African clinics on the frontline of the fight against cervical cancer
Health experts will meet at the upcoming Geneva Health Forum to discuss the WHO’s new roadmap for the elimination of cervical cancer. Hopes are high for funding to expand services in countries where they are needed the most.
At Newlands Clinic in Harare, Zimbabwe, the waiting room is always busy with women waiting to do a simple cervical cancer screen as part of the routine package of available reproductive and sexual health services. HIV positive women can receive free screening and follow-up treatment if they are found to be at risk of cervical cancer, which is the most common form of cancer among women living with HIV.
Newlands is one of a growing number of clinics across Zimbabwe and other countries in sub-Saharan Africa that have started to incorporate cervical cancer prevention, screening and treatment services into their women’s health programmes. The countries with the highest incidences of cervical cancer - Malawi, Mozambique, Comoros, Zambia and Zimbabwe - also have a high prevalence of women living with HIV/Aids, which makes rolling out these services all the more urgent.
Even so, the lack of public awareness and an equally large dearth of funding and international support have created challenges to making such services more mainstream.
“HIV, TB, Malaria - those are major killers so they tend to get the lion's share of the attention,” says Dr Cleophas Chimbetete, deputy director of Newlands Clinic, who is one of a number of experts speaking at a keynote session on Cervical Cancer Elimination at the upcoming Geneva Health Forum running from 16-18 November.
“Cervical cancer can only be addressed if we have more international organisations coming in to assist, to make noise, and to make cervical cancer programmes. Because [at the moment] most cervical cancer screening is linked to HIV programmes.”
He and other experts gathering at the forum hope that a new global strategy from the World Health Organisation (WHO) to eliminate cervical cancer as a public health problem will give more impetus to donor action. The WHO strategy sets out a roadmap for expanding vaccination, screening and treatment worldwide by 2030.
A preventable and treatable disease. Cervical cancer is still the fourth most common form of cancer among women in the world, despite being one of the few malignancies that is preventable and highly treatable provided it is diagnosed and managed early.
The cancer also reflects global inequity, as its burden is greatest on low and middle income countries where access to public health services are limited. In 2018, nearly 90 per cent of all cervical cancer-related deaths worldwide occurred in low and middle income countries, where the proportion of women who die from the disease is greater than 60 per cent. This is more than twice the number than in many high income countries.
The tools to prevent, detect and treat the disease already exist, yet developing countries face a number of challenges in expanding vaccination and screening programmes. The WHO’s strategy, therefore, marks a long overdue call to the global community to put the elimination of cervical cancer higher on their agenda, ensuring that all countries have the necessary policies, health services and funding in place.
Rolling out the vaccine. As of 2020, less than a quarter of low income countries have introduced the HPV (human papillomavirus) vaccine, a safe and effective way to protect women from a key cause of cervical cancer, into their national immunisation schedules. In contrast, more than 85 per cent of high-income countries have done so.
In recent years, however, more and more low and middle income countries have taken steps to roll out the vaccine.
In Zimbabwe, where cervical cancer is the leading cause of cancer-related deaths among women, the country introduced the HPV vaccine into its national immunisation programme in 2018 with funding from Gavi, the Vaccine Alliance, which allocated funds sufficient to reach over 800,000 girls aged 10-14.
Gavi has been supporting the vaccine’s gradual roll-out to low and middle income countries since 2013. That has enabled Dr Chimbetete’s clinic in Harare to offer the vaccine to adolescents, as well as screening and treating older women.
“Once people are aware, the uptake is good, but there still needs to be a lot of work to highlight the importance of HPV vaccination among the general population,” he says.
Beating the stigma in Cameroon. Like Zimbabwe, Cameroon introduced the HPV vaccination onto its national immunisation programme last month following a six-year long pilot phase.
Completion of the pilot, first launched in 2011, faced many challenges. Dr Simon Manga, a reproductive health specialist for the Cameroon Baptist Convention Health Services (CBCHS), explains that parents were initially reluctant to have their children vaccinated, believing it would make them sterile.
Now the national immunisation programme is getting started, some communities that initially accepted the vaccine earlier this year have later refused it, due to an unfounded belief that it is in fact an experimental Covid-19 vaccination. Misinformation has been rife on local and social media during the pandemic, with Gavi CEO Seth Berkley describing the situation in one article as “the worst I have ever seen.”
Dr Manga said: “People are afraid that they want to sterilise their girls, and worst of all it coincided with the period of Covid-19…There’s currently a lot of resistance.”
Dr Manga is a member of the National Planning Committee for the vaccine programme. He still hopes that with the help of the government and cooperation from community leaders, vaccine uptake will expand. A nationwide campaign is currently being organised to raise awareness about the importance of the vaccine, and quash the rumours that have been circulating.
Inexpensive cancer screening with novel methods. Dr Manga also supervises the CBCHS’ Women’s Health Programme (WHP) which offers cervical cancer screening as well as breast examinations as part of its other reproductive health and family planning services.
Like most facilities rolling out these services in Africa, the screening method used is not the traditional “pap smear” that requires expensive laboratory analysis, but rather an on-the-spot visual inspection of potential abnormalities on a cervix dabbed with acetic acid, and then examined with the help of new digital cervicography. Here, too, HIV positive women are prioritised due to their increased vulnerability to cervical cancer.
Unlike the vaccine, there is no national programme for free screening services, and Dr Manga explains this is a major barrier for women. When the CBCHS have trialled free services before, the uptake has been unsurprisingly high.
In addition, encouraging those women who show signs of pre-cancer or cancer to return for follow-up treatment is also a challenge. Dr Manga explains many women do not understand the seriousness of the need for follow up, are put off due to the additional cost, or are advised not to return by faith healers in their communities.
Despite this, Dr Manga says the programme hopes to expand their services, increasing their use of mobile clinics and developing a “centre of excellence” by which local healthcare workers can gain training from different organisations and experts that they can use in their facilities. As with screening services, however, more funding is needed.
“One of the things that is slowing down our rapid expansion is funding - if we start getting funding then we can expand rapidly,” says Dr Manga. “[The WHO’s strategy] gives me hope that very soon there will be a lot of funding.”
Like in Cameroon, costs are a barrier to treatment. More funding is needed. Because Dr Chimbetete's clinic is funded by the Swiss-based Ruedi Lüthy Foundation, he has the mandate to provide the screening and treatment services free for HIV positive women. However this is not the case at public primary care clinics across the country.
At those clinics, while screening is widely available, follow-up treatment services generally come at a cost. Dr Chimbetete explains that the cost - which usually includes travel to a central facility that offers treatment as well as the treatment itself - prevents many women returning for follow-up, even when they know they have or are at risk of developing cervical cancer.
“Anything other than screening is not free, even in patients who are diagnosed with cervical cancer,” he explains. “Cost becomes an issue ... especially now when we are going through economic challenges, it may not be a priority. So even though as a nation we are offering cervical cancer screening we still see very high incidences of cervical cancer because of all these issues. ”
“Cervical cancer can only be addressed if we have more international organisations coming in to assist,” concludes Dr Chimbetete. “People need to make more noise. Noise has helped with HIV, noise has helped with TB, but I don't think in my view we have made enough noise around cervical cancer. And now, because Covid has become such a huge global issue, there is a fear that everything else becomes insignificant. So some people really need to make noise around cervical cancer. ”