Cervical cancer screening: Safety, acceptability, and feasibility of a single-visit approach in Bulawayo, Zimbabwe

Prevalence of Cervical Cancer and Clinical Management of Women Screened positive using visual inspection with acetic acid and Cervicography in selected public sector health facilities of Manicaland and Midlands provinces of Zimbabwe, 2021

BACKGROUND

Zimbabwe has high cervical cancer (CC) burden of 19% and mortality rate of 64%. Zimbabwe uses Visual Inspection with Acetic Acid and Cervicography (VIAC) for CC screening. Manicaland and Midlands provinces recorded low VIAC positivity of 3% (target 5-25%) and treatment coverage of 78% (target = 90%) between October 2020 and September 2021.

OBJECTIVES

We explored VIAC positivity rate and clinical management of clients screening positive in Manicaland and Midlands provinces.

METHODS

We conducted a retrospective cross-sectional study using routine VIAC and CC management data for period October 2020 to September 2021. Two samples were used, 1) a sample drawn from 48,000 women VIAC screened to measure positivity rate, and 2) a sample of 1,763 VIAC positive women to assess clinical management. Kobo-based tool was used to abstract data from facility registers, and data were analyzed using STATA 15.

RESULTS

We analyzed data for 2,454 out of 48,000 women screened through VIAC. About 82% (2,007/2,454) were HIV positive, median ages were 40 and 38 years for HIV positives and negatives respectively. Most (64% and 77%) of HIV positive and negative clients respectively were married. VIAC positivity was 5.9% and 3.4% among HIV positive and negative women screened for the first time, and 3.2% and 5.6% for repeat visits respectively. Overall, 89.1% (1,571/1,763) of VIAC positive women received treatment. Most (41%) of those treated received thermocoagulation. Overall, 43.1% of clients received treatment on VIAC day, and 77.4% within 30 days. Six-month post-treatment coverage was 3.8%.

CONCLUSION

VIAC positivity among HIV positive women screening for the first time was 5.9%, within the expected 5-25%. Treatment coverage was high, and turnaround time from diagnosis to treatment met national standards. Post-treatment coverage was suboptimal. We recommend continued implementation of quality improvement initiatives, capacity building of clinicians, and optimization of post-treatment review of clients.

Implementation research on noncommunicable disease prevention and control interventions in low- and middle-income countries: A systematic review

BACKGROUND

While the evidence for the clinical effectiveness of most noncommunicable disease (NCD) prevention and treatment interventions is well established, care delivery models and means of scaling these up in a variety of resource-constrained health systems are not. The objective of this review was to synthesize evidence on the current state of implementation research on priority NCD prevention and control interventions provided by health systems in low- and middle-income countries (LMICs).

METHODS AND FINDINGS

On January 20, 2021, we searched MEDLINE and EMBASE databases from 1990 through 2020 to identify implementation research studies that focused on the World Health Organization (WHO) priority NCD prevention and control interventions targeting cardiovascular disease, cancer, diabetes, and chronic respiratory disease and provided within health systems in LMICs. Any empirical and peer-reviewed studies that focused on these interventions and reported implementation outcomes were eligible for inclusion. Given the focus on this review and the heterogeneity in aims and methodologies of included studies, risk of bias assessment to understand how effect size may have been compromised by bias is not applicable. We instead commented on the distribution of research designs and discussed about stronger/weaker designs. We synthesized extracted data using descriptive statistics and following the review protocol registered in PROSPERO (CRD42021252969). Of 9,683 potential studies and 7,419 unique records screened for inclusion, 222 eligible studies evaluated 265 priority NCD prevention and control interventions implemented in 62 countries (6% in low-income countries and 90% in middle-income countries). The number of studies published has been increasing over time. Nearly 40% of all the studies were on cervical cancer. With regards to intervention type, screening accounted for 49%, treatment for 39%, while prevention for 12% (with 80% of the latter focusing on prevention of the NCD behavior risk factors). Feasibility (38%) was the most studied implementation outcome followed by adoption (23%); few studies addressed sustainability. The implementation strategies were not specified well enough. Most studies used quantitative methods (86%). The weakest study design, preexperimental, and the strongest study design, experimental, were respectively employed in 25% and 24% of included studies. Approximately 72% of studies reported funding, with international funding being the predominant source. The majority of studies were proof of concept or pilot (88%) and targeted the micro level of health system (79%). Less than 5% of studies report using implementation research framework.

