Integrating cervical cancer and HIV services for early detection and treatment in Malawi
Liana Charles receiving counselling on cervical cancer at Mangochi District Hospital
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Malawi has the second-highest rate of cervical cancer in the world, with 72.9 cases per 100,000 people.[1] According to the National Cervical Cancer Control Strategy (2016-2020), cervical cancer is the second most common cancer in Malawi, representing 40% of all cancer cases.[2] Despite the fact that the disease is preventable and curable in its early stages, 63% of the 3,684 women diagnosed with cervical cancer annually do not survive.[3] Women living with HIV are at higher risk of the disease.
The Government of Malawi, through the Ministry of Health (MOH), has been committed to implementing a Cervical Cancer Control Program (CECAP) in collaboration with its stakeholders. In 2004, the MOH piloted a cervical cancer screening program in eight health facilities in the southern part of Malawi, which was scaled up to 81 health facilities across the country by 2011. The CECAP focuses on the following key priority areas: community awareness and mobilization, policy and advocacy, primary prevention (including human papilloma virus vaccination scale-up), secondary prevention, tertiary care, and research, monitoring and evaluation. |
Despite the introduction of the CECAP, Malawi experiences low cervical cancer screening coverage – at 27% in 2015 – and more than 80% of cervical cancer cases are diagnosed too late for treatment.[4] Cervical cancer nurse Kelita Maston, stationed at Mangochi District Hospital, explains, “The low cervical cancer screening coverage is a result of a lack of awareness among the general public, a shortage of healthcare providers and policymakers, inadequate cervical cancer prevention and control equipment and services, poorly-coordinated referral systems between and within health facilities, and fragmented healthcare infrastructure.” Research on barriers to screening and early treatment services conducted in 2012 highlighted a lack of equipment and supplies, staff and space shortages, long distances to health facilities, inadequate knowledge about cervical cancer, preference for female providers who are older than the client, and lack of involvement of male partners as factors contributing to a low uptake of cervical cancer services.[5]
In an effort to increase cervical cancer screening and treatment coverage among women living with HIV, the USAID-funded Tingathe program, implemented by Baylor College of Medicine Children’s Foundation Malawi, is coordinating with the Ministry of Health to offer cervical cancer services in 10 health facilities – including the district hospitals – in Balaka, Machinga, Mangochi, Mulanje, Phalombe, and Salima districts. The program focuses on integrating cervical cancer with antiretroviral therapy (ART) services as well as strengthening existing systems and structures for effective service delivery. Tingathe began by providing training to clinical staff, as well as supportive supervision and mentorship, on VIA screening and treatment of precancerous lesions using thermocoagulation from October 2018.
To create demand for uptake of these services, the Tingathe program conducts awareness-raising within the health facilities and in the communities, including health talks by community health workers on ART days. Those who consent to screening are fast-tracked and linked to a nurse overseeing the cervical cancer services. Clients with a VIA positive result – who have signs of abnormal cells or precancerous lesions – are treated with cryotherapy, a treatment which destroys these cells by freezing them, or thermocoagulation, which applies high temperatures to destroy the cells, right at the health facility. Clients who are diagnosed with more invasive cancer are referred for specialized therapy.
As of March 31, 2019, a total of 7,803 women have been screened for cervical cancer. Of these, 3,242 were women living with HIV, representing 41.5% screening coverage of women living with HIV. Out of these 3,242 women screened, 184 were found to be VIA positive, with 121 of these treated using thermocoagulation.
The Tingathe program conducted a one-week cervical cancer awareness campaign at Mangochi District Hospital from March 18-22, 2019. The campaign aimed to increase access to cervical cancer services as well as mentor newly recruited VIA providers on the use of thermocoagulation to promote high quality VIA screening. A total of five nurses, one clinical officer, one VIA coordinator and two VIA mentors were available to offer these services. The hospital made use of the public address system to spread messages across the communities surrounding the hospital on the availability of cervical cancer screening at the hospital. The cervical cancer nurses at the hospital promoted the campaign through health talks at the ART clinic. A total of 496 women were screened during the awareness week, where 141 were women living with HIV. Out of 141 HIV-positive women screened, 11 were VIA positive, with two having precancerous signs. A total of 15 VIA positive cases were treated and seven were referred for palliative care.
Tingathe plans to scale the services to additional communities through outreach screening, where existing screening points will be utilized. The program also plans to expand screening spaces in other health facilities such as Balaka District Hospital. Tingathe’s collaboration with the MOH to integrate services and standardize cervical cancer screening as a core component of routine ART care for women living with HIV should contribute toward early diagnosis and treatment, ensuring Malawian women live longer and healthier lives.
