By: KM. Banda, D Mwansa, K Rice National Health Research Authority Citation Style For This Article: Banda KM, Mwansa D, Rice K, Save a Cervix, Save a Life! “Reinforcing test and treat for HIV positive women in Zambia. Health Press Zambia Bull. 2020; 4(01); pp 4-8
Citation Style For This Article: Banda KM , Mwansa D, Rice K,. Save a Cervix, Save a Life! “Reinforcing test and treat for HIV positive women in Zambia. Health Press Zambia Bull. 2020; 4(01); pp 4-8
Key Messages
• Cervical cancer (CaCx) is the highest cause of all cancer deaths in Zambia.1
• About seven women are diagnosed with CaCx and about four women die from CaCx every day in Zambia.2
• More than half (53%) of all women with CaCx are HIV positive.2
• Only about 20% of HIV positive women have been screened for CaCx.2 • Opt-out testing, at 90% screened, decreases the number of estimated HIV positive women at risk of developing late-stage CaCx by about 168,828 Problem Statement Zambia’s double burden of CaCx and HIV Table 1: World Ranking of Cervical Cancer Incidence (2012)
• Opt-out testing, at 90% screened, decreases the number of estimated HIV positive women at risk of developing late-stage CaCx by about 168,828
Problem Statement
Zambia’s double burden of CaCx and HIV
Table 1: World Ranking of Cervical Cancer Incidence (2012)
• Zambia ranks 4th highest in the overall incidence of CaCx and highest in age-specific incidence of CaCx compared to the rest of the world. (See Table 13 and Figure 14) • Zambia has a high prevalence of HIV (about 15%) in the adult women population.5 • The significant intersection of HIV prevalence and CaCx risk has contributed greatly to the increase of CaCx and worsening of its prognosis.6-9
Figure 1: Estimated CaCx Age-specific Incidence Rates
Increasing Screening Reduces the Cost of CaCx and Saves Lives Unlike many other cancers, there is incredible evidence that screening for cervical cancer is one of the most efficient preventive measures with effective results. For instance, there was a dramatic fall in cervical cancer mortality as screening became widespread in North America and Western Europe between the 1950s and 1970s, and meta-analysis of CaCx trends of countries in five continents showed that in countries where effective screening had been in place for a long time the consequences of underlying increases in cohort-specific risk were largely avoided 10. However, in Zambia, only about 21% of all women aged 25-49 had screened for cervical cancer11 and only an estimated 20% of the HIV positive women had screened for CaCx.2 CaCx screening is particularly important for women living with HIV/ AIDS as their risk of infection is higher compared to the general population.2,7
What are we saying?
Figure 2: Estimated Cases of CaCx Prevented and Diagnosed among HIV Positive Women Screened
Policy Option
“Opt-Out” strategy for reinforcing CaCx test and treatment for HIV positive women in Zambia” Developing an “Opt-Out” strategy in an effort to reinforce existing guidelines for Treatment and Prevention of HIV will promote testing and treatment of CaCx at early stages. “Opt-out” strategy essentially means HIV positive women are told that CaCx screening will be conducted in the standard tests (that is to say, the screening will be given to all HIV positive women) unless they decline.
WHAT: Routinely CaCx screening for all HIV positive women with adequate information is provided to them as described in the HIV Treatment and Prevention guidelines during the health facility visits for ART.
WHY: According to the 2017 Zambia Population-based HIV Impact Assessment report, 86% of people living with HIV are on ART, which means that they would visit a health facility at some point for treatment. Currently, estimations show that only about 5% of the HIV positive have screened for CaCx at some point. Routine testing during treatment visits increases the number of women screened and the number of times a woman is screened for CaCx. The literature on a similar strategy employed in increasing HIV testing from Zimbabwe12 and Tanzania13 shows that this strategy has increased HIV testing up to 90%. In our model, applying the opt-out strategy for CaCx screening in one year at 45% and 90% screening, would increase the number of women screened and treated by about 37% and 80% respectively. FEASIBILITY: MEDIUM to HIGH.
This strategy builds on the government’s decision to ‘test and treat’ women for CaCx. It will require increasing the number of facilities providing CaCx screening, clinician’s adherence to the guidelines, trained counselors, and an increase in ‘test and treat’ supplies and equipment.
Policy Option Scenarios
Table 2 provides a comparison of costs and effects under two scenarios proposed to increase screening. We compare the existing status quo to an “Opt-Out” strategy to increase screening, targeting 45% or 90% of HIV positive women.