CONCLUSIONS

Despite growth in implementation research on NCDs in LMICs, we found major gaps in the science. Future studies should prioritize implementation at scale, target higher levels health systems (meso and macro levels), and test sustainability of NCD programs. They should employ designs with stronger internal validity, be more conceptually driven, and use mixed methods to understand mechanisms. To maximize impact of the research under limited resources, adding implementation science outcomes to effectiveness research and regional collaborations are promising.

Patient expectations and experiences with loop electrosurgical excision procedure in inpatient and outpatient settings

BACKGROUND

Loop electrosurgical excision procedure (LEEP) for high-grade squamous intraepithelial lesion is performed in both an inpatient setting under general anaesthesia and an outpatient setting under local anaesthesia. Efficacy and safety are comparable and outpatient LEEP may save time and cost in the Australian setting.

AIMS

We aim to compare patient satisfaction with inpatient LEEP compared to outpatient LEEP for Australian best practice.

MATERIALS AND METHODS

This was a prospective quantitative and qualitative cohort study. An online questionnaire was sent to patients undergoing inpatient and outpatient LEEP to assess satisfaction with the procedure. Further histopathological and demographic data were also collected from the medical records. Groups were compared using Fischer's exact test and pain scores were compared using non-parametric tests.

RESULTS

Ninety-three outpatients and 52 inpatients responded to the survey. No difference was found between groups with regard to rate of positive histopathological margins or number of passes required. Outpatients found the procedure to be more convenient than inpatients (P = 0.007), and experienced more pain during the procedure than the inpatient group (P < 0.001). There was no significant difference in pain scores following the procedure or post-procedure anxiety.

CONCLUSIONS

Outpatient LEEP is an acceptable and well-tolerated procedure, comparable to inpatient LEEP. Regardless of the option chosen, patients are highly likely to be satisfied with their choice. Increased efforts should be made to reduce pre-procedural anxiety, which may in turn reduce expectations and experiences of pain.

Association of HIV status and treatment characteristics with VIA screening outcomes in Malawi: A retrospective analysis

Background

Although evidence from high-resource settings indicates that women with HIV are at higher risk of acquiring high-risk HPV and developing cervical cancer, data from cervical cancer “screen and treat” programs using visual inspection with acetic acid (VIA) in lower-income countries have found mixed evidence about the association between HIV status and screening outcomes. Moreover, there is limited evidence regarding the effect of HIV-related characteristics (e.g., viral suppression, treatment factors) on screening outcomes in these high HIV burden settings.

Methods

This study aimed to evaluate the relationship between HIV status, HIV treatment, and viral suppression with cervical cancer screening outcomes. Data from a “screen and treat” program based at a large, free antiretroviral therapy (ART) clinic in Lilongwe, Malawi was retrospectively analyzed to determine rates of abnormal VIA results and suspected cancer, and coverage of same-day treatment. Multivariate logistic regression assessed associations between screening outcomes and HIV status, and among women living with HIV, viremia, ART treatment duration and BMI.

Results

Of 1405 women receiving first-time VIA screening between 2017–2019, 13 (0.9%) had suspected cancer and 68 (4.8%) had pre-cancerous lesions, of whom 50 (73.5%) received same-day lesion treatment. There was no significant association found between HIV status and screening outcomes. Among HIV+ women, abnormal VIA was positively associated with viral load ≥ 1000 copies/mL (aOR 3.02, 95% CI: 1.22, 7.49) and negatively associated with ART treatment duration (aOR 0.88 per additional year, 95% CI: 0.80, 0.98).

