraepithelial neoplasia (CIN) 2-3 and invasive cervical cancer.

RESULTS

There were 4252 women in the intervention group and 4392 in the comparison group. Histologically confirmed CIN 2 or worse was diagnosed in 31 (0.7%) and 115 (2.6%) women, and invasive cancer was diagnosed in 4 women (0.09%) and 43 women (1.00%), in the intervention and comparison groups, respectively. The adjusted odds ratio was 4.2 (95% confidence interval [CI], 2.7-6.4) for CIN 2 or worse, and 13.9 (95% CI, 4.9-39.6) for invasive cervical cancer in the comparison group.

CONCLUSION

A lower prevalence of CIN 2-3 and invasive cervical cancer was seen in women previously screened by VIA, as compared with women not previously screened by VIA, implying that a single VIA screening can lower the population risk for cervical cancer.

Looking ahead: a case for human papillomavirus testing of self-sampled vaginal specimens as a cervical cancer screening strategy

Even in the era of highly effective human papillomavirus (HPV) prophylactic vaccines, substantial reduction in worldwide cervical cancer mortality will only be realized if effective early detection and treatment of the millions of women already infected and the millions who may not receive vaccination in the next decade can be broadly implemented through sustainable cervical cancer screening programs. Effective programs must meet three targets: (i) at least 70% of the targeted population should be screened at least once in a lifetime, (ii) screening assays and diagnostic tests must be reproducible and sufficiently sensitive and specific for the detection of high-grade precursor lesions (i.e., CIN21), and (iii) effective treatment must be provided. We review the evidence that HPV DNA screening from swabs collected by the women in their home or village is sufficiently sound for consideration as a primary screening strategy in the developing world, with sensitivity and specificity for detection of CIN21 as good or better than Pap smear cytology and VIA. A key feature of a self-collected HPV testing strategy (SC-HPV) is the move of the primary screening activities from the clinic to the community. Efforts to increase the affordability and availability of HPV DNA tests, community education and awareness, development of strong partnerships between community advocacy groups, health care centers and regional or local laboratories, and resource appropriate strategies to identify and treat screen-positive women should now be prioritized to ensure successful public health translation of the technologic advancements in cervical cancer prevention.

Advancing cervical cancer prevention initiatives in resource-constrained settings: insights from the Cervical Cancer Prevention Program in Zambia

Groesbeck Parham and colleagues describe their Cervical Cancer Prevention Program in Zambia, which has provided services to over 58,000 women over the past five years, and share lessons learned from the program's implementation and integration with existing HIV/AIDS programs.

Cervical cancer risk factors and feasibility of visual inspection with acetic acid screening in Sudan

Objectives:

To assess the risk factors of cervical cancer and the feasibility and acceptability of a visual inspection with acetic acid (VIA) screening method in a primary health center in Khartoum, Sudan.

Methods:

A cross-sectional prospective pilot study of 100 asymptomatic women living in Khartoum State in Sudan was carried out from December 2008 to January 2009. The study was performed at the screening center in Khartoum. Six nurses and two physicians were trained by a gynecologic oncologist. The patients underwent a complete gynecological examination and filled in a questionnaire on risk factors and feasibility and acceptability. They were screened for cervical cancer by application of 3%–5% VIA. Women with a positive test were referred for colposcopy and treatment.

Results:

Sixteen percent of screened women were tested positive. Statistically significant associations were observed between being positive with VIA test and the following variables: uterine cervix laceration (odds ratio [OR] 18.6; 95% confidence interval [CI]: 4.64–74.8), assisted vaginal delivery (OR 13.2; 95% CI: 2.95–54.9), parity (OR 5.78; 95% CI: 1.41–23.7), female genital mutilation (OR 4.78; 95% CI: 1.13–20.1), and episiotomy (OR 5.25; 95% CI: 1.15–23.8). All these associations remained statistically significant after adjusting for age, educational level, employment, and potential confounding factors such as smoking, number of sexual partners, and use of contraceptive method. Furthermore, the VIA screening method was found to be feasible and acceptable to participants.

Conclusion:

This pilot study showed that women who have uterine cervix laceration, assisted vaginal delivery, female genital mutilation, or episiotomy are at an increased risk of cervical cancer. It also showed that VIA is a feasible and acceptable cervical cancer screening method in a primary health care setting.

Cryotherapy Treatment for Cervical Intraepithelial Neoplasia: Women's Experiences in Peru

Our objective was to examine cryotherapy experiences among women who received treatment for cervical intraepithelial neoplasia in a cervical cancer prevention project in rural Peru. The sample consisted of all women receiving cryotherapy during a 4-month period (July through October 2001). Structured interviews were conducted to collect information about the adequacy of information provision, women's satisfaction with cryotherapy, their ability to comply with postcryotherapy recommendations and condom use, their experience with cryotherapy side effects, and their satisfaction with cryotherapy follow-up. Of the 224 women who were interviewed, user satisfaction with cryotherapy treatment was generally good. A few women engaged in sex earlier than 30 days after treatment, primarily due to partner pressure to resume sex and the women's inability to successfully negotiate abstention from sex. These couples were not always able to use condoms. The percentage of women reporting vaginal discharge was within the range of responses reported in other studies. Cryotherapy appears to be acceptable to women in low-resource settings such as Peru.