Implementation of a "see and treat" cervical cancer prevention program linked to HIV care in Zambia

Objective

To establish a public-sector "see and treat" cervical cancer prevention program in Zambia by linking services to an HIV care and treatment infrastructure.

Methods

We modeled our infrastructure after a successful PEPFAR-funded HIV care and treatment program and selected HIV-infected women as our initial target population. Zambian nurses underwent classroom and clinically-mentored training to become primary service providers for screening women for cervical lesions using visual inspection with acetic acid (VIA) and treatment with cryotherapy, when indicated. Women with cryotherapy-ineligible lesions were referred to the university hospital where physicians were trained to perform punch biopsy and loop electrosurgical excision procedure (LEEP) for histologic evaluation. We utilized telecervicography for distance consultation as well as reviewing digital images weekly for quality assurance and continuing education. Patients with invasive cancer were referred for hysterectomy, radiation or palliation, depending on the stage of their disease

Results

Between January 2006 and October 2007 we established 14 prevention sites in outlying government-operated public health clinics and a modern outpatient evaluation center. During this 22-month period 8,823 women were screened, 41.5 percent of whom were HIV-infected. The 15 specially-trained nurses independently managed 83.3 percent of clients in the outlying clinics and referred the remaining 16.7 percent for further evaluation. Four physicians managed the outpatient evaluation center, performing punch biopsy or LEEP, the latter with minimal intra- and post-operative complications. Pathologic analysis confirmed 144 high-grade lesions (CIN2/3) and 149 invasive cancers (58% micro invasive).

Conclusion

We successfully established the first phase of a population-based "see and treat" cervical cancer prevention program in Zambia by linking the services to an HIV care and treatment program, integrating them into government-operated public health clinics and utilizing task-shifting and distance consultation to optimize care provision.