CERVICAL CANCER “An NCD We Can Overcome”
Therese LETHU Global Health Objectives Acronyms
GHO ...... Global Health Objectives CKC...... Cold Knife Conization EVA System ...... Enhanced Visual Assessment GFATM ...... Global Fund Against Aids, Tuberculosis and Malaria HPV ...... Human Papillomavirus HUG ...... Hospitals University of Geneva ICT...... Information and Communication Technology ITU...... International Telecom Union IAEA ...... International Atomic Energy Agency IARC...... Agency for Research on Cancer LEEP...... Loop Electrosurgical Excision Procedure mHealth ...... Mobile Health MOH ...... Ministry of Health NCD ...... Non Communicable Disease OIF ...... International Organization of the Francophonie Pap smear...... Papanicolaou test PEPFAR ...... The U.S. President's Emergency Plan for AIDS Relief SMS...... Short Message Service STI ...... Sexual Transmitted Infection TB ...... Tuberculosis UNICEF ...... United Nation’s Fund for Children UNAIDS ...... The Joint United Nations Program on HIV/AIDS UNFM ...... Université Numérique Francophone Mondiale UNFPA ...... United Nations Population Fund UNDP...... United Nations Development Program USNCI ...... Us National Cancer Institute VIA...... Visual Inspection with Acetic Acid VILI ...... Visual Inspection with Lugol's Iodine WHO...... World Health Organization
Cervical Cancer in Africa : “An NCD We Can Overcome”
“This was the theme of the round table we organized in Geneva with various experts to highlight the way forward. This is the report of the discussion”.
22 May 2016 - 3.30 to 6.30 pm Starling Hotel, Geneva
Geneva - July 2016
Therese LETHU Global Health Objectives
1 AGENDA
Thérèse Lethu, Executive Director, Global Health Objectives: Welcoming words and moderator...... P. 3
Michel Sidibé, Executive Director, UNAIDS: HIV/HPV Interactions: new opportunities for joining forces...... P. 4
Prof John-Paul Bogers, Coordinator of The WAKA-HPV Project: A promising public and private approach at regional level...... P. 7
Dr Sharon Kapambwe, National Coordinator Cancer Prevention, Ministry of Health, Zambia: Lessons learned from experience...... P. 9
Curtis Peterson, VP Global Health Mobile ODT: Screening cervical cancer using mobile phones...... P.13
Dr Anne-Caroline Benski, Obstetrician/gynecologist, University Hospital of Geneva: Innovative Mobile Health System for HPV Screening in Low Income Countries....P.14
Dr Ophira Ginsburg, WHO: The new UN Global Joint Program for Cervical Cancer Prevention and Control..P.16
Dr Qhing Qhing Dlamini: Afya Health Management Associates: The way forward...... P.17
Discussion: key insights...... P.18
Therese Lethu: Conclusions...... P.24
2 Therese Lethu, Executive Director, Global Health Objectives (GHO): Welcoming words and overview
According to WHO, screening and treatment of cytology (Pap test). Molecular-based HPV diagnos- pre-cancerous lesions to prevent cervical cancer is tics are being tested in research and pilot projects in one of the “best buy” for addressing NCDs preven- a number of countries to clarify the diagnostic, cli- tion and control, while reducing premature deaths nical, and programmatic implications of HPV scree- by 25% by 2025. Taking into account current and ning for cervical cancer prevention. In addition, two projected burden of disease, cost-effectiveness, certified HPV vaccines provide new powerful tools fairness, technical knowledge and feasibility of new to scale up current programs, with the potential to interventions, cervical cancer programs have pro- prevent 70% all cases. (Newer vaccines which tar- ven to be cost-effective and high-impact initiatives. get more of the cancer-causing subtypes of HPV will eventually be able to prevent a greater proportion Cervical cancer remains the most common type of cases, for example Gardisil 9, which targets 9 sub- of cancer among women in sub-Saharan Africa: af- types, currently prohibitively expensive for most fecting as high as 22%. In the WHO AFRO region, countries). every year, 34 out of every 100 000 women are dia- gnosed with the disease and 23 out of these die HIV/HPV co-infection is another opportunity to in- [REF Globocan/IARC]. Human papil- tegrate screening of cervical can- loma virus (HPV) is the primary cause cer into existing HIV testing and of cervical cancer. While most infec- counseling, care and treatment tions with HPV are cleared by the bo- services. According to scientific dy’s immune system, some infections sources, there is a higher inci- persist and lead to cervical dysplasia, dence, greater prevalence and pre-cancers and ultimately invasive longer persistence of HPV in- cancer Despite being one of the few fection amongst HIV infected types of cancer that can be prevented women. Research is ongoing with a vaccine and by screening with to develop more effective and simple treatment of pre-cancers, cost-effective methods of scree- more than 95% of affected women ning and treatment, but cryothe- have never been screened for the rapy, large loop excision of the disease. Cancer control programs are not yet part transformation zone (LEEP/LLETZ), and cold knife of existing primary sexual and reproductive health conization (CKC) are standard practices depending care services. Knowledge and awareness of this on the clinical situation and the setting*. disease remains poor, and facilities for prevention, diagnosis and treatment are still widely inadequate. Our roundtable highlighted new major strategic As a result, most of women are diagnosed at the and technologic steps for advancing screening and advanced stage and this incidence is on the increase treatment of cervical cancer in Africa, raising awar- in some countries. eness and providing key data to help political lea- However, new strategies to both primary and se- ders, partners and funders to take action. condary prevention have been scientifically proven Prior to the sixty-ninth World Health Assembly, held over the last decade. The approaches, tools and in Geneva, from 23 to 28 May 2016, the roundtable equipments for new screening methods, vaccina- enabled Commonwealth member countries’ dele- tion, treatment and awareness should create addi- gates to participate in the discussion. An interactive tional opportunities for innovative actions, syner- exchange provided an overview of current interven- gies and promising partnerships. tions and research as it relates to cervical cancer in Africa. Particular emphasis was placed on assessing Such interventions should help increase access for the enabling environment for those strategies to women aged 30–49 years to early treatment and succeed, exchanging experiences and knowledge screening to identify precancerous lesions, as re- for optimizing results, including standard data col- commended by WHO guidelines. Available scree- lection and analysis for quality control. ning tests include a Human Papillomavirus (HPV) *http://www.who.int/reproductivehealth/publications/can- test, Visual Inspection with Acetic Acid (VIA), and cers/cervical-cancer-guide/en/
3 Michel Sidibé, Executive Director, UNAIDS: HIV/HPV Interactions: new opportunities for joining forces
As Executive Director of UNAIDS, since 2009, technologies, programmes and entry points that Michel Sidibé’s vision of zero new HIV infections, are mobilized for HIV prevention, treatment, care zero discrimination and zero AIDS-related deaths and support can be successfully combined with has been integral in securing HIV as a priority of other sexual and reproductive health services, in- political agendas. Having spent more than 30 cluding those for cervical cancer – as highlighted years in public service, M. Sidibé’s ideas of shared in the 2016 Political Declaration on HIV and AIDS, responsibility, global solidarity and the critical role the UNAIDS Strategy 2016-2021 and the United of the civil society and community mobilization, in- Nations Secretary General’s 2016 report. cluding meaningfully engaging women living with The 2016 Political Declaration on HIV and AIDS HIV and the women’s rights movement, have [PD] («On the Fast-Track to Accelerate the Fight been embraced by the international community, against HIV and to End the AIDS Epidemic by including most affected countries. His experience 2030»), emphasizes the importance of addressing as far as it concerns the lessons learned from the the linkage between HIV and HPV infections, and fight against the HIV/AIDS epidemic could help HIV-cervical cancer co-morbidity. To guarantee advance the prevention and treatment of cervical the sustainability of HIV prevention, treatment, cancer in Africa and is of great value to our discus- care, and support services, information and edu- sion. cation, the PD calls for the integration of those services with national health systems and services Cervical cancer is the most common cancer in to address co-infections and co-morbidities, inclu- women in sub-Saharan Africa and globally is the ding prevention, screening and treatment for cer- fourth most common cancer in women. Every year vical cancer and HPV. 527,624 