Addressing Cervical Cancer in PEPFAR Programs: Progress and Future Directions

Carol Langley, MD, MPH Office of the U.S. Global AIDS Coordinator
AIDS 2012 - Turning the Tide Together

Overview
1.History of PEPFAR involvement in cervical cancer programming 2.PEPFAR approach to cervical cancer 3.Country example - Zambia 4.PEPFAR partnership in Pink Ribbon Red Ribbon 5.Future directions

Background - PEPFAR involvement in cervical cancer programming

Rationale for PEPFAR involvement: established link between HIV and cervical cancer, with the recognition of cervical cancer as an opportunistic process PEPFAR funded initial pilot program in Zambia in 2006, implemented by the Center for Infectious Disease Research in Zambia (CIDRZ) Given growing interest in cervical cancer in a number of other countries, PEPFAR convened a Technical Consultation on HIV and Cervical Cancer in March 2008; recommendations formed the basis for developing current PEPFAR policy Currently, PEPFAR supports cervical cancer screening and treatment for women infected with HIV at over 250 clinical sites in 11 African countries. Cervical cancer screening and treatment are offered in HIV care and treatment settings, offering integrated service delivery.

PEPFAR approach to cervical cancer

PEPFAR focuses on secondary prevention of cervical cancer, providing screening and treatment for precancerous lesions to prevent the development of invasive cancer. PEPFAR supports use of simple, cost-effective screen and treat approaches, primarily using visual inspection with acetic acid (VIA) and treatment with cryotherapy. The screen and treat approach is relatively inexpensive and can be readily performed in resource-limited settings by trained nurses; it also allows screening and treatment in a single visit, improving compliance and reducing costs. In a limited number of sites, PEPFAR supports more complex diagnostic and treatment modalities, including loop electrosurgical excision procedure, or LEEP, which can be used to manage many precancerous lesions which are not amenable to cryotherapy.

PEPFAR Guidance on Cervical Cancer

HIV positive women have a high burden of precancerous lesions and cancer of the cervix... Thus, in the context of HIV infection, cervical cancer can be considered an opportunistic process. The optimal approach to screening and treatment to prevent cervical cancer in HIV positive women has not been determined, but given accumulating data and recent technological advances, it is important to provide some support to screening programs in HIV care and treatment settings. PEPFAR can support, as part of a comprehensive approach to opportunistic infections, screening and treatment to prevent cervical cancer in HIV positive women.
Countries are encouraged to consider approaches which are feasible and cost-

effective, such as provision of screening (for example with visual inspection) and management (for example with cryotherapy) in a single visit.
- Care and Treatment Section, 2012 Technical Considerations

PEPFAR approach to cervical cancer: Leveraging health systems

However, providing a comprehensive approach to cervical cancer requires a systems approach
Need comprehensive systems for human resources and training laboratories data systems for monitoring and reporting logistics and supply chain Infrastructure and equipment

Also critical to consider continuum of care for cervical cancer referral systems for patients with more advanced lesions

PEPFAR approach to cervical cancer: Leveraging health systems

PEPFARs prevention, care and treatment programs have made significant contributions to strengthening health systems, addressing human resources, laboratories, data systems and surveillance, logistics and supply chain, and infrastructure. These investments, and the resulting strengthening of health systems, have created a platform which is now well-positioned to address broader health issues, including non-communicable diseases such as cervical cancer. Given limited resources and increasing demand, it is critically important to maximize synergies and efficiencies in developing the response to HIV and non-communicable diseases, including cervical cancer. PEPFARs cervical cancer programs build on the PEPFAR HIV platform to the extent possible to leverage existing systems and maximize synergies and efficiencies.

PEPFAR approach to cervical cancer: Support to national programs

PEPFAR encourages country teams to work in close collaboration with host country leadership at each step of planning and implementation to promote country ownership and sustainability: PEPFAR approach must be in accord with country policy and normative guidance, with approval from Ministry of Health Country teams should document a detailed assessment of capacity to provide services related to cervical cancer (e.g. technical capacity, infrastructure and lab, treatment capacity, human resource capacity) PEPFAR technical staff have provided support to PEPFAR programs and to governments to help with assessment of country capacity and development of national cervical cancer plans and strategies.

