CERVICAL CANCERCONTROL PROGRAMME IN MALAWI OVERVIEW FOR 2015 PROGRAMME PERFORMANCE

CERVICAL CANCERCONTROL PROGRAMME IN MALAWI OVERVIEW FOR 2015 PROGRAMME PERFORMANCE

Burden of Cervical Cancer & its risk Commonest in women accounting for 45% of all cancers factors in Malawi Over 2,300 new cases per year (WHO HPV Centre) Over 1,600 women die of Ca Cx every year (WHO HPV Centre) Women aged 15-49 at risk: 4 million HIV in women aged 15-49: 12.9% (DHS 2010) HPV prevalence: 33.6% (WHO HPV Center)

Malawi National Cervical Cancer Control Programme Was established in 2004 Prevention Interventions & Strategies Primary Prevention HPV Vaccine Demonstration Project successfully implemented in in 2 districts (Zomba & Rumphi) Year 1 Fully immunized: 86% Year 2 Fully immunized: 91% Secondary preventions Other efforts with positive impact on Ca cx risk factors Cervical Cancer screening using visual inspection with acetic acid (VIA)- about 130 functional screening sites Pap Smear- Pvt hosp and some CHAM (Malamulo Mission Hosp) Cryotherapy- 39 functional sites Cold coagulation- 11 sites Voluntary male medical circumcision (intensified with support from partners) HIV prevention and treatment- One of the best in southern Africa

HPV and Cervical Cancer Human Papilloma Virus (HPV) is major cause of Cervical cancer accounting for 95% of cases HPV also causes other anal-genital cancers (anal, vulval, vaginal and penile) and genital warts. There are over 130 subtypes of HPV. The ones known to cause cervical cancers are: HPV subtype: 16, 18, 31, and 45 account for 80% while 6, 33, 35, 39, 51, 52, 56, 58 and 59 account for 20% HPV subtype 6 and 11 cause genital warts HPV subtype 16 and 18 account for 70% Ca Cx

Primary Prevention: HPV Vaccine Cervalix Gardansil Type Bivalent Quardvalent HPV subtypes 16,18 6,11 (Genital warts) 16,18 (Ca Cx) Target group Girls: 9-13 years old Girls: 9-13 years old Administration IM IM Doses - 2 Vaccine schedule - 2-dose regimen at 0, 6 months Strategy - Sch-based, STD 4, All girls regardless of age. High coverage but expensive Facility-based, Cheap but coverage is likely to be very low

Malawi HPV Vaccine Sch-based Demo Project Zomba Rumphi Total No. Coverage No. Coverage No. Coverage Year 1: Target pop 1,292-4,292-6,222 Dose 1 1,176 91 4,120 96 9,511 95 Dose 2 1,124 87 3,992 93 5,600 90 Dose 3 967 75 3,863 90 5,351 86 Year 2: Target pop 1,720-3,296-5,016 - Dose 1 1,565 91 3,169 96 4,734 94 Dose 2 1,514 88 3,055 93 4,569 91 Year 3:

Year 3: Schedule Zomba (scaled-up to the whole district) Rumphi (whole district) Dose 1 23-27 Nov 2015 Target: Coverage In-Sch 15,830 91.4% Out of Sch 701 63.6% Total 16,531 90.2% Jan 2016 Dose 2 May/June 2016 July 2016

No. of women screened for Cervical Cancer: 2011-2015 Year Number of women screened Number of women with VIA postive Number of women with VIA positive treated Number of women with advance cancer n %Coverage n % n % n % 2011 15,331 894 5.8 388 43.4 798 5.2 2012 22,400 14.0 1,069 4.8 400 37.4 1,098 4.9 2013 20,490 12.4 1,447 7.1 528 36.5 1,294 6.3 2014 37,493 22.0 1,628 4.3 655 40.2 1,434 3.8 2015 48,064 27.3 2,177 4.5 896 41.2 1,625 3.4 Total 143,778 7,215 5.0 2,867 39.7 6,249 4.3

Trends in the no. of women screened for Cervical cancer: 2011-2015

Number of women screened by age and HIV status Total VIA Positive Suspect cancer VIA Positive or suspect cancer n % n % n % n % Age (years): <30 13,532 28.2 290 2.1 163 1.2 453 3.3 30-45 26,960 56.1 1,495 5.5 694 2.6 2189 8.1 >45 7,572 15.8 392 5.2 893 11.8 1285 17.0 All with known age 48,064 100.0 2,177 4.5 1750 3.6 3,927 8.2 HIV status: Negative 21,217 55.0 1,061 5.0 623 2.9 1,684 7.9 Positive 6,109 15.8 529 8.7 390 6.4 919 15.0 Unknown 11,242 29.1 542 4.8 513 4.6 1,055 9.4 All with HIV status data 38,568 100.0 2,132 5.5 1,526 4.0 3,658 9.5

Key Issues & Challenges 1. Inadequate Cryo machines; 5 districts have no Cryo at all. VIA positive women eligible for Cryo are referred to the next site, hence only 40% were done- Ethical issue. 2. Inadequate trained providers (on average only 2/site and have other duties) 3. Inadequate funding for Community mobilization, M & E and quality control (supportive supervision bi-annual programme reviews)

Lessons learnt & Opportunities Primary (HPV vaccine) & Secondary ( Screen and Treat using VIA) Cervical Cancer prevention is feasible in Malawi Partners (WHO, UNFPA, UNICEF, BLM, PCI, SSDI, DREAM, Dignitas, Mission Hospitals & other NGOs) are supporting the National Programme The sustained high impact HIV interventions are beneficial to cervical cancer control

Recommendations/Way forward 1. Strengthen the screen & treat approach by scaling up Cryo sites and maintain their functionality 2. Strengthen linkage between VIA Clinic and ART Clinic aiming at screening at least 80% of women on ART 3. Strengthen capacity building by training new providers and re-fresh old ones. 4. Improve awareness on Cervical cancer at all levels: National level with stakeholders and suppliers e.g. suppliers of gas and Cryo suppliers Zonal level at quarterly reviews and supportive supervision DHMT Health workers Community 5. Strengthen the capacity for M & E, surveillance including data management

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