women are diagnosed with cervical cancer and 265,653 While introducing the round- women die from the disease. The table discussion entitled “An majority of new cervical cancer NCD that we can overcome”, cases (85%) and deaths (88%) oc- Michel Sidibé emphasized the cur in low-income and middle-in- movement from “just AIDS”, as come countries. This is a largely underlined in the UN Secretary preventable tragedy thanks to General’s 2016 report and re- the HPV vaccine, and curable if minded of the SG’s call to scale detected and treated early. Cer- up and monitor collaboration vical cancer is four to five times across HIV and other health is- more common among women sues, including cervical cancer, living with HIV than women who by adopting medium-term tar- are HIV-negative. Women living gets towards 2030, such as: 1) with HIV are also more likely to to screen every woman living have an increased risk of developing precancerous with HIV for cervical cancer by 2020, 2) Re-screen lesions, those lesions to progress rapidly to inva- women living with HIV whose screening results sive cervical cancer and a recurrence of precance- are negative (no precancer) within three years, rous lesions after treatment. With the increased and 3) to reduce by 25% cervical cancer deaths longevity of HIV-positive women on anti-retroviral and all other NCDs related mortality by 2025. ”We therapy (ART), their risk of exposure to HPV fur- are not there yet, but a few years back, we we- ther elevates, providing the time required for pro- ren’t even dreaming of such a target on HIV. Today gression to cervical cancer. we are completely bringing HIV out of isolation, Addressing HIV-HPV co-infection and HIV-cer- for better integration and greater accessibility to vical cancer co-morbidities as well as prevention those most in need. So we need to also fast-track of both and integration of HIV and cervical can- the response for the cervical cancer as well as get- cer prevention, screening and treatment services ting back to zero and making sure that we reach are, thus, an effective and efficient approach for the 90-90-90 goals”. responding to these diseases. Many of the same 4 Integration 1.5 million in 2010 to 1.1 million in 2015. Over 50% of patients now have access to treatment. In addi- Based on the lessons learned from HIV and tuber tion, 2.5 million people were newly infected with culosis service integration, Michel Sidibé stressed HIV, which is a real progress in ten years, including the importance of further integration: “We learned a reduction of up to 50% for newborns. Those very early that we were treating people affected major outcomes have been made possible thanks with HIV and we were letting them die from tu- to a local collaborative organization designed to berculosis. So integration with medical health scale up the programme activities. This commu- and women’s sexual and reproductive health nity-centred and –based strategy should also be programmes, among others, is very important. critical to successfully implement and extend any We learned that integration is very cost-effective programme on sexually transmitted diseases pre- to help reach more people”. Collaboration and vention and treatment, including cervical cancer. integration between HIV and tuberculosis pro- The integration of services must include advocacy grammes has led to a big increase in HIV testing and information, including age-appropriate com- for tuberculosis patients. prehensive sexuality education and communica- Those found to be HIV-positive are started as tion regarding HPV and cervical cancer. soon as possible on ART, which has been proven to reduce the number of deaths in tuberculosis “Furthermore, our experience related to fighting patients more than waiting until the tuberculo- stigma and discrimination related to HIV and sis treatment is completed. Isoniazid preventive AIDS is crucial to overcome cervical cancer’s therapy reduces the rate at which people living challenges and move forward”. UNAIDS Exe- with HIV develop tuberculosis, even if they are cutive Director mentioned the home-based care also taking ART. Molecular diagnostic platforms strategy as another successful people-centered for tuberculosis (geneXpert), which increase the and community-based service delivery approach: yield especially in patients with dual infection, are “In doing so, we need to work with faith com- now also beginning to be used for HIV viral load munity actors, and community based partners and infant DNA-based HIV testing. In many coun- to extend our reach”. According to Michel Sidi- tries, the number of deaths among people living bé, it is necessary to leverage existing opportu- with HIV have declined, in particular, thanks to the nities, experience and synergies within the HIV/ reduction in the number of tuberculosis-related AIDS programmes to accelerate progress towards deaths among people living with HIV, which have cervical cancer programmes, including screening, fallen by 32% since 2004. prevention and care, especially in Africa, the re- gion in greatest need. M. Sidibé reminded of another lesson from the global AIDS response, particularly, the key role Decentralisation that community partnerships, civil society activism and advocacy, and community mobilization play, M. Sidibé has additionally highlighted the impor- and the high return in investments in commu- tance of decentralization of services and strategic nity-led service delivery and human resources for information, including data on barriers to acces- universal health coverage to strengthen people- sing HIV and cervical cancer services. “Early, we centred service delivery. Furthermore, he reaf- understood that we needed to decentralize data firmed that the collaboration and partnerships collection and the prevention and care process, forged between the women’s rights movement including clinical and laboratory services, to and networks of women living with HIV were cri- reach out to the greater number of people at the tical in ensuring that gender equality, women’s community level”. The lesson of decentralizing empowerment, sexual and reproductive health, clinical and laboratory services is very important and rights were prioritized as part of the global as far as it concerns cervical cancer programmes. HIV response. “We can share our experience re- “We should start filling more data on cervical can- garding access to treatment at large scale, es- cer related to HIV- HPV co-infection’s scientific pecially in changing the service delivery concept evidence, HPV field research, quality control and completely by creating the demand and the transparency including stigma and discrimination, ownership at the community level”, said Michel so that we can think about how to deal with these Sidibé. The HIV treatment coverage had increased issues which are keeping women away from both from 24% in 2010 to 54% in 2015. As a result, the services for HIV and cervical cancer, in so many number of AIDS deaths had been reduced from places”. 5 90-90-90 targets to apply the lessons learned from the accelerated treatment scale up to non-communicable disease Based on the progress made in the AIDS response programmes, namely cervical cancer. “For the first globally, M. Sidibé underlined both the need and time we put almost 17 million people on treatment, opportunities for countries to accelerate efforts to in a few years, providing the support needed to en- end the AIDS epidemic by 2030. sure that those chronic care programmes can work The goal is to reach the 90-90-90 targets in 2020, in resource limited settings. As highlighted in the namely: 90% of people living with HIV to know their Secretary General’s report, the failure to control the status, 90% of people who know their status to ac- AIDS epidemic will undermine efforts to end tuber- cess HIV treatment and, 90% of people on treat- culosis and reduce rates of maternal and child mor- ment to achieve viral suppression, and proposed tality, hepatitis C and cervical cancer».
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UNAIDS JOINS CERVICAL CANCER INITIATIVE
UNAIDS is joining with Cervical Cancer Action (CCA)—a global coalition to stop cervical cancer among women and girls in developing countries—to launch a new five-year initiative. Taking Cervical Cancer Prevention to Scale: Protecting All Women and Girls, an initiative spearheaded by Ambassador Sally Cowal, is convening a partnership committed to prioritizing investments in the health of women and adolescent girls. It will build momentum for action on global cervical cancer pre- vention over the next five years. FFFFF
Sally Cowal, Senior Vice president, Global Health, American cancer Society
“US$ 3.65 billion over 10 years for cervical cancer control to save the lives of countless women and girls is not beyond us, integrating these invest- ments with hiv prevention and control leverages multiple benefits.” FFFFF
* Ferlay, J, Soerjomataram, I, Dikshit, R et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer. 2015; 136: E359–E386.