Conclusion

In this population of women living with HIV with high rates of ART coverage and viral suppression, HIV status was not significantly associated with abnormal cervical cancer screening results. We hypothesize that ART treatment and viral suppression may mitigate the elevated risk of cervical cancer for women living with HIV, and we encourage further study on this relationship in high HIV burden settings.

Uterine cervical neoplasms mass screening at the University Hospital Centre of Libreville, Gabon: Associated factors with precancerous and cancerous lesions

The objectives of this study were to identify the associated factors with cancerous and precancerous lesions of cervix. In Africa, the incidence of uterine cervical neoplasms varies from one region to another, where most women with uterine cervical neoplasms are seen at an advanced stage. For this reason, uterine cervical neoplasms mass screening reduces the incidence and mortality due to this disease, similar to what is being done in Europe. A cross-sectional analytical study was conducted. Socio-demographic characteristics, gynaecological-obstetrical history, risk factors, data from visual inspection with acetic acid and visual inspection with Lugol, colposcopy impressions and results of cytological analysis were performed. A simple and multiple regression were performed to establish a statistically significant difference between certain factors and the presence of precancerous or cancerous lesions of uterine cervical. In this study, of 63 women diagnosed histologically, 43 had precancerous lesions and 20 had cancerous lesions. we found that being older than 35, having the first intercourse before 18, having an antecedent of STI, being a widow and using of tobacco were risk factors associated with precancerous lesions (p = 0.013 with OR = 3.44 (1.22–9.73), p = 0.009 with OR = 4.07 (1.69–13.08), p < 0.001 with OR = 3.80 (1.94–7.47), p < 0.001 with OR = 9.77 (3.87–24.70) and p < 0.001 with OR = 5.47 (2.60–11.52)) respectively. Only being older than 45, being a widow and using tobacco were risk factors associated with cancerous lesions (p = 0.021 with OR = 2.01 (1.58–3.56), p = 0.02 with OR = 2.96 (2.10–3.87), p = 0.041 with OR = 1.98 (1.46–2.44)) respectively. Among participants diagnosed with uterine cervical neoplasms, there was a significant association with the STI, marital status and smoking. Despite the integration of the detection of precancerous uterine cervical neoplasms lesions into health facilities in Gabon, uterine cervical neoplasms ranks second among women’s cancers in terms of incidence and first in terms of mortality.

Cervical Cancer Screening Uptake and Associated Factors among HIV-Positive Women in Ethiopia: A Systematic Review and Meta-Analysis

Background

Women living with human immunodeficiency virus (HIV) are more likely to develop an increased risk of invasive cervical cancer. Morbidity and mortality due to cervical cancer could be reduced with early detection through cervical screening. Though uptake of cervical screening was investigated in Ethiopia, inconsistent findings were reported. Therefore, this systematic review and meta-analysis was designed to estimate the pooled prevalence of cervical cancer screening uptake among HIV-positive women and its associated factors in Ethiopia.

Methods

A comprehensive search of PubMed/MEDLINE, Scopus, EMBASE, CINAHL, Google Scholar, Science Direct, and Cochrane Library was conducted. The data were extracted using a standardized data extraction format. Statistical analysis was done using the STATA, version 14, software. The heterogeneity of the studies was assessed using the I² test. Funnel plots and Egger's test were used to check publication bias. A random effects model was computed to estimate the pooled prevalence of cervical cancer screening uptake. Moreover, pooled odds ratios with 95% confidence intervals were used to determine the association of identified determinant factors with cervical cancer screening uptake.

