Cervical cancer, an often-preventable disease, kills more than a quarter of a million women each year. Women in low- and middle-income countries are disproportionately impacted by the disease and represent more than 85 percent of all cervical cancer-related deaths worldwide.
Virtually all cervical cancers are caused by infection with human papillomavirus (HPV), a very common sexually transmitted infection.
In high-income countries, early detection and treatment of pre-cancerous lesions has dramatically reduced cervical cancer deaths. Similar programs are not widely available in many of the countries where CHAI works.
However, access to HPV vaccination and programs that screen and treat women for -pre-cancerous lesions offer the opportunity to eliminate cervical cancer for good.
Then, the pandemic hit…
In 2019, CHAI launched our cervical cancer program with support from Unitaid. We partnered with governments in seven countries— India, Kenya, Malawi, Nigeria, Rwanda, South Africa, and Zambia. Our objective was to scale up safe, effective, and affordable pre-cancer screening and treatment technologies and assist partner governments in achieving global cervical cancer elimination targets, aiming to reduce the rate of premature mortality from the disease by a third.[1]
In 2020, we planned to build on the start we had made. Then, the pandemic hit.
Health service planning and delivery across many disease programs, including cervical cancer, were disrupted. Ministries of health in many countries had to suspend screening programs and treatment services for preventative diseases for extended periods and healthcare workers were reassigned to manage COVID-19 response activities. While necessary to deal with the crisis, the suspension of healthcare services and the shift of healthcare worker capacity threatened to undo the gains governments and partners had made, especially around diseases that can be cured if diagnosed early.
Seeing this challenge, we stepped in to support our partner governments to safely move forward with their cervical cancer screening and treatment plans.
In Kenya, CHAI worked with the National Cancer Control Program to roll out community-based HPV self-sampling after realizing that women were hesitant to visit facilities due to the risk of COVID-19 exposure. In South Africa, CHAI helped the National Department of Health to make existing project plans comply with national COVID-19 response strategies and develop innovative digital tools to support the continuation of essential healthcare services. In Malawi, CHAI supported the Ministry of Health to conduct rapid COVID-19 resource mapping and mobilize additional funding to keep the cervical cancer program running.
Enabling a conducive policy environment
At the same time, CHAI helped partner governments push forward their existing programs.
CHAI worked with ministries of health to update protocols in line with the latest WHO guidelines. As a result, six of our seven partner countries now recommend thermal ablation for eligible pre-cancerous lesions. Thermal ablation devices are much easier to use and manage than the prevalent treatment method, cryotherapy, which is cumbersome and logistically difficult to maintain.
In Malawi, Zambia, and Nigeria, CHAI is supporting strategic planning and policy initiatives for 2021 and beyond. In Zambia, CHAI has been instrumental in supporting the Ministry of Health to develop HPV testing guidelines and loop electrosurgical excision procedure (LEEP) training manuals. LEEP is a procedure that uses electrical current to remove pre-cancerous cells.
In India, we supported the Madhya Pradesh State Ministry of Health to raise awareness around thermal ablation devices – leading to its inclusion in the trainer’s manual for healthcare providers on effective treatments for common cancers. We also facilitated the approval of thermal ablation and LEEP devices by the Central Drugs Standard Control Organization (CDSCO), a key milestone that will catalyze device deployment across the country.
In Nigeria, CHAI helped develop a training manual for cervical cancer screening and treatment, including job aids, that was launched by the Minister of Health and adopted into national training materials at the opening ceremony of International Cancer Week 2020 (picture below).
Opening of the 2020 International Cancer Week in Nigeria.
Rolling out comprehensive interventions to improve access to screening and treatment services
In 2018, the World Health Organization (WHO) issued a call to action to eliminate cervical cancer, the first major global commitment to the elimination of a cancer. The WHO officially launched its strategy to eliminate cervical cancer in November 2020.
CHAI is helping partner governments design and deliver on a comprehensive set of secondary prevention services aligned with the WHO’s strategy. We are supporting the procurement and distribution of thermal ablation devices, training healthcare providers how to use them, and helping generate demand among women to services. We are ensuring health workers are adhering to updated treatment guidelines and promoting effective patient management strategies to ensure the continuum of care and minimal loss to follow-up.
In Rwanda, we have trained or mentored healthcare providers on HPV testing and treatment of pre-cancerous lesions; as a result, over 15,000 women have already been screened and at least 240 have been treated using thermal ablation devices. We have also helped the Ministry of Health develop a patient tracking tool to ease follow-up of care.
In Madhya Pradesh, India, CHAI has supported similar training, leading to over 19,000 cervical cancer screens. In Kenya and Nigeria, in preparation for the rollout of their screening and treatment programs, a vast majority of senior health workers (master trainers) have already been trained to pass their knowledge on to state health workers. Thermal ablation and LEEP devices have also been placed in facilities.
In Malawi, 18 new health facilities have started providing cervical cancer screening, of which 14 are equipped to treat women who have tested positive for pre-cancerous lesions. This is possible because facilities have been equipped with thermal ablation devices and health workers trained on their use. In Zambia, CHAI’s efforts have helped expand screening and treatment facilities in some of the most remote and under-served areas.
In 2021 in Nigeria, CHAI will facilitate the screening of 430,000 women and provide appropriate treatment for those who have tested positive for pre-cancerous lesions. In South Africa, CHAI will partner with the National Health Laboratory Service to pilot HPV testing and deploy portable treatment devices and colposcopes to facilities in priority provinces.
In Kenya, CHAI plans to help deploy 1,000 thermal ablation devices and train up to 2,000 healthcare workers. In India, with the support of CDSCO, CHAI is helping deploy over 350 thermal ablation devices to public health facilities.
Building on our momentum
With the ground set for pre-cancer screening and treatment programs across our partner governments, the year ahead will be about building on political will and operational momentum to maximize the number of women who are screened, treated, and followed-up.
CHAI will support our partner governments in adopting new technologies, ensuring pre-cancer screening and treatment programs are practical, affordable, widely accessible, and sustainable.
Contributing authors: Kelly McCrystal, Karen Milch Hariharan, Parth Bahuguna,Tamlyn Roman, Patricia Njiri, Memory Samboko, Ranveer Singh, Lola Ameyan, Leslie Berman, Sylvie Gaju.
[1] Mortality impact of achieving WHO cervical cancer elimination targets: a comparative modelling analysis in 78 low-income and lower-middle-income countries