The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNES- CO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals.
FFFFF 6 Prof John-Paul Bogers, Coordinator of the WAKA-HPV Project: A promising public and private approach at regional level
As a coordinator of the WA- in Africa, African countries KA-HPV program and an will increasingly introduce experienced pathologist, Pr HPV vaccines into their na- John-Paul Bogers, of the Uni- tional immunization pro- versity of Antwerp, in Belgium, grams. Therefore, they need explained how this promising baseline data on the locally multi-country program was set existing HPV types. Howe- up, its evolution and impact, ver, most of those countries the successful factors needed lack comprehensive and valid to reach its objectives, as well data on this issue. In addition, as the way to go forward. Africa may also host various unexplored types which are The WAKA - HPV Program is designed to: uniquely founded in various cancers and benign • set up a HPV reference centre; lesion. Countries such as Uganda and Kenya which • establish a HPV research network within have documented HPV infections have benefitted the African region - taking VLIR-UOS, from collaborative work with Northern countries. the Flemish Interuniversity Council’s collaborations “In Kenya, we identified specific topics to discuss as a stepping stone. mainly about laboratories, implementing quality monitoring in these labs and setup quality pro- ”We started this initiative in the University of grams. A priority was given to collect valid HPV Antwerp. Since the 90s, we have been developing data to generate epidemiological information for projects on HPV in all these countries, and so the public health purposes, monitor HPV vaccination idea was to start talking to each other. In 2010, impact and conduct training on HPV testing and the initial focus of the project was on infectious genotyping. As almost 90% of HPV burden is in diseases, with various topics including HIV/HPV as low-income countries, we are in urgent need of one of the most important, in close cooperation getting this data in order to define and steer our with the University of Limpopo and the University interventions. Thus, we decided to talk together, of Antwerp, where I was leading the HPV topic. to join forces and build a network”. Based on the external reviewers, we put the focus on Sexually Transmitted Infections, such as HPV, HPV refence center Chlamydia, etc. As the primary goal at that time, we decided to set up a research consortium with As a result of those preliminary steps, the WA- laboratory facilities and public health expertise in KA-HPV program was launched to set up a HPV re- STIs, specifically for Sub-Saharan Africa”, said Pr ference center for the region, based in South Afri- Bogers. ca, and also to establish a research network within African countries. “The WAKA-HPV collaboration “We had a few Masters and PhD students, and started as a cooperation of all these countries and one of the PhD projects was specifically on HPV. their HPV projects. It was initially supported by PhDs can potentially drive a part of this project, as North-South cooperation grants from the Flemish after graduation, they can reach levels where they government and European funds. In addition to are influential and can help communities. Then we South Africa, where the program was launched, wanted to build capacities not only in people, but it was extended to Ethiopia, Kenya, Burundi, De- also in technical and interpretation equipment, mocratic Republic of Congo, Uganda, Zambia, collaboration and cytology: it was some kind of and then to Malawi, and Ghana. We also started integration as Michel Sidibé was talking about”. cooperation with Pathologists without Borders, an Italian NGO, to strengthen the laboratory capaci- As HPV is the main, almost unique cause of cer- ties”. vix carcinoma in adult women and due to the The goal of this network was to exchange com- high incidence and mortality rate of the disease plementary research projects, to standardize and 7 validate protocols and to develop multi-center ini- presentation, insisting on the need for further la- tiatives. In order to achieve this objective, the pre- boratory capacity in both Human Resources and liminary step was to strengthen the local laborato- laboratory equipment in Africa. “The center in ry capacities to improve their quality. “We needed South Africa is designed to be used as a roll-out more local molecular and cytology capacity, as and support for local initiatives, including for trai- well as lab quality awareness, to set up laboratory nings and techniques. I strongly believe that PhD networks and perform Immunology Quality As- students can play major roles in actually steering sessment. Pr Bogers insisted on awareness as a the process. We’re still far away from solving the key successful factor “We have to educate people major issue. This is why we need more political in the laboratories but also the health care pro- support for implementation. Regarding HPV, we fessionals, on how to handle HPV program, en- still do not really have easy testing possibilities. dowing them with expertise on HPV testing, ge- We can do self sampling, but not self testing. The- notyping and HPV typing in their own individual refore, we still need laboratories at the moment. laboratories”. They can be done locally or centralized. I think lo- cally and decentralized is a very interesting sug- Research network gestion from the previous speaker, Michel Sidibé. We not only still need labs, but high quality labs. The research network organized several mee- That is my way of looking at the HPV related issue tings. The kick-off meeting of the WAKA program as one part of the solutions”. was held in Pretoria, South Africa, in May 2014, with 29 delegates from sub-Saharan countries, FFFFF Belgium, and South Africa. At this occasion, on- going research was discussed, a standardized sur- Fourth WAKA HPV Symposium vey protocol was defined and a platform website was created. A three-day workshop was organized in South Afri- ca for the WAKA HPV AFRICA network members The second meeting was held in May 2015, in Jo- on September 22/24, 2016, with 25 invited dele- hannesburg, to discuss previous and ongoing HPV gates of 7 countries. The symposium included a research, share expertise, collaborate and stren- workshop on practicalities on quality assurance gthen the WAKA-HPV AFRICA network through and quality control, and the SASGO-meeting. At collaborations. This occasion was also an oppor- this occasion, the PhD students from each partici- tunity to showcase the new HPV and STls training pating country presented data to be shown on the centre for Africa with the participation of some next HPV world congress. A lot of practical issues key world leaders on HPV. were discussed on cervical cancer research and lab based research in Low Income Countries and In Kinshasa, in December 2015, the third mee- academic capacity building. ting was organized for the WAKA-HPV AFRICA network members, invited delegates were from FFFFF Pathologists without borders and the local Ins- titute Supérieur des Techniques Médicale. The focus was put on training for pathologists and cyto-technicians. PhD students from each country presented data on ongoing or planned research The Program WAKA-HPV Program benefits from a collabo- projects, as well as presentations from local and rative dynamic team with Prof. Jean-Pierre Van Geertruyden (University of Antwerp) and Jeffrey Mphahlele / Lisbeth Le- international delegates on HPV research in their belo (University of Limpopo, in South Africa). Funded by the institutions and countries. “Four of our PhD stu- Belgian Development Cooperation, VLIR–UOS supports the dents have worked on HPV programs. We also WAKA HPV program as a model of partnerships between started reference laboratories, like the one ope- universities, in Flanders and in the South, looking for innova- ned by the Vice Chancellor of the Health Univer- tive responses to global and local challenges, including Nor- th-South and South-South cooperation, projects and scho- sity in Pretoria. It’s an HPV and STI training center larships. for Africa which was also inaugurated in 2015”. www.uantwerpen.be/en/projects/waka-hpv-africa/
In conclusion, Pr Bogers made a summary of his FFFFF 8 Dr Sharon Kapambwe, National Coordinator Cancer Prevention, Ministry of Health, Zambia: Lessons learnt from experience Zambia has the second highest incidence of vical cancer in our country, I would really like cervical cancer in the sub-Saharan region and to give the context of what was happening in the sixth highest in the world. In 2003, the 2003: At that time, the physician patient-ratio First Lady, Maureen Mwanawasa, expressed was 0.12 per1000 with only 25 gynecologists in her worry regarding the rates of the disease the country. Even though there was a local cy- among Zambian women amounting to as high tology-based screening, there were no cytolo- as 30% of all types of cancer. “Other diseases gists. We had almost no screening going on, the such as cancer need as much at- pap smears were given to women tention as HIV and AIDS”, she with symptomatic events in public said. As a result of her political lea- sector and at a cost in private cli- dership, a program was launched nics”. Dr Kapambwe said before that year to fight this disease as continuing her comments: “So we a major public health concern. Dr had a very huge need of human re- Sharon Kapambwe explained the sources, as far as the doctors were progress made over the years and concerned, and there was inade- the challenges to scale up scree- quate laboratory infrastructure for ning and early diagnosis, such as cytology-based screening. There inadequate number of specialists was no HPV vaccination available. in health centres, poor infrastruc- In addition, there was an increase ture, low laboratory capacity and lack of can- of cervical cancer cases, meaning that the cer screening tools. Her recommendations are country had competing priorities considering particularly inspiring for other countries. She that the HIV prevalence was 16.5%. Currently has been working on this program since the HIV prevalence is 13.3%.” mid 2000s and she remains equally committed to further partnerships at regional level. Local field experience corroborates what Michel Sidibé said regarding the crucial need for an in- Dr Kapambwe brought to our roundtable discus- creased decentralization and integration of the sion, her strong field experience with emphasis programs. “Between July and September 2004, on the implementation modalities, the outco- 150 non-pregnant women accessing HIV treat- mes and lessons learnt from the cervical cancer ment and care at University teaching Hospital program, including the various activities of pre- the main tertiary hospital in Zambia, were offe- vention/awareness, vaccination and treatment. red screening. From the cytological results 19% “Given the background of the fight against cer- lesions suggestive of cervical cancer ».