Results

A total of 10358 studies were retrieved, and 7 studies were included in the meta-analysis. The pooled prevalence of cervical cancer screening uptake among HIV-positive women in Ethiopia was 18.17% (95% CI : 11.23, 25.10) with exhibited heterogeneity (I² = 96.6%; p < 0.001). Educational status of women (AOR = 3.50; 95% CI : 1.85, 6.07), knowledge of women on cervical cancer (AOR = 3.26; 95% CI : 2.50, 4.43), and perceived susceptibility (AOR = 3.26; 95% CI : 2.26, 4.26) were significantly associated with cervical cancer screening uptake among HIV-positive women.

Conclusion

The uptake of cervical cancer screening among HIV-positive women in Ethiopia was low. The findings of this study suggest the need to improve the existing national strategies of cervical cancer screening so as to strengthen reproductive health education and promotion, in addition to providing screening services. Furthermore, cervical screening service should be integrated to the routine care and treatment, so that HIV-positive women can get counseling services in every clinical contact.

Health system constraints affecting treatment and care among women with cervical cancer in Harare, Zimbabwe

Background

Cervical cancer is a major cause of morbidity and mortality among women yet access to treatment and care remains a huge challenge in Zimbabwe. The objective of this study was to investigate health system constraints affecting engagement into treatment and care by women with cervical cancer in Harare, Zimbabwe.

Methods

A sequential explanatory mixed methods design was used for this study. Phase 1 comprised of two surveys namely: patient and health worker surveys with sample sizes of 134 and 78 participants respectively. Validated structured questionnaires programmed in Android tablet with SurveytoGo software were used for data collection during the surveys. Univariate analyses were conducted using STATA® version 14 to generate descriptive statistics. In phase 2, 16 in-depth interviews, 20 key informant interviews and 6 focus groups were conducted to explain survey results. Participants were purposively selected and sample sizes were informed by saturation principle. Participants in phase 1 and 2 were different. English transcripts were manually coded line by line in Dedoose software using the thematic codes that had been established from the survey data. The final codes were used to support and explain the survey data at the interpretation stages.

Results

Health system constraints identified in surveys were: limited or lack of training for health workers, weakness of surveillance system for cervical cancer, limited access to treatment and care, inadequate health workers, reliance of patients on out-of-pocket funding for treatment services, lack of back-up for major equipment. Qualitative inquiry revealed the following barriers to treatment and care: high costs of treatment and care, lack of knowledge about cervical cancer and bad attitudes of health workers, few screening and treating centres located mostly in urban areas, lack of clear referral system resulting in bureaucratic processes, and limited screening and treating capacities in health facilities due to lack of resources.

Conclusion

The results of this study show that health system and its organization present barriers to access of cervical cancer treatment and care among women. Strong political will, mobilization of resources both domestically and from partners in addition to sound policies are imperative to address key health system challenges.

Ablative Therapies for Cervical Intraepithelial Neoplasia in Low-Resource Settings: Findings and Key Questions

Barriers to access for cervical precancer care in low-resource settings go beyond cost. Gas-based cryotherapy has emerged as the standard treatment in these areas, but there are barriers to this technology that have necessitated the development and implementation of affordable and portable alternatives. This review identifies knowledge gaps with regard to technologies primarily used in low-resource settings, including standard cryotherapy, nongas-based cryotherapy, and thermoablation. These gaps are addressed using evidence-based guidelines, patient and provider acceptability, long-term obstetric outcomes, and treatment of women with HIV infection. This review highlights the need for prospective studies that compare ablative methods, especially given the increasing use of thermoablation.

Determinants of access and utilization of cervical cancer treatment and palliative care services in Harare, Zimbabwe

Background

Cervical cancer treatment and care services have remained largely centralized in Zimbabwe thereby entrenching inequities to access amongst patients. The objective of this study was to investigate the determinants of access to treatment and care among women with cervical cancer in Harare, Zimbabwe.

