National Coordinator Cancer Prevention Ministry of Health Zambia Dr. Sharon Kapambwe National Coordinator Cancer Prevention Ministry of Health Zambia

Conflict of Interest No conflicts of interest to declare.

BACKGROUND Invasive cervical cancer is one of the commonest malignancies worldwide Accounts for 22% of estimated new female cancer cases in sub-Saharan Africa Most common cancer in adult population in Zambia (over 30%)

HIV and Cervical Cancer HIV infected women at much higher risk for incidence, progression and persistence of cancer causing HPV infection Present at younger age with cervical cancer More rapid progression of chronic persistent HPV infection Relative immunosuppressive state Limited to nonexistent cervical cancer screening services

The Zambian Programme A country of 16 million people Life expectancy 60 years 56% live in rural areas HIV prevalence 13.3%

Zambian Context-2003 Physician patient ratio: 0.12/1,000 Raging HIV epidemic (HIV Prevalence 16.5%) Increasing cervical cancer cases No chemo-radiation treatment centre centre Limited cytology based screening doctor led No HPV vaccination 25 gynecologists in the nation 6 pathologists in the public sector No cytologists Competing priorities Most of our countries could be here

Gynecol Oncol 2006; 103: 1017-22. screened 150 consecutive in 2004, non-pregnant HIV-infected women accessing HIV/AIDS care services in Lusaka, Zambia. collected cervical specimens for cytological analysis by liquid-based monolayer cytology (ThinPrep Pap Test®). HPV typing using the Roche Linear Array® PCR assay. median age of study participants was 36 years (range 23–49 years). their median CD4+ count was 165/μL (range 7–942).

Local solutions Visual Inspection with Acetic (available, low-cost, same-visit, and optimally accurate) Inadequate laboratory infrastructure to support cytology based-screening Treatment of pre-cancer that is setting-appropriate , lower cost, and relatively easily implemented Cryotherapy- Challenges encountered Thermal coagulation offers better alternative Local training program for nurses and doctors in VIA, Cryotherapy and LEEP Introduction of innovation: “electronic cervical cancer control”—eC3 Point of care data electronic data collection Distance consultation Monitoring and evaluation Continuing medical education Patient education Develop local solutions Distance consultation, Use of technology to circumvent prevailing challenges.

Program Implementation 2006 Integrated into two government-operated public health clinics Nurse led, VIA based, “Screen and Treat” platforms Government and PEPFAR/CDC-supported Target HIV-infected women Open to women with HIV uninfected and unknown status HIV testing offered

1 2 3 Three-Phase National Scale-Up with government ownership Provincial hospitals - Nursing schools, functioning theatre - VIA, Cryotherapy, LEEP 2 District hospitals - VIA, Cryotherapy +/- LEEP Scaling up to national levels through a thorough process 3 Health facilities - VIA, Cryotherapy

2006 One district- 04 clinics

Cervical Cancer Screening Clinics in Zambia (2017) Nchelenge Chienge Kaputa Mporokoso Mpulungu Mbala Nakonde Kawambwa Mungwi Kasama Isoka Luwingu Mwense Chinsali Chilubi Chama Mansa Samfya Mpika Mwinilunga Milenge 1 Solwezi Lundazi 3 2 4 5 6 Lufwanyama 7 Chavuma Masaiti Serenje Mufumbwe Zambezi Kabompo Mambwe Mpongwe Kasempa Mkushi Petauke Chipata Kapiri Mposhi Katete Chadiza Lukulu Kabwe Urban Nyimba Kabwe Kaoma Mumbwa Chibombo Kalabo Mongu Chongwe Lusaka (12) Taken a decade for most districts to access screening services Luangwa Key: Itezi-Tezhi Kafue Senanga Namwala Mazabuka 1. Chililabombwe Monze VIA only Shangombo Siavonga 2. Mufulira Choma 3. Chingola LEEP and VIA Gwembe 4. Kalulushi 5. Kitwe Sesheke Kalomo Sinazongwe Kazungula 6. Ndola Urban Livingstone 7. Luanshya Carried forward from 1997: 45,180. Supplied in 1998: 33,160 UNICEF 34,000 JICA Total: 112,340 Minus stock carried forward to 1999: 42,288 TOTAL CONSUMED IN 1998: 70,052 Total forecast: 132,000 % of forecast consumed: 53%

Achievements Cervical cancer screening part of HIV treatment guidelines, HIV linkages in National Cancer Control Strategic Plan Linkages with HIV care and treatment clinics Close to 370,000 women screened, 29% HIV infected HPV vaccination demonstration done, national scale planned Establishment of chemoradiation centre with in patient facilities Increased number of partners

Challenges Funding limited for cervical cancer Still not “mandatory” for women living with HIV to get screened for cervical cancer Integration needed between cervical cancer screening and HIV HPV vaccination for adolescent and screening needed

Recommendations Make cervical cancer screening part of HIV care Strategies needed for adolescents living with HIV to be vaccinated and screened Research on HPV infection in adolescents needed Increased funding base for cervical cancer screening

Acknowledgements Ministry of Health, Zambia Centre for Infectious Disease Research in Zambia Co-operating partners The nurses, doctors and all support staff working in screening centres around the country The International AIDS Society for this session Women of Zambia for advocating and accepting this programme UN Agencies, Global Fund, PRRR, PEPFAR funded NGOs, Civil Society inc. Cancer Support Groups,