Cervical cancer in Zambia in 2003: - 6th highest in the world, Structures and human resources: - 2nd highest in Africa, • Physician- patient ratio: 0.12/1,000 - Most common cancer in Zambia (30%), • 25 gynecologists - Most common cancer in women ( nearly 30%), No gynecological oncology unit - Cervical cancer screening coverage <5% • 6 pathologists in the public sector • Increasing cervical cancer cases • No cytologists • Competing priorities • Raging HIV epidemic (Adult HIV Prevalence 16.5%) Socio-economic factors : • No chemo-radiation centre • Life expectancy: 48 years • Cytology based screening doctor led • Per capita income: $1,721 • No HPV vaccination (70% live below poverty), • Population: 12 million (56% live in rural areas) 9 a doctor who is further away, often in the capital See and treat city. We also use the eC3 for monitoring as with the pictures, we can see the areas to be strengthened Cancer among women was increasing, especially and also for evaluating the program, using the cer- cervical cancer with 30% of all new cases (Globo- vicograms”. can and National Cancer Registry); “We had to look for the most appropriate way to screen women. eC3 In 2006, we started by two government-funded health centers and then we extended the screening The pictures also help with patient education to to other facilities with great support from Pepfat strengthen awareness and patient education as a vi- through CDC, initially targeting HIV infected wo- tal strategy to save women’s lives, particularly in this men ». As a result of the shortage of physicians in setting as Dr Kapambwe said: “It is especially im- general, task-shifting was applied to make the best portant particularly that 90% of the women scree- use of available health workforce. “Same day treat- ned for the first time, have never had a pelvic exam ment approach was adopted. «See and Treat» to in their lives, apart from the time of their pregnancy reduce the number of women who would not come and sometimes it is limited to the delivery. Thanks back for the treatment. In our low-resource setting, to Ec3, women can see the pictures with the camera the key is to integrate the cervical cancer program and a monitor which lets them know more about into the existing infrastructure in order to really cervical cancer, and this helps a lot”. sustain the program”. “Be healthy, be mobile” In that context, the method of treatment was se- lected for it was available, low-cost, accurate and As most of the people actually live in the rural areas, possible the same day: “We also had to develop the she insisted on the benefits of the mHealth pro- treatment of pre-cancer lesions looking at the most gram launched in 2015, with the support of WHO appropriate solution, low-cost and easy to imple- and ITU. Zambia is one of eight pilot countries of ment, and so we selected cryotherapy. But cost and the so called program “Be Healthy be Mobile” for avaibility of nitrous oxide have been challenging due testing the feasibility of mHealth to prevent NCDs, to local constraints”. such as cervical cancer, using SMS-based campaigns. In the lead facilities in Lusaka, nurses deliver cryo- “We have piloted sending texts messages to women therapy to the eligible women, but those who do to ensure their access to the right information regar- not meet the criteria have to be referred. “For wo- ding screening and treatment services”. men in rural areas, it means going to the provincial hospital and this has it’s own implications. So we did As a result of the efforts, over 350,000 women have the national scale-up in 3 phases, transitioning the services to the government. The first stage was in been screened for cervical cancer at least once in “Our experience confirms the appro- provincial hospitals where we established nursing their lifetime. priateness of the use of mobile screening initia assistance, with adequate human ressource in terms tives HPV of nurses who are the backbone of the programme. to reach out to a large number of women. They’re also now able to do VIA and cryotherapy. vaccination has been among our greatest achieve- The second stage is the district hospitals and finally, ments. We’re raising the awareness in our country the health facilities with basically the VIA and cryo- also with the help of the first Lady Esther Lungu, as therapy techniques. No center is doing VIA only; well as political and known figures including socio- the nurses can either do cryotherapy or thermocoa- cultural and traditional leaders who helped mobilize gulation”. local communities. Over 30000 eligible girls have re- ceived their doses over the first two years. Our target In order to improve the strategies, new equipment is 20’000 girls, by the third year. The coverage is 89% and innovative approaches have been introduced. for the second dose in 2016 which is a drastic impro- “We used the electronical cervical cancer control vement. To reach our objectives, we strengthened and the eC3 approach. Monitoring is important school health programs through a specific school- especially that the nurses are located in different based type of HPV vaccination”. parts of the country. As we’ve gone through the country, we’ve seen that VIA is very subjective since Another key outcome is the establishment of a natio- it depends on the examiner's experience. With the nal cancer control strategic plan 2016-2021 and the eC3, the nurses can upload the picture and consult costing of a comprehensive cervical cancer care and 10 control tool. “We prioritized four types of cancer: in their packages: Right now, even private insu- breasts, cervix, prostate and retinoblastoma for the rance facilities inform that if women want to go for next 5 years, in order to be really impactful and also screening, they’ll firstneed to consult a doctor and looking at the burden of these cancers, in children be charged a consulting fee, and only after that and men as well”. they can go for screening. Therefore we need to look again at these insurance packages, including Political backing is a key successful factor, as Dr cervical cancer prevention as a package for free”. Kapambwe insisted while mentioning the remaining challenges: “If we want continuity, there has to be po- Molecular testing litical backing, and the First Lady’s office is one of the key ones helping the cervical cancer prevention pro- This approach should help create a sustainable and gram move forward. However government cannot coherent strategy: “We need to look at molecular do it alone. We need partnerships at the local level, testing for further screening, but we also need to NGOs and international level. Challenges remain, for look at alternative treatment, Zambia imports Ni- instance pathology services are still inadequate and trous Oxide from South Africa. It’s not only about surgical skills for early cervical cancer treatment are the cost, it’s also about the supply and when we lacking. There’s really no way that you can achieve so don’t have it, we have women coming back for much success without having pathological services in more visits hence the need for thermocoagulation. So further research and treatments are crucially any cancer control program. Internet connectivity re- needed. In line, with our national strategic plan, mains a challenge but we’re using as much as we can the cervical cancer treatment program should of it to help in quality improvement across the sites. provide an opportunity for breast cancer scree- It should be better. We need more funding conside- ning and other NCDs. We also need to define ring the number of women with cervical cancer in our referral systems for mobile screening and have population”. the outreach programs used only to make sure that we’re ‘mopping up’ the women as fast as we Dr Kapambwe recommended developing alterna- could. This is because the cancer numbers are so tive treatment for