Methods

A sequential explanatory mixed methods design was used. In phase 1, three surveys (namely community, patient and health worker) were conducted with sample sizes of 143, 134 and 78 participants respectively. Validated structured questionnaires programmed in Android tablet with SurveytoGo software were used for data collection during the surveys. Univariate, bivariate and multivariate logistic regression analyzes were conducted using STATA® version 14 to generate descriptive statistics and identify determinants of access to cervical cancer treatment and care. In phase 2, 16 in-depth interviews, 20 key informant interviews and 6 focus groups were conducted to explain quantitative data. Participants were purposively selected and saturation principle was used to guide sample sizes. Manually generated thematic codes were processed in Dedoose software to produce final outputs for qualitative study.

Results

Knowledge of causes (p = 0.046), perceptions of adequacy of specialists (p < 0.001), locus of control (p = 0.009), service satisfaction (p = 0.022) and walking as a means of reaching nearest health facilities (p < 0.001) were associated with treatment or perceptions of access by healthy women. Perceptions of access to treatment amongst health workers were associated with their basic training institution (p = 0.046), health service quality perceptions (p = 0.035) and electricity supply status in their respective health facilities (p = 0.036).Qualitative findings revealed health system, societal and individual factors as barriers to accessing treatment and palliative care.

Conclusions

There are numerous prevailing multi-dimensional barriers to accessing cervical cancer treatment and palliative care in a low –income setting. The findings of this study revealed that heath system and societal factors were more important than individual level factors. Multi-sectoral approaches are recommended to address all the multifaceted barriers in order to improve cervical cancer treatment and palliative care access for better outcomes in resource-limited contexts.

Utilization and outcomes of cervical cancer screening services in Harare City, 2012-2016: a secondary data analysis

BACKGROUND

Visual inspection with acetic acid and cervicography (VIAC) is a method used to screen for cervical cancer. VIAC can be used as part of a "see and treat" strategy. Nine Harare city council health facilities offer VIAC free of charge with the aim of reducing morbidity and mortality from cervical cancer. Between 2014 and 2016, the number of women utilising VIAC dropped by 35%. We analysed records of clients who utilise VIAC at Harare city health facilities to characterise women accessing VIAC and their outcomes to make recommendations for improving the services.

METHODS

We conducted a descriptive cross-sectional study using data collected for the Harare city VIAC program. We analysed all records of clients who utilised VIAC services at nine Harare city health facilities from 1 May 2012 to 31 December 2016.

RESULTS

We analysed 46,217 records, the median age of the clients was 34 years [Q₁ = 27: Q₃ = 42]. Of the 46,217 clients screened, 3001 (6.5%) were VIAC positive, and 512 (1.1%) had suspicious of cancer lesions. The prevalence of VIAC positive ranged from 58 to 74 per 1000-screened clients over the 5 years. The prevalence of suspected cancer ranged from 9 to 14 per 1000-screened clients, and there was a general decrease in the prevalence between 2012 and 2016. Of the 3513 clients with VIAC positive or had suspicious of cancer lesions, 2090 (74.1%) did not receive treatment at the site where the screening took place.

CONCLUSION

The majority of women who are accessing VIAC services in Harare are middle-aged, multiparous and married women. There is a treatment gap at most of the VIAC centres such that clients are referred to other centres for management. The objective of "see and treat" is not being realised.

Prevention of cervical cancer in HIV-seropositive women from developing countries through cervical cancer screening: a systematic review

BACKGROUND

There is scanty or inconclusive evidence on which cervical cancer screening tool is effective and suitable for human immunodeficiency virus (HIV)-seropositive women. The aim of this review was to assess, synthesise and document published evidence relating to the available cervical cancer screening modalities for HIV-seropositive women in developing countries. This paper did not review the issue of human papillomavirus (HPV) prophylactic vaccine on HIV-seropositive women.

METHODS

Five electronic databases were systematically searched from inception to January 2018 for relevant published original research examining cervical cancer prevention modalities for HPV infection, abnormal cytology and direct visualisation of the cervix amongst HIV-seropositive women in developing countries. Extra studies were identified through reference list and citation tracking.