[1] World Cancer Research Fund. Available at: https://www.wcrf.org/dietandcancer/cancer-trends/cervical-cancer-statistics
[2] National Cervical Cancer Control Strategy 2016-2020. Available at: https://malawi.unfpa.org/sites/default/files/resource-pdf/National_Cervical_Cancer_Strategy_A5_30Oct17_WEB.pdf.
[3] Cervical cancer control and prevention in Malawi: need for policy improvement. Available at: http://www.panafrican-med-journal.com/content/article/22/247/full/.
[4] National Cervical Cancer Control Strategy 2016-2020.
[5] Exploring barriers to the delivery of cervical cancer screening and early treatment services in Malawi: some views from service providers. Available at: https://www.dovepress.com/exploring-barriers-to-the-delivery-of-cervical-cancer-screening-and-ea-peer-reviewed-fulltext-article-PPA
In an effort to increase cervical cancer screening and treatment coverage among women living with HIV, the USAID-funded Tingathe program, implemented by Baylor College of Medicine Children’s Foundation Malawi, is coordinating with the Ministry of Health to offer cervical cancer services in 10 health facilities – including the district hospitals – in Balaka, Machinga, Mangochi, Mulanje, Phalombe, and Salima districts. The program focuses on integrating cervical cancer with antiretroviral therapy (ART) services as well as strengthening existing systems and structures for effective service delivery. Tingathe began by providing training to clinical staff, as well as supportive supervision and mentorship, on VIA screening and treatment of precancerous lesions using thermocoagulation from October 2018.
To create demand for uptake of these services, the Tingathe program conducts awareness-raising within the health facilities and in the communities, including health talks by community health workers on ART days. Those who consent to screening are fast-tracked and linked to a nurse overseeing the cervical cancer services. Clients with a VIA positive result – who have signs of abnormal cells or precancerous lesions – are treated with cryotherapy, a treatment which destroys these cells by freezing them, or thermocoagulation, which applies high temperatures to destroy the cells, right at the health facility. Clients who are diagnosed with more invasive cancer are referred for specialized therapy.
As of March 31, 2019, a total of 7,803 women have been screened for cervical cancer. Of these, 3,242 were women living with HIV, representing 41.5% screening coverage of women living with HIV. Out of these 3,242 women screened, 184 were found to be VIA positive, with 121 of these treated using thermocoagulation.
The Tingathe program conducted a one-week cervical cancer awareness campaign at Mangochi District Hospital from March 18-22, 2019. The campaign aimed to increase access to cervical cancer services as well as mentor newly recruited VIA providers on the use of thermocoagulation to promote high quality VIA screening. A total of five nurses, one clinical officer, one VIA coordinator and two VIA mentors were available to offer these services. The hospital made use of the public address system to spread messages across the communities surrounding the hospital on the availability of cervical cancer screening at the hospital. The cervical cancer nurses at the hospital promoted the campaign through health talks at the ART clinic. A total of 496 women were screened during the awareness week, where 141 were women living with HIV. Out of 141 HIV-positive women screened, 11 were VIA positive, with two having precancerous signs. A total of 15 VIA positive cases were treated and seven were referred for palliative care.
Tingathe plans to scale the services to additional communities through outreach screening, where existing screening points will be utilized. The program also plans to expand screening spaces in other health facilities such as Balaka District Hospital. Tingathe’s collaboration with the MOH to integrate services and standardize cervical cancer screening as a core component of routine ART care for women living with HIV should contribute toward early diagnosis and treatment, ensuring Malawian women live longer and healthier lives.
[1] World Cancer Research Fund. Available at: https://www.wcrf.org/dietandcancer/cancer-trends/cervical-cancer-statistics
[2] National Cervical Cancer Control Strategy 2016-2020. Available at: https://malawi.unfpa.org/sites/default/files/resource-pdf/National_Cervical_Cancer_Strategy_A5_30Oct17_WEB.pdf.
[3] Cervical cancer control and prevention in Malawi: need for policy improvement. Available at: http://www.panafrican-med-journal.com/content/article/22/247/full/.
[4] National Cervical Cancer Control Strategy 2016-2020.
[5] Exploring barriers to the delivery of cervical cancer screening and early treatment services in Malawi: some views from service providers. Available at: https://www.dovepress.com/exploring-barriers-to-the-delivery-of-cervical-cancer-screening-and-ea-peer-reviewed-fulltext-article-PPA