pre-cancerous lesions methods, huge, we cannot be doing it only with screening introducing thermocoagulation, providing surgical as it would take us so much time to reach every oncology training and creating platforms for initiation of breast cancer screening/NCDs. She also insisted on the need to create an enabling Integration environment for women to access prevention ser- of cervical cancer prevention programs into existing vices, such as a market-based strategy with the in- infrastructure surers. “Social insurance schemes need to include • VIA as the main approach prevention cervical cancer and NCDs prevention • Training nurses/doctors in VIA,Cryotherapy and LEEP • Thermocoagulation recently introduced Level 1 Provincial hospitals Innovation - Nursing schools, functioning theatre Electronic cervical cancer control/eC3 - VIA, Cryotherapy, LEEP • Point of care/data electronic data collection • Distance consultation Level 2 District hospitals • Monitoring and evaluation - VIA, Cryotherapy +/- LEEP • Continuing medical/patient education • mHealth awareness program Level 3 Health facilities Screening - VIA, Cryotherapy • 350,000 women screened Treatment • Outreach/mobile screening No surgical oncology available - Creation of gynae-oncology unit HPV Vaccination Demonstration Project - Over 13,000 patients seen at Cancer • 3 year HPVvaccination in selected districts Diseases Hospital since inception in 2006 • Over 30,000 girls got 3 doses in first two years - Cervical cancer is the most common • Targeted 20,000 in 2016 ( 89% coverage) for se- cancer observed (a third of all cases) cond dose - High demand/only one chemo-radiation centre • New partners and opportunities - Chemo-radiation centres: currently • School health programs for sustainability and centralised but decentralisation has started with two reduced cost of delivery. more chemoradiation planned. • Planned submission to GAVI for national roll out. 11 woman. Our Government is fully committed been able to leverage international support and towards expanding access to cervical cancer resources from PEPFAR and others. Global fund treatment and care services in all the districts has not yet started releasing funds but allowed by 2021. Cooperation between countries is very Zambia to include cervical cancer. Final approval is commendable. It provides us with opportunities expected and then funds will be available through to learn from each other, creating synergies and Global Fund. further collaborations. At the regional level, Zam- bia has already trained over 300 healthcare pro- This will help expand the cervical cancer pro- fessionals from 14 countries”. gram and integrate it into the health care system without placing extra burden on it, thus maxi- Zambia has been a flagship country for the Pink mizing the potential of the “screen and treat” Ribbon-Red Ribbon Initiative to scaling up scree- approach. This experience should be of great ning services, HPV vaccination and supporting value to other countries in the region facing the the Cancer Registry, since 2011. The country has same challenges.
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Christine Kaseba-Sata, former first Lady of Zambia
“Cervical cancer is critical and becoming a crisis. Deaths due to cervical cancer are projected to rise by 20% by 2020. We need to move as quickly as we can.”
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Strategic plan – Prioritised four types of cancer (Breast, Cervix, NCDs Strategic plan 2013-2016 Prostate and Retinoblastoma) – Guidelines on NCDs Office of Registrar created – Management of NCDs • Supported by NCI up to 2016, govern – Training of health workers ment onwards • Not yet population based but enhanced National Cancer Control strategy operations – Pilot done on with WHO Costing of comprehen- • Critical for evidence creation and policy sive cervical cancer care and control tool making
12 Curtis Peterson, VP Global Health MobileODT: Improved screening for cervical cancer by leveraging the power of mobile phones
“No woman should die from cervical cancer. If in low resource settings such as Kenya”. detected early, cervical cancer can be prevented and existing early-stage cervical cancer is trea- Apart from Kenya, the Enhanced Visual Assess- table. MobileODT is committed to bringing ment System is currently being used globally in mobile cervical cancer screening technology to over fifteen countries, including Nicaragua, Haiti, all women, everywhere, by producing solutions and Ethiopia. “In Kenya, on February 4th 2016, to like the EVA System and by continually suppor- mark World Cancer Day, we helped to screen over ting our partners to strengthen their programs 200 women for cervical cancer in one day”. and extend their reach”. Curtis Peterson shared information on the MobileODT’s EVA System, The hardware includes a lens, light source, and an which uses a low cost, portable colposcope to integrated mobile phone (currently only compa- strengthen all cervical cancer screening (and treat- tible with the Android operating system). Health ment) programs, including those using VIA, VILI, providers use the device to visualize the cervix HPV, and/or Pap. from a distance of approximately 15 centime- ters. Providers use the EVA Sys- Experience has shown that large- tem software application to cap- scale screening of pre-cancerous ture images. Through cellular or lesions with cytology is difficult to wifi connectivity, providers at the scale in low- and middle-income point-of-care can send the images countries due to the lack of spe- to their peers or supervisors for a cialists and infrastructure. Visual second opinion. Images and pa- inspection with acetic acid (VIA) is tient information are also uploaded an inexpensive alternative but sub- to a secure online portal that faci- jective since it depends on the exa- litates remote image analysis and miner's competency. Historically, explanations on how to improve training and supervision for front- diagnosis and treatment. line health workers performing VIA has been resource-intensive and sporadic. There- “The use of mobile colposcope along with smart fore, mobile telemedicine is a very promising tool phones for services, training and collecting data is in order to support health-care workers performs a real innovative approach to help cervical cancer cervical cancer screening. screening especially in rural areas. The hardware and decision support tools within the EVA System This is why Mobile ODT is promising to boost cer- can reinforce existing programs, like VIA as well vical cancer screening with the introduction of an as HPV vaccination. Another advantage is that it’s inexpensive and non-invasive hand-held device possible to better identify risky cases, to avoid that can help detect early signs of the disease. unnecessary surgery and biopsy, while improving “The device can be used by nurses and midwives standard data collection, and real time control conducting VIA with minimal training.” said Mr analysis and evaluation”. Curtis Peterson. “So our device is most popular
Mobile ODT is: • A lightweight and durable medical device, rechar- • A mobile colposcope with a reliable light source and geable, with long-lasting battery for up to 10 hours a powerful lens for enhanced visualization. of continuous examinations. • A secure application for patient image and data cap- • Information and patient data are securely stored in the ture for remote consultation, patient tracking, and online portal for designated people to: referral coordination. • Review patient information and screening decisions • An encrypted online portal which safely stores for quality monitoring and evaluating as well as analytics. infomation for real-time program monitoring and • Provide remote clinical supervision and quality assu- case management. rance. • API access for electronic medical records systems.