RESULTS

Due to methodological and clinical heterogeneity, a narrative synthesis was presented. Of the 2559 articles, 149 underwent full-text screening and 25 were included in the review. Included studies were of moderate quality, and no exclusions were made based on quality or bias. There is no standard cervical cancer screening test or programme for HIV-seropositive women and countries screening according to available resources and expertise. The screening methods used for HIV-seropositive women are the same for HIV-negative women, with varying clinical performance and accuracy. The main cervical cancer screening methods described for HIV-seropositive women are HPV deoxyribonucleic acid/messenger RNA (DNA/mRNA) testing (n = 16, 64.0%), visual inspection with acetic acid (VIA) (n = 13, 52.0%) and Pap smear (n = 11, 44.0%). HPV testing has a better accuracy/efficiency than other methods with a sensitivity of 80.0-97.0% and specificity of 51.0-78.0%. Sequential screening using VIA or visual inspection with Lugol's iodine (VILI) and HPV testing has shown better clinical performance in screening HIV-seropositive women.

CONCLUSION

Although cervical cancer screening exists in almost all developing countries, what is missing is both opportunistic and systematic organised population-based screenings. Cervical cancer screening programmes need to be integrated into already existing HIV services to enable early detection and treatment. There is a need to offer opportunistic and coordinated screening programmes that are provider-initiated to promote early identification of cervical precancerous lesions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018095702.

Barriers to accessing cervical cancer screening among HIV positive women in Kgatleng district, Botswana: A qualitative study

Background

Low and middle-income countries have a greater share of the cervical cancer burden, but lower screening coverage, compared to high-income countries. Moreover, screening uptake and disease outcomes are generally worse in rural areas as well as in the HIV positive population. Efforts directed at increasing the screening rates are important in order to decrease cancer-related morbidity and mortality. This study aimed to explore the barriers to women with HIV accessing cervical cancer screening in Kgatleng district, Botswana.

Methods

A phenomenological qualitative study utilising semi-structured interviews with fourteen HIV positive women, selected by purposive sampling. The interviews were transcribed verbatim and the 5-steps of the framework method, assisted by Atlas-ti software, was used for qualitative data analysis.

Results

Contextual factors included distance, public transport issues and work commitments. Health system factors highlighted unavailability of results, inconsistent appointment systems, long queues and equipment shortages and poor patient-centred communication skills, particularly skills in explanation and planning. Patient factors identified were lack of knowledge of cervical cancer, benefits of screening, effectiveness of treatment, as well as personal fears and misconceptions.

Conclusion

Cervical cancer screening was poorly accessed due to a weak primary care system, insufficient health promotion and information as well as poor communication skills. These issues could be partly addressed by considering alternative technology and one-stop models of testing and treating.

Distribution of cervical abnormalities detected by visual inspection with acetic acid in Swaziland, 2011-2014: A retrospective study

BACKGROUND

 Cervical cancer is the fourth most common cancer worldwide among women, with the number of new cases increasing from 493 243 in 2002 to 527 000 in 2012. These numbers are likely to be underestimated because given the lack of registration resources, cervical cancer deaths are usually under-reported in low-income countries.

AIM

 To describe the distribution of and trends in visual inspection with acetic acid (VIA) to detected cervical abnormalities in Swaziland by reviewing records of VIA examinations performed at two main hospitals in Swaziland between 2011 and 2014.

SETTING

 Mbabane Government Hospital and Realign Fitkin Memorial (RFM).

METHODS

 Records of cervical screening using VIA at the Mbabane government hospital and RFM hospital between 2011 and 2014 were retrieved. Positivity rates (PRs) of VIA with 95% confidence intervals (95% CI) were calculated and used as proxies of cervical abnormalities. Odds ratios of the association between VIA-detected cervical abnormalities and human immunodeficiency virus (HIV) status were estimated using logistic regressions.

