Developing Cervical Cancer Screening Program using HIV/ART care and treatment infrastructure. Dr. Mulindi H Mwanahamuntu

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1 Developing Cervical Cancer Screening Program using HIV/ART care and treatment infrastructure Dr. Mulindi H Mwanahamuntu

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3 Cancer Statistics in Africa Jemal, et al. Cancer [January 17, 2012] 00: 1-13

4 Zambia Slightly larger than Texas 8 international borders 11.5 million people 2/3 live on < $2/day HIV prevalence: 16% nationally; 22% Lusaka

5 All other Cancer Cases 22% Cervix 24% Lung Bronchus 0% Penis 0% Leukemia 1% Corpus Uterine 1% Connective Tissue 1% Vaginal Vuval 1% Intestine 1% Overy 1% Eye 11% Liver 1% Stomach 1% Blaader 1% Oesophagus 2% Buccal Cavity& Phaynx 3% Skin Melamnoma 5% Prostrate 6% Breast 8% kaposis Sarcoma 9%

6 Problem 1 Most countries in Africa do not have the satisfactory health infrastructure and facilities for cancer prevention, surgery, chemotherapy and radiotherapy. The lack of equipment for the management of cancer in Africa is compounded by an acute shortage of cancer experts and pathologists. Dr Luis Sambo WHO Regional Director for Africa 2007

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9 Problem 2 Lack of access to good screening and treatment services Lack of Awareness

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13 Problem 3 AIDS Life expectancy for Zambia s 11.5m people is only years 86% below poverty line; 50% unemployed 16.5% are infected with HIV 1,000,000 living with HIV/AIDS 100,000 deaths from AIDS 1,250,000 children orphaned by AIDS

14 Impact of AIDS on life expectancy in five African countries, Life expectancy at birth (years) Botswana South Africa Swaziland Zambia Zimbabwe United Nations Population Division (2004). World Population Prospects: The 2004 Revision, database. 41

15 Challenge and Opportunity Cervical cancer made worse by HIV/AIDS Higher risk of HPV infection Rapid rate of progression from HPV infection to invasive cancer Diagnosed at younger ages and more advanced stages

16 CYTOLOGY RESULTS 150 HIV infected women Suggestive of Cancer 19.32% Normal 6.21% ASCUS 17.22% HSIL 33.83% LSIL 23.42% Gynecol Oncol 2006;103:

17 PEPFAR Encourages HIV FP Services Endorses making HIV counseling and testing as well as referrals for prevention of mother-to-child transmission and HIV care and treatment services available in family planning programs. Endorses the use of PEPFAR funds for this purpose. We have added Cervical cancer prevention

18 Opportunity PEPFAR FUNDING (November 2005) $70,000 2 clinics 5 nurses Cervical cancer prevention program targeting HIV infected women Nurse led single visit screen and treat Free, integrated into government operated public health clinics

19 Cervical Cancer Prevention in Zambia Outcomes Opened 18 nurse led sites in 4 of Zambia s provinces Screened >82,000 women (1/3 HIV positive) Treated > 12,000 women for precancer/cancer Trained 185 healthcare personnel from Zambia and 10 other African nations Program replicated in 8 African nations For every 46 HIV infected women screened one death from cervical cancer is prevented Prof. Parham training nurse at point of care

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22 Jorge Alberto Perez

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25 Patient enrollment (Jan 2006 Dec 2011) n=56,000

