Early experiences in integrating cervical cancer screening and treatment into HIV services in Zomba Central Hospital, Malawi

Pfaff, Colin

doi:10.4314/mmj.v30i3.14

Cited by 25 publications

(40 citation statements)

References 24 publications

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“…Among WLHIV (n = 133), the figure was slightly lower with only 91% recurrence free: this is again in line with international findings and supports the need for careful follow-up in this group of women. 39,45,46 Thermal ablation has now been widely adopted within Malawi both within government and non-governmental organization (NGO)-supported screening services and its use is reported in other contexts. 49,47,48 Critically, in 2019, the WHO 43 issued revised guidance for treatment of cervical precancer lesions, for the first time supporting the use of thermal ablation.…”

Section: Thermal Ablationmentioning

confidence: 99%

Cervical cancer screening – The challenges of complete pathways of care in low-income countries: Focus on Malawi

Cubie

Campbell

2020

Womens Health (Lond Engl)

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Cervical cancer is the fourth most common cancer among women globally, with approximately 580,000 new diagnoses in 2018. Approximately, 90% of deaths from this disease occur in low- and middle-income countries, especially in areas of high HIV prevalence, and largely due to limited prevention and screening opportunities and scarce treatment options. In this overview, we describe the opportunities and challenges faced in many low- and middle-income countries in delivery of cervical cancer detection, treatment and complete pathways of care. In particular, drawing on our experience and that of colleagues, we describe cervical screening and pathways of care provision in Malawi, as a case study of a low-resource country with high incidence and mortality rates of cervical cancer. Screening methods such as cytology – although widely used in high-income countries – have limited relevance in many low-resource settings. The World Health Organization recommends screening using human papillomavirus testing wherever possible; however, although human papillomavirus primary testing is more sensitive and detects precancers and cancers earlier than cytology, there are currently costs, infrastructure considerations and specificity issues that limit its use in low- and middle-income countries. The World Health Organization accepts the alternative screening approach of visual inspection with acetic acid as part of ‘screen and treat’ programmes as a simple and inexpensive test that can be undertaken by trained health workers and hence give wider screening coverage; however, subjectivity and variability in interpretation of findings between providers raise issues of false positives and overtreatment. Cryotherapy using either nitrous oxide or carbon dioxide is an established treatment for precancerous lesions within ‘screen and treat’ programmes; more recently, thermal ablation has been recognized as suitable to low-resource settings due to lightweight equipment, short treatment times, and hand-held battery-operated and solar-powered models. For larger lesions and cancers, complete clinical pathways (including loop excision, surgery, radiotherapy, chemotherapy and palliative care) are required for optimal care of women. However, provision of each of these components of cancer control is often limited due to limited infrastructure and lack of trained personnel. Hence, global initiatives to reduce cervical mortality need to adopt a holistic approach to health systems strengthening.

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Section: Thermal Ablationmentioning

confidence: 99%

Cervical cancer screening – The challenges of complete pathways of care in low-income countries: Focus on Malawi

Cubie

Campbell

2020

Womens Health (Lond Engl)

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“…Studies from sub-Saharan Africa have recommended integrating cervical cancer screening into other health services, particularly HIV care [ 26 , 47 – 49 ]. But our analysis, alongside findings from other studies of cervical cancer integration [ 50 , 51 ], suggests that smooth and successful integration will require adequate funding, robust monitoring and referral systems, a sufficient pool of well-trained and available health workers (across cadres, to enable task shifting), and ongoing demand from clients [ 51 – 55 ]. There may also be hidden “costs” of integration, for example increasing stigma if other services are bundled with HIV treatment [ 53 , 54 ], and providers may need special training in the process of integration (not only each stand-alone service, but the provision of integrated care) as well as appropriate support and accountability for offering comprehensive services [ 54 ].…”

Section: Discussionmentioning

confidence: 77%

Health care workers’ experiences with implementation of “screen and treat” for cervical cancer prevention in Malawi: A qualitative study