13 Dr Anne-Caroline Benski, Obstetrician/gynecologist, University Hospital of Geneva: Innovative Mobile Health System for HPV screening in low-income countries
Geneva University Hospitals (HUGs) are the first that, we screen, treat and follow-up on the same university hospitals in Switzerland and interna- day, insuring a good quality assessment”. tionally recognized reference. HUGs also act globally to promote universal access to health- With this objective in mind, the project was care, in close collaboration with international designed to enable the use of smartphones to Geneva's organizations such as the WHO. The assist health-care workers and to evaluate the support to African countries to improve wo- diagnostic reliability and accuracy of cervical exa- men’s access to cervical cancer screening and mination with smartphone photos of VIA (D-VIA) care is in continuity of its humanitarian tradi- compared to conventional VIA for women tes- tion. HUGs contribute to promote early dia- ting positive for HPV. Based on the results, an gnosis and treatment taking advantage of the educational training and quality assurance pro- availability of new technologies. gram for health providers for VIA was developed to scale-up cervical cancer control. The triage by Dr Anne-Caroline Benski explained her expe- VIA has helped reduce not only an excessive re- rience through two ongoing pilot projects in Ca- ferral rate but also an excessive treatment delay, meroon and Madagascar, with an giving the possibility of a "screen emphasis on process, new tools, (HPV), see (VIA/D-VIA), and treat and outcomes. As a result, 3000 program” in a single visit or two. women have been screened and treated. She also acknowledged “The VIA exam helps us decide the benefits of mHealth in sca- if we’re going to treat the case ling up awareness campaign via or not. If the exam is patholo- text messaging, diagnosis as gical then we decide to do the well as quality control through thermal coagulation. The device Electronic Medical Records. used is practical, requiring 60 se- The methodology developed by conds at 120 degrees, electricity HUGs is comparable to the Mo- is needed, but it’s a very simple bile ODT. The pilot projects are device. We also use HPV/DNA still going on to screen and treat test, followed by the thermal women in the two countries. A new study of coagulation. We treated HPV 14, 16 and 18, and mHealth data collection system for women par- the results showed that it was a good solution. ticipating in a cervical campaign in Madagascar It’s a one-day “screen and treat”, we don’t need has been launched with a group of 150 patients, to contact the women afterwards, and we also between June and September 2016. sensitize them at this occasion. For the moment we’ve been doing both Genexpert and doctor In those countries, as the previous speaker said, sampling as well as the biopsies and quality there is a need to focus on low screening and controls too. We’ve been doing questionnaires loss of follow-up. Dr Benski confirmed this posi- on qualitative and quantitative results and we tion: “Our program started 10 years ago. One of have very good feedback from the women, pa- the biggest problems our University found in de- tients and health professional. In the end, a lot of veloping countries was the use of the Pap smear women, at least in Madagascar, started coming test, with the delivery of the results of 1-2 weeks, again as they were not stigmatized because inducing the loss to follow-up. We thought that of HPV results. When they came to the health it wasn’t ethical to practice screening if we can’t centers, they thought they were going to have guarantee treatment. Therefore, we decided to surgery to remove their uterus. We explained apply the C- Entry strategy using m-health to to them what we do and how they can do it provide mobile phone awareness text-messa- themselves in their settings, showing them the ging, diagnosis and electronic medical records. images, which made our experience successful. We wanted to avoid the loss to follow-up, so The electronic medical records were appropriate
14 for assessing the quality of care and providing training to increase local capacities for using relevant statistics for academia. The personal colposcopy.” The tool we used is a very simple information and other data are uploaded in the image/icon-based application, with a simple per- cloud medical unit to be used from anywhere sonal form, allowing task-shifting in order not with an access code. The results of the genXpert to rely on the gynecologists, but just get their test can be compared and analyzed. The project backup in the nearest health centers, to secure demonstrated that it is an easy process to imple- quality control. We also intend to bypass the ment with a high capacity of about four exams pathologists, because, as I said, the idea of our per hour”. treatment is not to use the cytology test in this case, just HPV/DNA test and the VIA/VILI on “First, we developed a smartphone application, the same day. The process with self-sampling like the ODT or similar to it, to help the diagno- can be extended to rural areas, along with awar- sis on VIA and VD exam. Then, we looked at eness on cervical cancer and all the STDs, being the cervical cancer prevention system, which is analyzed on the same day. It is easy and cost ef- an application to provide the electronic records fective, about 5 cents per sampling”. and to guarantee the quality assessment of our The device uses any kind of smartphone and a entire strategy. The first one is called ‘exam’ and 2-3 day training program is provided to explain the second is called one ‘cc-piece’. We took the how to use the smart phone device and the pho- images during the exam, they’re not for gyneco- tography for recognizing pathological lesions logists, but for nurses or midwives with a backup automatically. In addition, the HUG’s team is control in Switzerland, France or UK, to review working on a mobile clinic, with specific equip- the images and provide real-time advice about ment, including a gynecological chair to increase the treatment. We also used these images for the outreach of the greatest number of women academic information, for further analysis and in rural areas.
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Since 2010 the Department of Gynecology and Obstetrics dé, Cameroon), made it happen supported by the Natio- of HUG has organized successful workshops with their Ca- nal Committee for the Fight against Cancer in Cameroon meroonian partners on prevention and screening of cervical and the Ministry of Public Health. First, an inventory of the cancer, colposcopy, management of pre-invasive lesions knowledge concerning cervical cancer among women and and vaccination against HPV. health professionals was established by two doctorantes from Geneva, followed by two Master students on the ac- The collaborative program dates back to the early 2000’s. In ceptability among women of testing for HPV, using two 2001, HUG along with 3 Cameroonian doctors, two patho- procedures: self-sampling by the woman herself, or sam- logists and one gynecologist, previously trained in Geneva, pling by a health professional. The work revealed the wide examined the feasibility of a cytology-based cancer scree- acceptance of self-sampling and the importance of proper ning in a rural area. In 2008, Pr Patrick Petignat (HUG) and information of women before undergoing the procedure.” Dr Pierre-Marie Tebeu (University Hospital Center in Yaoun-
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Using a smartphone to: - Access Visual Inspection Acetic Acid (VIA) • Provide training: and Lugol’s lodine (VILI) o Review images after pathology results, - Scale up cervical cancer screening and treatment o Academic tool Cancer (Cervix Prevention System) • Scale up awareness and prevention • Optimize the quality control of the diagnosis: o Large outreach in rural areas. o Reviewing the images, o Cost effective o comparing VIA and VILI, o having expert opinions 15 Dr Ophira Ginsburg, WHO: The new UN Global Joint Program for Cervical Cancer Prevention and Control
Dr Ophira Ginsburg is a medical oncologist But we need engagement with all partners and with expertise in cancer epidemiology, preven- high political commitment. Pilot countries in tion and screening, and a primary focus in wo- each WHO region will be selected through a ri- men’s health equity and global cancer control. gorous process. We will not be able to fund the She joined WHO in 2015 to build policy and implementation of all the activities directly, but programs for women’s cancers, which include we will assist countries in prioritizing and costing guidance, recommendations, and implemen- activities, while finding ways to access the addi- tation frameworks on cancer early detection/ tional resources needed through domestic and screening and management in collaboration international sources, and through innovative fi- with the WHO International Agency for Re- nancing mechanisms. This is why we’re going to search on Cancer (IARC), the International Ato- need a lot of collaborative work, with academia, mic Energy Agency (IAEA,) and other interna- with civil society, etc. We will organize a donor’s tional partners. conference soon, to kick start the programme and get the full support from Dr Ginsburg’s contribution was the international community”. a great highlight of the round table discussion as she spoke As a response to what Dr. about the new UN joint program Kapambwe said about the tech- on cervical cancer under the nical constraints of the cryothe- umbrella