1. Seeing is Believing: VIA and the Single-Visit- Approach to Cervical Cancer Prevention Dr. John E. Varallo - Senior Technical Advisor Heather Harrison - Senior Program Officer Katherine Lilly - Senior Program Coordinator Global Health Mini-University 2015 Washington, DC 2 March 2015

2. Session Outline/Learning Objectives  Presentation; Demonstration Stations  Describe the principals of visual inspection with acetic acid (VIA) and the single-visit-approach  Describe/demonstrate training techniques for VIA and cryotherapy  Describe why VIA/cryotherapy is a cervical cancer prevention "best buy"  Describe programmatic lessons learned

3. Magnitude of the Problem Source: GLOBOCAN 2012 Less developed regions bear 85% of global cervical cancer burden Expected to worsen to 98% by 2030 3 Leading cause of cancer mortality among women in many developing countries

4. WHO Guidance Note 2013

5. What Is VIA?  Use bright white light to visualize cervix with unaided eye  Clean cervix with dilute 3-5% acetic acid solution (white vinegar)  Wait at least one minute  Abnormal tissue temporarily appears white (acetowhite)  Get immediate results  Promotes linkage of screening with treatment Before VIA POSITIVE NEGATIVE 5

6. Why VIA? Evidence-based: supported by WHO, FIGO, ACCP, others Accuracy: comparable to or better than pap smear Low-tech, simple: little infrastructure needed Task-shifting: frontline providers Immediate results: promotes linkage of screening- treatment 6

7. Categories for VIA NEGATIVE POSITIVE SUSPECT CANCER 7

8. What is Cryotherapy?  Ablative therapy for cervical lesions  Freezing accomplished through special probes using carbon dioxide or nitrous oxide gas  Freezing process that destroys cervical precancerous tissue by: 1. Direct cell injury 2. Vascular stasis 8

9. Why Cryotherapy? Effective: Cure rates >90% Safe: <1% infection; no effect on future fertility Highly Acceptable Low-cost: $4-5/treatment Task-shifting: nurses Mobile: bring services to the community; no electricity require Links screening with treatment 9

10. Cervical Cancer Prevention: A WHO NCD “Best Buy”  Cervical cancer prevention through: screening (VIA) and treatment of precancerous lesions with cryotherapy  “Very cost-effective”  “Very low cost”  “Feasible” (frontline) 10

11. Single Visit Approach (SVA) Steps 1.Education and Counseling 2.Pelvic exam followed by speculum exam to see cervix 3.Apply 3-5 % acetic acid to cervix; Wait at least 1 minute 4.Inspect cervix for acetowhite lesions 5.If VIA+, determine if cryotherapy eligible 6.Discuss results and treatment options  Obtain consent  Apply Cryotip to cervix and freeze for 3 minutes  Defrost for 5 minutes  Re-freeze for 3 minutes  Review post-treatment and follow-up instructions 11

12. 12 Competency-based Training Approach  Learning by doing  Classroom Simulation  Hands-on Clinical Practice  Focuses on performance  Knowledge, Skills and Attitude  Utilizes qualified clinical trainers  Proficient in the procedure  Ability to effectively transfer skills  Key Elements:  Adult learning principles  Humanistic training  Role Modeling  Support new provider after training VIA & Cryotherapy Training

13. Main Components of VIA/Cryotherapy Course Classroom-based knowledge update, demonstration and skills practice Ongoing skills practice and assessment Final knowledge and skills assessment Precourse knowledge and skills assessment Ongoing competency development and evaluation Clinical skills checklists Final knowledge assessment; Checklists 13

14. Classroom-based Course Activities  Knowledge, skills, attitudes  Images  Demonstration, coaching  Models, checklists

15. Images

16. Clinic-based Course Activities  Flashcard practice  Group education  1-on-1 counseling  VIA  Cryotherapy  Post-counseling  Mentoring  Skills assessment

17.  Guyana  Haiti  Indonesia  IPPF/Caribbean  Nepal  Peru  Philippines  Thailand Jhpiego Country Experience: Programs and Initiatives  Burkina Faso  Cote d’Ivoire  Ethiopia  Ghana  Kenya  Malawi  Mozambique  Rwanda 17  South Africa  Tanzania  Uganda  Zambia  Zimbabwe

18. Programmatic Lessons 1.Strong commitment from stakeholders critical 2.Capacity building requires more than initial training 3.Integrate with other services (e.g., HIV) 4.Ensure treatment – SVA and strengthen referral linkages 5.Strengthening M&E is key: Using data for decision making 6.Develop effective community sensitization Program Components and Objective 18

19. Programmatic Lessons  Strong commitment from stakeholders is critical  Capacity building requires more than initial training 19

20. Programmatic Lessons  Integrate with other services (e.g., HIV)  Guyana: 95% of HIV-infected women screened with VIA at least once over 3 years  Cote D’Ivoire: 72%  Ensure treatment – SVA and strengthen referral linkages  Tanzania: 95% SVA; 96% all treated  Guyana: 85% SVA; 94% all treated  Referrals: Initially virtually all lost to f/u; following referral strengthening, 79% and 71% treated 20

21. Programmatic Lessons  Develop effective community sensitization  Strengthening M&E is key: Using data for decision making 21

22. Thank You! Let’s divide into two groups for the stations: 1.VIA and Cryotherapy 2.Using Data/Program support