columnBy Janet Fleischman and Julia Nagel
Cervical cancer kills an estimated 275,000 women every year, 85 percent of whom are in developing countries. The link between HIV and cervical cancer is direct and deadly; HIV-infected women who are also infected with specific types of human papilloma virus (HPV) are 4-5 times more susceptible to cervical cancer than HIV-negative women. This has important implications for HIV programs, especially in countries with significant HIV epidemics.
To understand the opportunities and challenges of integrating cervical cancer screening and treatment into HIV services for women, we traveled to Zambia, which has been at the forefront of integrating these services. Dr. Joan Katema, provincial coordinator for the cervical cancer screening program, explained why this integration is so critical: "Most of the attention was drawn to HIV only... But we'd still find that despite [women] accessing the ARVs and all the services that come with the ART clinic, they were still dying from cervical cancer."
Attention to cervical cancer in Zambia has been heightened with the December 2011 launch of the Pink Ribbon Red Ribbon (PRRR) initiative, led by the George W. Bush Institute, the U.S. State Department, Susan G. Komen for the Cure, UNAIDS, and several corporate partners. PRRR is designed to build off the HIV services supported by PEPFAR to expand cervical and breast cancer prevention, screening, and treatment. Zambia is the first PRRR focus country, and President George W. Bush and Mrs.
Laura Bush initially launched the program there. The Zambian government has also been very engaged in PRRR, led by the first lady, Dr. Christine Kaseba Sata, an obstetrician and gynecologist herself. The impact of this leadership is apparent, according to a nurse supervisor with the cervical cancer program: "We've been encouraged a lot by our women leaders in this country... including the First Lady.
She's been talking about cervical cancer screening and [its] importance a lot on TV, on radio, and so as a result, we've seen that a lot of women have reacted positively, received the message and have come in for screening."
Since the start of PRRR in December 2011, the demand for screening has been growing in Zambia, sometimes overwhelming the roughly 50 health care workers who have been trained. Between September 2011 and December 2012, some 22,000 women had been screened, about a third of whom are HIV-positive. The screening itself is simple and cost-effective, involving soaking the cervix in acetic acid, such as that found in common vinegar, to check for abnormal lesions. If small lesions are found, they are removed at the clinic using cryotherapy, which is nitrous oxide. More advanced cases are referred to either Kabwe District Hospital or the University Teaching Hospital in Lusaka, but those sites are still unreachable for most women across the country.
To be sure, this is only the beginning; much more needs to be done to effectively integrate cervical cancer screening into HIV services throughout Zambia, and to build the capacity to screen, refer and treat.
Ultimately, the HPV vaccine could be critically important in preventing infection with the viruses that cause cervical cancer, and a demonstration project in Zambia to evaluate the feasibility of vaccine delivery through a school-based program for adolescent girls is scheduled to begin in March 2013.
Yet HIV-positive women in Zambia are now learning that screening and treatment for cervical cancer can save their lives. In the words Paxina, an HIV-positive women who had been successfully treated: "Cervical cancer screening can help women living with HIV and AIDS. They will stay healthier and they will stay for a long time. Like I am. I am HIV positive. I went for cervical cancer screening and here I am today."