Evaluation of Cervical Cancer Screening Programs in Côte d'Ivoire, Guyana, and Tanzania: Effect of HIV Status.

BACKGROUND: HIV infection increases a woman's risk for cervical cancer, and cervical cancer incidence and mortality rates are higher in countries with high HIV prevalence and limited resources for screening. Visual inspection with acetic acid (VIA) allows screening and treatment of cervical lesions in a single-visit approach (SVA), but data on its performance in HIV-infected women are limited. This study's objective was to examine cervical cancer screening using VIA/SVA in programs serving HIV-infected women. METHODS: A VIA/SVA program with cryotherapy for VIA-positive lesions was implemented in Côte d'Ivoire, Guyana, and Tanzania from 2009 to 2012. The effect of HIV status on VIA positivity and on presence of cryotherapy-eligible lesions was examined using a cross-sectional study design, with Chi-square tests for comparisons and constructed multivariate logistic regression models. A P-value of < 0.05 was significant. FINDINGS: VIA was performed on 34,921 women, 10% (3,580) were VIA positive; 2,508 (85%) eligible women received cryotherapy during the same visit; only 234 (52%) of those who postponed returned for treatment; 622 (17%) VIA-positive women had lesions too large to be treated with cryotherapy and were referred for excisional treatment. In multivariate analysis-controlling for HIV status, location of the screening clinic, facility location, facility type, and country-compared to HIV-uninfected/unknown women, HIV-infected women had higher odds of being VIA positive (OR 1.95, 95% CI 1.76, 2.16, P<0.0001) and of having large lesions requiring referral (OR 1.93, 95% CI 1.49, 2.51, P< 0.0001). Minor treatment complications occurred in 19 of 3,032 (0.63%) women; none required further intervention. CONCLUSIONS: This study found that compared to HIV-uninfected/unknown women, HIV-infected women had nearly twice the odds of being VIA-positive and to require referral for large lesions. SVA was safe and resulted in significant reductions in loss to follow-up. There is increased need for excisional treatment in countries with high HIV prevalence.

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.

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.