Moucheraud

Kawale

Kafwafwa³

et al. 2020

Implement Sci Commun

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Background Cervical cancer remains a major cause of mortality and morbidity in low- and middle-income countries, despite the availability of effective prevention approaches. “Screen and treat” (a single-visit strategy to identify and remove abnormal cervical cells) is the recommended secondary prevention approach in low-resource settings, but there has been relatively scarce robust implementation science evidence on barriers and facilitators to providing “screen and treat” from the provider perspective, or about thermocoagulation as a lesion removal technique. Methods Informed by the Consolidated Framework for Implementation Research (CFIR), we conducted interviews with ten experienced “screen and treat” providers in Malawi. We asked questions based on the CFIR Guide, used the CFIR Guide codebook for a descriptive analysis in NVivo, and added recommended modifications for studies in low-income settings. Results Seven CFIR constructs were identified as positively influencing implementation, and six as negatively influencing implementation. The two strong positive influences were the relative advantage of thermocoagulation versus cryotherapy (Innovation Characteristics) and respondents’ knowledge and beliefs about providing “screen and treat” (Individual Characteristics). The two strong negative influences were the availability of ongoing refresher trainings to stay up-to-date on skills (Inner Setting, Implementation Climate) and insufficient resources (staffing, infrastructure, supplies) to provide “screen and treat” to all women who need it (Inner Setting, Readiness for Implementation). Weak positive factors included perceived scalability and access to knowledge/information, as well as compatibility, leadership engagement, and team characteristics, but these latter three were mixed in valence. Weak negative influences were structural characteristics and donor priorities; and mixed but weakly negative influences were relative priority and engaging clients. Cross-cutting themes included the importance of broad buy-in (including different cadres of health workers and leadership at the facility and in the government) and the opportunities and challenges of offering integrated care (screening plus other services). Conclusions Although “screen and treat” is viewed as effective and important, many implementation barriers remain. Our findings suggest that implementation strategies will need to be multi-level, include a diverse set of stakeholders, and explicitly address both screening and treatment.

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“…Two previous studies, which integrated HIV and cervical cancer screening, have been reported in Malawi, both completed in urban and tertiary facilities. 16 17 This practical experience of integration experience of cervical cancer screening may provide valuable lessons for scale-up in rural Malawi.…”

Section: Discussionmentioning

confidence: 98%

“…VIA will be done alongside the introduction of thermo-coagulation, an alternative method of treating cervical pre-malignant lesions, which has been shown to be feasible in other settings in Malawi. 16 24 Additionally, lessons from integration with HIV care will be applied to integration with other services, such as for patients with common chronic NCDs, to maximise access to and uptake of cervical cancer screening services in rural Malawi.…”

Section: Discussionmentioning

confidence: 99%

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Improving uptake of cervical cancer screening services for women living with HIV and attending chronic care services in rural Malawi

Talama¹,

Shaw

Maloya³

et al. 2020

BMJ Open Qual

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Malawi has the second highest age-standardised incidence rate and the highest mortality rate of cervical cancer in the world. Though the prevalence of HIV is currently 11.7% for Malawian women of reproductive age, cervical cancer screening rates remain low. To address this issue, we integrated cervical cancer screening into a dual HIV and non-communicable disease clinic at a rural district hospital in Neno, Malawi. The project was implemented between January 2017 and March 2018 using the Plan-Do-Study-Act model of quality improvement (QI). At baseline (January to December 2016), only 13 women living with HIV were screened for cervical cancer. One year after implementation of the QI project, 73% (n=547) of women aged 25 to 49 years living with HIV enrolled in HIV care were screened for cervical cancer, with 85.3% of these receiving the screening test for the first time. The number of women living with HIV accessing cervical cancer services increased almost 10 times (from four per month to 39 per month, p<0.001). Key enablers in our QI process included: strong mentorship, regular provision of cervical cancer health talks throughout the hospital, nationally accredited cervical cancer prevention training for all providers, consistent community engagement, continuous monitoring and evaluation, and direct provision of resources to strengthen gaps in the public system. This practical experience integrating cervical cancer screening into routine HIV care may provide valuable lessons for scale-up in rural Malawi.

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Early experiences in integrating cervical cancer screening and treatment into HIV services in Zomba Central Hospital, Malawi

Cited by 25 publications

References 24 publications

Cervical cancer screening – The challenges of complete pathways of care in low-income countries: Focus on Malawi

Cervical cancer screening – The challenges of complete pathways of care in low-income countries: Focus on Malawi

Health care workers’ experiences with implementation of “screen and treat” for cervical cancer prevention in Malawi: A qualitative study

Improving uptake of cervical cancer screening services for women living with HIV and attending chronic care services in rural Malawi

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