RESULTS

 VIA was positive in 1828 of 12 151 VIA records used for analysis (15%, 95% CI: 14.4-15.7). VIA was positive in 9% (36 of 403) women under the age of 20, in 15.5% (1714 of 11 046) of women aged 20-49 years and in 11.1% (78 of 624) of women aged 50-64 years. A decreasing trend of VIA positivity was observed over time at both screening centres (p for trend < 0.001). Of 2697 records with Papanicolaou results, 20% (67 of 331) VIA-positives and only 5% (114 of 2366) VIA negatives had high-grade squamous intraepithelial lesion. Among 4578 women with reported HIV status, 1702 were HIV-positive (37.2%, 95% CI: 35.8-38.6). The prevalence of HIV in VIA-positive women was 62.5% (95% CI: 58.7-66.2), almost double that among VIA-negative women (33.0%, 95% CI: 31.6-34.5) and that among all women screened (p < 0.001). HIV-positive women were 3.4 times more likely to have cervical abnormalities on VIA than HIV-negative women (OR: 3.4, 95% CI: 2.8-4.0, p < 0.01).

CONCLUSION

 The high VIA PRs observed over four years in this study may reflect the prevalence of cervical abnormalities, in particular, in HIV-positive women. VIA is not a robust screening test, but it can play a major role in strengthening and expanding cervical cancer screening prevention programmes in resource-limited countries.

Expanding the Single-Visit Approach for Cervical Cancer Prevention: Successes and Lessons From Burkina Faso

The single-visit approach was implemented with strong attention to systems in 14 health facilities. In the 2 largest facilities, nearly 14,000 women screened for cervical cancer over 4 years. Of approximately 9% who screened positive, about 66% received same-day cryotherapy. Attention is needed to ensure local technicians can repair cryotherapy equipment, supplies are consistently in stock, and user fees are not prohibitive to accessing care.

Background:

Cervical cancer accounts for 23% of cancer incidence and 22% of cancer mortality among women in Burkina Faso. These proportions are more than 2 and 5 times higher than those of developed countries, respectively. Before 2010, cervical cancer prevention (CECAP) services in Burkina Faso were limited to temporary screening campaigns.

Program Description:

Between September 2010 and August 2014, program implementers collaborated with the Ministry of Health and professional associations to implement a CECAP program focused on coupling visual inspection with acetic acid (VIA) for screening with same-day cryotherapy treatment for eligible women in 14 facilities. Women with larger lesions or lesions suspect for cancer were referred for loop electrosurgical excision procedure (LEEP). The program trained providers, raised awareness through demand generation activities, and strengthened monitoring capacity.

Methods:

Data on program activities, service provision, and programmatic lessons were analyzed. Three data collection tools, an individual client form, a client registry, and a monthly summary sheet, were used to track 3 key CECAP service indicators: number of women screened using VIA, proportion of women who screened VIA positive, and proportion of women screening VIA positive who received same-day cryotherapy.

Results:

Over 4 years, the program screened 13,999 women for cervical cancer using VIA; 8.9% screened positive; and 65.9% received cryotherapy in a single visit. The proportion receiving cryotherapy on the same day started at a high of 82% to 93% when services were provided free of charge, but dropped to 51% when a user fee of $10 was applied to cover the cost of supplies. After reducing the fee to $4 in November 2012, the proportion increased again to 78%. Implementation challenges included difficulties tracking referred patients, stock-outs of key supplies, difficulties with machine maintenance, and prohibitive user fees. Providers were trained to independently monitor services, identify gaps, and take corrective actions.

Conclusions:

Following dissemination of the results that demonstrated the acceptability and feasibility of the CECAP program, the Burkina Faso Ministry of Health included CECAP services in its minimum service delivery package in 2016. Essential components for such programs include provider training on VIA, cryotherapy, and LEEP; provider and patient demand generation; local equipment maintenance; consistent supply stocks; referral system for LEEP; non-prohibitive fees; and a monitoring data collection system.