We estimated the number of women remaining under each scenario at risk of developing late-stage CaCx if left unscreened. We based the estimated numbers on high-risk HPV prevalence in HIV positive women (20-40%) using proxy data on US women from the National Center for Health Statistics14. Opt-out testing at 90% screening can potentially decrease the number of estimated HIV positive women at risk of developing late-stage CaCx of approximately 200,000 women (the maximum at risk if only 5% are screen (229,123) minus the maximum at risk if 90% are screened (24,118)).
Figure 3 shows the total number of women screened and estimated total costs for each of the scenarios proposed in Table 1. The figure shows the combined total costs of delivering a screen and treat program and costs of cancer treatment and care for women diagnosed with CaCx at each opt-out level over one year, compared to the status quo.
We include all financial costs from the Ministry of Health perspective, which include the overhead cost of operating medical facilities for cervical cancer screening and treatment, costs for VIA test kits and supplies, costs for medical equipment and supplies for cold coagulation and LEEP procedures, medication, cancer treatment costs, and all personnel labor (physicians and/or nurses).
Recommendations and Next Steps
An opt-out strategy for reinforcing HIV treatment guidelines is a feasible option to increase CaCx ‘Test and Treat’ among HIV positive women in this analysis. This strategy has been adopted for HIV testing in countries like Zimbabwe and Tanzania and henceforth could provide similar effective results for CaCx in Zambia. The opt-out strategy reduces the potential future burden of CaCx on the country and saves women’s lives in the long term. Successfully implementing this strategy will require
• Expanding CaCx screening to more facilities in all the provinces.
• Ensuring clinicians’ adherence to the guidelines.
• Increasing close collaboration between the CaCx screening and HIV/ ART programs at the Ministry of Health in developing operational strategies.
• Collaborating between partners working in CaCx and HIV/ART. Opt-Out strategy for increasing ‘Test and Treat’ will have a high public health impact in addressing the growing incidence of cervical cancer in Zambia!
LIST OF REFERENCES
1. Zambia National Cancer Registry Report. 2013
2. Parham GP, et al. Population-Level Scale-Up of Cervical Cancer Prevention Services in a Low-Resource Setting: Development, Implementation, and Evaluation of the Cervical Cancer Prevention Program in Zambia. 2015. PLoS ONE 10(4): e0122169. DOI: 10.1371/journal.pone.0122169
3. Ferlay J, et al. GLOBOCAN 2012 v1.1, Cancer Incidence, and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; 2014.
4. Bruni L, et al. ICO Information Centre on HPV and Cancer (HPV Information Centre). Human Papillomavirus and Related Diseases in Zambia. 2017.
5. Central Statistical Office. Zambia Demographic Health Survey. 2014
6. Ullrich A, et al. Long-term care of AIDS and non-communicable diseases. Lancet 2011; 377: 639–640. DOI: 10.1016/S0140- 6736(11)60233-X PMID: 21334535
7. Parham GP, et al. Prevalence and predictors of squamous intraepithelial lesions of the cervix in HIV-infected women in Lusaka, Zambia. Gynecol Oncol 2006; 103: 1017–1022. PMID: 16875716
8. Cogliano, V, et al. Carcinogenicity of human papillomaviruses. 2005. [Congresses]. Lancet Oncol, 6(4), 204.
9. Strickler HD, et al. Natural history possible reactivation of human papillomavirus in human immunodeficiency virus-positive women, J Natl Cancer Inst, 2005, vol. 97 (pg. 577-86)
10. Salvatore V, et al. Worldwide trends in cervical cancer incidence: Impact of screening against changes in disease risk factors. 2013. https://doi.org/10.1016/j.ejca.2013.04.024
11. Ministry of Health. Zambia STEPS survey. 2017
12. Ferrand R, et al. The effectiveness of Routine Opt-Out HIV testing for children in Harare, Zimbabwe, Acquired Immune Deficiency Syndrome, 2016
13. Baisley K, et al. Uptake of voluntary counseling and testing among young people participating in an HIV prevention trial: comparison of the opt-out and Opt-in strategies, Plos One, 2012
14. McQuillan G, et al. Prevalence of HPV in adults aged 18–69: the United States, 2011–2014. NCHS data brief, no 280. Hyattsville, MD: National Center for Health Statistics. 2017