Cervical Cancer Prevention Program in Zambia

PEPFAR funded initial pilot program in Zambia in 2006, implemented by the Center for Infectious Disease Research in Zambia (CIDRZ), led by Dr. Groesbeck Parham A modern minimally invasive Gynecologic Cancer Prevention Clinic was established at University Teaching Hospital in Lusaka for patients needing more extensive evaluation to provide: diagnostic services (cervical biopsy) therapeutic services (loop electrical excision procedure LEEP) support services

Started with 2 sites in the capital city of Lusaka and managed by 5 nurses
Has expanded to 18 sites, 4 of which are in rural areas, with 18 nurses providing services

Cervical Cancer Prevention Program in Zambia

Zambia program is now considered a flagship program and a model for African and other countries Program uses a variation on screen and treat approach, using digital cervicography, taking a digital photo of the cervix; this provides
Magnified view of cervix Documentation of findings Patient education Real time distance consultation as needed with physician Quality assurance (all photos reviewed weekly with all providers)

Since program began in 2006, over 80,000 women have been screened; about 12,000 women have been treated for precancerous lesions or cancer; most women treated with same-day cryotherapy

Cervical Cancer Prevention Program in Zambia:

Digital Cervicography

Cervical Cancer Prevention Program in Zambia:

Digital Cervicography Weekly QA Session

Cervical Cancer Prevention Program in Zambia:

Global Cervical Cancer Prevention Training Program
CIDRZ program has also developed didactic and clinical training focused on screen and treat approaches, as well as LEEP To date, 65 health personnel from throughout Zambia, as well as 110 international health personnel from 10 countries, have received training in screen and treat approaches PEPFAR supported two study tours (2008, 2010) involving key leaders and MOH staff from 8 African countries CIDRZ staff have also traveled to other countries (e.g. Cameroon) to provide on-site training

Expanding Impact through Partnerships: Pink Ribbon Red Ribbon

PEPFAR is now proud to be part of the Pink Ribbon Red Ribbon Partnership, formally launched in September 2011 to combat cervical and breast cancer in developing nations in Africa and Latin America. PEPFAR will work with the George W. Bush Institute, Susan G. Komen for the Cure, UNAIDS, and multiple private partners to expand the availability of cervical cancer screening and treatment, especially for high-risk HIV-positive women. Partners may also build on the PEPFAR platform to promote breast cancer awareness and education. The initiative will leverage the platform and resources of PEPFAR, including personnel and training resources, infrastructure, labs, supply chain and logistics, medical record and data management systems, systems for patient follow-up and referral, and monitoring and evaluation systems.

Expanding Impact through Partnerships: Pink Ribbon Red Ribbon

PEPFAR has committed $10 million in new funding for the partnership, as announced by Secretary Clinton at the launch of the partnership in September 2011. The $10 million will support expanded capacity for cervical cancer screening and treatment across a small group of lead countries. Zambia and Botswana have been announced as initial Pink Ribbon Red Ribbon lead countries, with other countries to follow. PEPFARs platform, programming and resources are already supporting significant efforts to combat cervical cancer. Through the Pink Ribbon Red Ribbon partnership, we plan to work to further expand the availability of screening and treatment for cervical cancer for high risk, HIV-positive women.

Future Directions
Strengthened collaboration with host countries to scale-up programs to gain greater impact Improved M&E and support for implementation science (e.g., examining impact and efficiency of scale-up strategies, approaches to monitoring and strengthening referral systems, etc) Continued engagement with Pink Ribbon Red Ribbon and other partners and governments to address other components of continuum of care, including primary prevention through HPV vaccines and treatment for more advanced disease

Poster from AMPATH Mosoriot Clinic, Kenya, promoting Government of Kenya Cervical Cancer Screening Program

Acknowledgements
Groesbeck Parham CIDRZ Program, Zambia Isaac Zulu CDC Zambia Kristie Mikus PEPFAR Zambia Sara Forhan CDC Barb Marston CDC Charles Holmes OGAC

Thank You!

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