of the UN inter-agency rapy, especially the challenging task-force for NCDs to eliminate availability of the gas needed, cervical cancer as a public health Dr Ginsburg underlined the im- concern by 2025. portance also of adequate ca- pacity to treat invasive cervical “We’ve signed a memorandum cancer. Invasive cervical can- to provide a framework to assist cer requires more specialized countries with technical assis- personnel and equipment, and tance at all levels, from national often includes all three cancer cancer control, national cervical cancer control, treatment modalities: surgery, medicines (che- planning and implementation, with the support motherapy), and of particular importance to of seven UN agencies: IARC, IAEA, UNAIDS, this cancer, radiotherapy. This is why the role UNFPA, UNICEF, and UN Women”. She des- of the International Atomic Energy Agency is cribed the purpose of the program, to provide so critical in cervical cancer control, particular- technical assistance to help countries implement ly in sub-Saharan Africa where resources are comprehensive cervical cancer programs, inclu- so profoundly limited. “Talking about activities ding primary prevention with HPV vaccination, from primary and secondary prevention through screening and treatment. All guidance for scree- to treatment, there is a piece often missing in ning and treatment are aligned with the WHO the discussions, but I’m glad it came up already “Comprehensive Cervical Cancer Control: gui- today in our discussions, that is, radiation. The delines for essential practice, Second edition” IAEA has such an important role to play in terms also known as our “Pink Book” *, produced in of cancer guidance with radiation safety and also collaboration with international experts and pu- technical cooperation for radiation medicine. blished in late 2014”. In the case of cervical cancer, there are certain phases that are curable if it is radiated properly Dr Ginsburg is confident towards reaching the within the timeframe; otherwise we need surge- objectives: the UN joint program will create the ry, plus/minus chemotherapy”. enabling environment internationally and more importantly locally: “A comprehensive cancer Regarding what Michel Sidibé said about the in- control should be possible in many countries. tersection of HIV/HPV and cervical cancer **, Dr 16 Ginsburg puts a special emphasis on this issue: “It The guidance identifies key opportunities and ages is absolutely critical. Clearly we need to address throughout a woman’s life when cervical control and this issue further”. She highlighted the (then) for- prevention can be put into action, especially for: thcoming launch at the International AIDS Confe- - Primary prevention: HPV vaccination targets girls rence (July 20, 2016, Durban) of a new Joint docu- aged 9 to 13 years, aiming to reach them before they ment: “HPV, HIV and Cervical Cancer: Leveraging become sexually active. synergies to save women’s lives”. - Secondary prevention: access to technology for women over 30 years of age, such as VIA or HPV Quality insurance testing for screening, followed by treatment of de tected precancerous lesions, which may develop into Dr. Ginsburg acknowledged the growing number cervical cancer. of new technologies similar to the Mobile ODT - Tertiary prevention: access to cancer treatment and She considered that real impact in terms of ac- management for women of any age, including surgery, cess and quality control are key preliminary issues. chemotherapy and radiotherapy “We need to know how these devices can be in- - When curative treatment is no longer an option, ac- tegrated into platforms to improve access, and I cess to palliative care is crucial. would say that the most important piece of this is the quality assurance. When you have non-MDs A variety of health services and programs are needed providing care, in this case, cervical screening, and to implement the different elements of these recom- the physician l is hours and hours away, knowing mendations. The guidance underlines the importance of that the interpretation of the test (normal or ab- collaboration between sectors, between health pro- normal) is correct is incredibly important. Mobile grams, and between professionals working at all levels phones can assist in this process to ensure high of the health service, for the success of cervical cancer quality of care and ongoing education for health prevention. workers. Also, through outreach strategies, in- cluding using smartphones for texting messages, The guidelines also show how cervical prevention and mobile phones can be used to minimize loss to control can be integrated into existing health care follow-up. That is a huge problem, as it has been delivery systems, including for family planning, post- said today, unless you do “same-visit” treatment, partum care and HIV/AIDS. The delivery of vaccinations which is not necessarily feasible everywhere and to adolescents for example, opens the door to reaching has its own drawbacks. Loss-to-follow-up may be them with additional health information, sexual education and advice about healthy life styles. enhanced through processes like SMS-texting and ** http://www.unaids.org/en/resources/presscentre/ re-contacting women after they go home”. featurestories/2016/july/20160720HPV Scaling up FFFFF * The Pink Book was designed to provide practical gui- “There are also other devices being tested, such as dance to help governments and healthcare professionals the cryo-pen, which uses electricity when available better prevent and control cervical cancer. It also underlines and the gases are out of reach, so if the science recent developments in technology and strategy for im- supports it, this could be a good option. Also the proving women’s access to health services to prevent and big cryo units themselves can break down, so for control cervical cancer. a variety of reasons we haven’t seen the kind of FFFFF scale-up we want. Rather, we’ve seen what people usually call ‘pilot programs’, with very little scale- Dr Qhing Qhing Dlamini, co director of AHMA thanked “the Minister of Health of Swaziland, Ma- up. Scaling-up is the biggest challenge that we dame Sibongile Ndlela Simelane, for her support face now, in both HPV vaccination and also scree- and leadership to the causes of women’s health, ning for cervical cancer. To approach the levels of especially on cervical cancer. She also thanked population-coverage needed to really start seeing the Swaziland Permanent mission’s representative a reduction in the number of cases and deaths to the UN for their welcome.” Dr Qhing Qhing from cervical cancer, we absolutely need govern- Dlamini was confident regarding the way forward, ment support, there’s no question, there has to be especially at the regional level where the coopera- a government-lead initiative.” tion’s potential is very promising”. FFFFF FFFFF 17 KEY INSIGHTS FROM THE DISCUSSION
The discussion was very much interactive, stressing issues regarding political commitment, lessons learned and opportunities for further collaboration in the region. We chose to publish all the exchanges to maintain their spontaneity and reveal the maturity of re- flections highly relevant to the fight against cervical cancer as a “NCD we can overcome.”
INTEGRATION / DECENTRALIZATION
Dr Matshidiso Rebecca Moeti, director, WHO cancer. We’ll be able to get a reduction in our regional office for Africa, shared her view about NCDs. At the moment Cervical cancer is num- the integration of HPV into HIV existing scree- ber one among our women while we’ve seen as ning and treatment programs: “I think it’s a very much as 50% of reduction for TB in the projec- practical suggestion after struggles for many tions, and I want to believe that even with cer- years with vertical approaches. So we’ve seen vical cancer we can treat everyone who is HIV how UNAids has really made an effort in the last positive, in order to at least get some benefits to couple of years in that direction. For example, them. I think it will be a good opportunity for us regarding HIV and tuberculosis programs, I re- in the cervical cancer domain and I agree that it member as a program manager in the regional is exciting. Regarding integration, as Michel Sidi- office a few years ago having an HIV program, bé of UNAids said, at the implementation level, a TB program, and a kind of HIV/TB program, we need to move away from vertical systems, in which I found quite inappropriate. So it seems order to build these integrated ones. We already that we’re moving forward and I hope that the have facilities integrated within our services; the joint program of the UN on cervical cancer will HPV front has had breakthroughs in terms of help boost our efforts. We will increasingly com- cervical cancer, with treatments fully funded by bine, in a kind of integrated health-care system, governments. It is necessary to recognize the all activities to deliver screening, prevention and importance that governments place on NCDs treatment, within current associated pathologies. I and cervical cancer. I think it’s great to have an have been advocating for integration and decen- opportunity to reinforce our collaboration with tralization in the African region for many years”. UNAids, as we have low capacities and skill re- tention is still a great concern for sustainability. Dr Shenaaz El-Halabi, Permanent Secretary, I have always advocated for integration, as we Ministry of Health of Botswana: “ I would like were able to easily see the cost-savings of inte- to say that we have done quite a bit on cervical gration of TB and HIV.