Digital Cervicography by Simply Portable Device as an Alternative Test for Cervical Cancer Screening in Rural Area of Thailand

Objective:

Various screening methods for cervical cancer are proved to be effective in reducing such type of cancer. We aims to introduce a new portable device as an alternative method for cervical cancer screening. The performance of device was tested on the assessment of cervical lesions using cervicograph score with the cervical cytology.

Methods:

325 non-pregnant women were tested from March 2013 to August 2015. The cervical and vaginal cells from the sample were collected for cytology, then all of them received the digital cervicography conducted with our new device and scored using cervicograph score. Small pieces of cervical tissues were also collected for histologic examination. SPSS software version 18.0 was used for the statistical analysis.

Results:

We grouped cytology results and cervicograph scores to 2 subgroups, ≤ ASC-US and ≥ LSIL, and 0-3 points and 4-6 points, respectively. The data then correlated with histology results which sub-grouped to ≤ CIN 1 and ≥ CIN 2. The accuracy, sensitivity, specificity, and positive predictive value (PPV) of cervicograph scores 4-6 points to detect CIN 2+ were 92%, 72.41%, 97%, and 84%, respectively which were not inferior to Pap smear did.

Conclusion:

The digital cervicography device provides similar accuracy to Pap cytology screening and is suitable to use in the area that lacks cytoscreeners. Large scale use and generalization are required for this new device.

Cervical cancer in Zimbabwe: a situation analysis

INTRODUCTION

Despite the wide-spread availability of cervical cancer prevention and screening programs in developed countries, the morbidity and mortality rates of cervical cancer in Zimbabwe are still very high. Limited resources as well as the high HIV prevalence are contributors to the high burden of cervical cancer. This paper aims to analyse the policies, frameworks and current practices in the management of cervical cancer in Zimbabwe.

METHODS

A review of national documents and published literature on cervical cancer prevention, screening, treatment and knowledge in Zimbabwe was done. Informal interviews were conducted to assess the practices of cervical cancer management.

RESULTS

Through strategic collaboration, a pilot for the HPV vaccination program is underway. The VIAC national cervical cancer screening program is being adopted into the current healthcare system. With regards to the treatment of precancerous lesions we found that the "see and treat" program has been implemented in colposcopy clinics. In addition, there are two multidisciplinary cancer treatment clinics installed in two central public hospitals. The general knowledge and understanding of cervical cancer is poor in Zimbabwe.

CONCLUSION

Limitations in resources, infrastructure, manpower, delays in treatment and patient knowledge play a role in the high morbidity and mortality of cervical cancer in Zimbabwe. The Ministry of Health needs to increase funding to expedite the availability of HPV vaccine and screening programs. Community engagement initiatives to raise awareness on cervical cancer should be established to provide education on how to prevent the development of cervical cancer, as well as promote screening for early detection.

Incisal margin condition after LEEP for cervical intraepithelial neoplasia patients and prognosis

The aim of the study was to examine the relationship between incisal condition after loop electrosurgical excision procedure (LEEP) operation for cervical intraepithelial neoplasia (CIN) patients and prognosis. A study of high-risk incisal margin positive cases was also performed. We compared the differences in the prognosis of the 1-year follow-up visit in the 120 CIN patients admitted to the hospital during the period from April 2013 to April 2014. A total of 43 cases of positive incisal margin (35.8%), and 77 negative cases were included in the study. The differences in age, course of disease, and CIN level between the two groups showed no statistical significance (P>0.05). In the positive group, the positive ratio was significantly higher than that of the negative group (P<0.05). The positive incisal margin showed a significant positive correlation with human papillomavirus (HPV) positivity (r=0.327, P=0.035). The condition of most patients with positive incisal margin and HPV was critical, which was followed by positive incisal margin and negative HPV. The patients with the best prognosis were those with significant negative incisal margin as well as HPV (P<0.05). In conclusion, the positive incisal margin after LEEP operation was associated with relapse of the disease. Thus, considering the HPV test into consideration is valuable for the prognosis of the disease.