26 Sociodemographic characteristics of the women screened in the Cervical Cancer Prevention Program in Zambia HIV seropositive HIV seronegative HIV serostatus unknown Total p-value (n=15081) (n=21322) (n=20024) (n=56427) Age, Median (IQR) 34 (29, 40) 29 (24, 37) 32 (26, 40) 32 (26, 39) <0.001 Missing age, n(%) 197 (1.3%) 234 (1.1%) 302 (1.5%) 733 (1.3%) Education, n(%) <0.001 Missing 4914 (32.6%) 4482 (21.0%) 4792 (23.9%) (25.1%) Less than high school 4703 (46.3%) 6615 (39.3%) 6752 (44.3%) (42.8%) High school completed 5464 (53.7%) (60.7%) 8480 (55.7%) (57.2%) Marital status, n(%) <0.001 Married 2312 (44.5%) 3001 (33.9%) 3562 (36.1%) 8875 (37.1%) Not Married 2882 (55.5%) 5847 (66.1%) 6306 (63.9%) (62.9%) Occupation, n(%) <0.001 Missing 5939 (39.4%) 6259 (29.4%) 6235 (31.1%) (32.7%) House wife 2805 (30.7%) 5917 (39.3%) 4838 (35.1%) (35.7%) Formal sector 1982 (21.7%) 3301 (21.9%) 2723 (19.7%) 8006 (21.1%) Informal sector 3226 (35.3%) 3659 (24.3%) 4387 (31.8%) (29.7%) Other 1129 (12.3%) 2186 (14.5%) 1841 (13.4%) 5156 (13.6%) Income, n(%) <0.001 Missing 5237 (34.7%) 5177 (24.3%) 5266 (26.3%) (27.8%) Less than K500, (57.6%) 8501 (52.7%) 7565 (51.3%) (53.3%) K500,000 or More 4178 (42.4%) 7644 (47.3%) 7193 (48.7%) (46.7%) Number of lifetime partners Median (IQR) 3 (2, 5) 2 (1, 3) 2 (1, 3) 2 (1, 4) <0.001 Missing number of lifetime partners, n(%) 263 (1.7%) 396 (1.9%) 902 (4.5%) 1561 (2.8%) Number of pregnancies Median (IQR) 3 (2, 5) 3 (2, 5) 3 (2, 5) 3 (2, 5) <0.001 Missing number of pregnancies, n(%) 826 (5.5%) 2120 (9.9%) 2705 (13.5%) 5651 (10.0%) Condom use with regular partner, n(%) <0.001 Missing 1396 (9.3%) 1695 (7.9%) 3033 (15.1%) 6124 (10.9%) Never 6855 (50.1%) (66.8%) (72.9%) (64.3%) Ever 6830 (49.9%) 6523 (33.2%) 4608 (27.1%) (35.7%)

27 Regression Model to identify independent predictors of VIA positivity. Covariate Adjusted Odds ratio (95% CI) p-value Age < years (ref) 1 30 years 1.00 (0.97, 1.03) 35 years 0.87 (0.82, 0.91) 40 years 0.74 (0.69, 0.79) Education <0.001 Less than high school (ref) 1 High school complete 0.89 (0.85, 0.94) Marital Status Not married (ref) 1 Married 0.95 (0.88, 1.02) Occupation House wife (ref) 1 Formal sector 1.00 (0.91, 1.09) Informal sector 1.01 (0.93, 1.08) Other 0.98 (0.90, 1.07) Income Less than K500,000 (ref) 1 K500,000 or More 0.92 (0.87, 0.97) Number of life partners < partner (ref) 1 2 partners 1.10 (1.04, 1.16) 3 partners 1.16 (1.10, 1.23) 4 partners 1.20 (1.13, 1.27) Age of sexual debut (per 1 year) 0.98 (0.98, 0.99) <0.001 Number of pregnancies < child (ref) 1 3 children 1.16 (1.09, 1.23) 5 children 1.02 (0.95, 1.10) Condom use with regular partner <0.001 Never (ref) 1 Ever 1.17 (1.11, 1.22) HIV Status <0.001 Negative (ref) 1 Positive 2.62 (2.49, 2.76) Unknown 1.41 (1.34, 1.48)

28 Trends of HIV status profile

29 VIA Positivity

30 Present Status 18 nurse led clinics (include rural provinces) Screened over 85,000 women; 1,100/month 20 nurses/4 doctors/35 Cervical Cancer Peer Educators Program Manager/Outreach Coordinator/Data Associates/IT Coordinator Online entry of all data from clinics (Peer educators) Cell phone based patient follow up system (Peer educators) Distance consultation website Quality assurance system System for procuring, storing and dispersing supplies Global impact For every 25 HIV infected women screened a cancer death is prevented

31 Conclusion Should cervical cancer prevention programs services be linked to HIV care and treatment programs? So far this is the only cost effective cervical cancer screening program that has worked in Zambia.