WAKA HPV PROGRAM:
Political support: Pr. Bogers: “I think it is pos- first PhD students who had been trained were sible to create laboratories wherever, but first, leaving. So I stroke a deal with the vice Chancel- there is a need for training, education, guide- lor of the University and I said to him ‘You have lines and a significant framework which is still to give them nice jobs, because otherwise we lacking in a lot of countries, not only in Africa, cannot pursue this program’, and he did. And but even in Europe. This is the reason why the there, again, we need the political will to create political support is so crucial.” enabling environments for people to stay in local Brain drain/sustainability: Pr. Paul John Bogers. universities. It’s very important. For me the first “That is an important question, and we had this result, as an academic, would be how to sustain on a micro level with our PhD students. The the network with local key partners. The brain
18 drain of trained healthcare workers in Africa is a gether and bring them in a room once a year key issue.” to talk about their common problems’. But then, we had a growing success and other countries Linkages to the MOH: Dr Shenaaz El-Halabi. “In joined the network. We started from a lab pers- addition, I would like to know the linkage of your pective, not from a public health perspective. program to the Ministries of Health, because But we are moving in this direction, developing that’s where the implementation should be relationships with local ministries to sustain our driven to. Of course, academia is always good activities, induce local ownership, and benefit to have and to know what’s happening but that from the local political support” link is important, in terms of sustainability and Francophone Africa: Paul-John Bogers: “There moving forward.” are francophone countries already involved, like DRC. We definitely would like to include more Criteria of selection: Dr Shenaaz El-Halabi “I francophone countries. The good thing about wasn’t quite sure on how you select the coun- Belgians is that we can do both languages, even tries. I think it’s important to always ask certain though meetings in English are often easier as questions on specific areas, or how specific the a common language. During the upcoming In- HPV or other diseases are, and the research with ternational HPV Conference in February 2017, in the areas. Cape Town, we will organize the WAKA Sympo- sium with all the “Waka-people”. I was asked by Paul-John Bogers: “I completely agree with you, one of the coorganizer of this roundtable, the we need much more. We are young and the idea UNFM, whether I could have a meeting for the came up in 2014. We didn’t select these coun- French speaking countries, at this occasion or tries, they selected us. Those we are working with another one. In francophone countries there are are involved because our country, Belgium, had strong ties with the Belgian government and our already been running projects on HPV in these research institute. We don’t need much to or- countries for many years, so we have strong ties ganize these networking events and that’s what with local teams and MOHs. We needed support we’re looking into and also making links with lo- and that’s when we said ‘let’s link them all to- cal universities to create sustainability”.
DNA TESTING
Dr Shenaaz El-Halabi: “I haven’t heard a lot now difficult and costly to train cytologists and keep about HPV DNA testing, particularly since our them trained, so it’s something you have to keep countries are facing a shortage of Human Re- into account. Our program will set up cytology sources, facilities and equipments, and the issue centers. We will look at it from each country and of loss to follow up is a concern”. check the data. That’s really the reason for starting WAKA, because there’s so little specific data out Pr John Paul Bogers: “About HPV DNA testing there, to make decisions on HPV vaccination for or nuclear testing in general, there are so many example. There are some general rules valid for DNA or RNA testing, it’s difficult to choose the every country in the world, but we even see regio- useful one for your specific country. So our HPV nal differences in very small countries. So we have WAKA program is designed to help countries to take that into account too”. with that. As for the cytology technologists trai- “There is a process which is now being internatio- ning and pap smears, I’ve seen a lot of results nally accepted for accredited HPV and DNA testing, from pap smear data from all over the world, and I know because my lab has been involved in the and as you know, the quality of the cyto-text GeneXpert accreditation. I think that there will surely, is vital throughout the entire process. It’s very shortly, be an imminent and a central publication”.
19 Dr Oshira Ginsburg: “Regarding HPV/DNA tes- to HPV testing too. Every HPV test covers 5-8 ting, it is really a fast evolving area, the concept years, so it protects for at least the next 5 years”. is well understood and there are numerous algo- rithms available”. Dr Oshira Ginsburg: “I wanted to add that in La- tin America, there’s been adequate data to show Dr Caroline Benski: “It’s proven that with the that, unfortunately, despite everyone’s efforts to GeneXpert women who are negative can wait implement population-based Pap tests as the up to 5 years before another HPV test, so there primary means of screening, it has largely been is no need to see them every 2 years like with ineffective in reducing mortality. WHO recom- the pap smears. So I think that’s one of the ad- mends that it’s still something you can try if you vantages of the GeneXpert”. have the infrastructure, but we are really looking toward these other options as more viable, more Dr John Paul Bogers:“Of course that holds true likely to reduce mortality in a short order”.
REGIONAL COOPERATION
Regional cooperation: Dr Sharon Kapambwe: way, and it will help also in terms of funding, es- “Actually I think collaboration is the only way we pecially in areas where it is really needed. are really going to be a strong force. We have So countries that are strong in a certain sense done so much but we still have a lot to learn. can help others where they need to be helped, For example, Zambia could be struggling with funding going to the right places, instead of ha- a certain issue and Swaziland might have found ving duplications leading to underachievement”. the solution to that problem, or the other way around. Of course we are not reinventing the Dr H Letsie, Director General, Health services wheel, so the countries need to show their stren- of the MOH, Lesotho: “I would like to thank gths, or what they bring to the table. It doesn’t you Zambia. We have greatly benefitted from matter if they just have plans or started in a small their support. We have being very much invol- way, the idea is that countries can do so much ved in fighting HIV/Aids because we have the more. For example HPV vaccination - it could be highest rate of HIV prevalence in the region, but that countries who have already scaled-up this we have no national center for cancer. We have program, can share experiences and we all can to send patients for treatment to South Africa, learn how to move forward. Zambia could have which is very expensive. So we have been to gone ahead with the screening program, and will Zambia, and we’re looking up to their program help other countries about the challenges, suc- and their cancer treatment centers, we welcome cesses and where we can cooperate. So I think their wonderful job, and would like to send our a regional network of collaboration is the only people there for trainings.”
INTERNATIONAL COOPERATION
Commonwealth: Mark Lodge, Director of the monwealth might be the place to go? “ International Network for Cancer Treatment and Research: “My question is on the Com- Dr Sharon Kapambwe: “I’m glad you brought the monwealth health ministers meeting. There’s a issue of Commonwealth, because as a y member new atmosphere about the sense and direction country, we haven’t really been having a lot of of the Commonwealth with a new Secretary Ge- collaboration. So it should be one of the initia- neral and there’s great talk and desire to work tives we can explore and learn more of how Com- together on mutual initiatives. I’ve wondered monwealth can raise the issue of cervical cancer if you thought that networks such as the Com- and pay increased attention to this concern. 20 There’s really a lack of funding in this area, and cancer forward, and analyze the benefits for the as much as possible we should think outside the people. The South African Development Commu- box, think about networks as a whole, and look nity should also be a good platform for extending at how best these networks can help achieve what the regional cooperation. As I said, our country is we need to achieve. Zambia is a Commonwealth ready and willing to cooperate with other coun- country, we all need to bring the issues of cervical tries to go forward with cervical cancer programs”.
mHEALTH PROGRAM
Dr Tulipoka Soko. Acting director, Nursing and objective of your projects in Madagascar and Ca- Midwifery services, in Malawi: “I’m hoping we will meroon? is it mainly to diagnose and treat?. You be able to use those new technologies and innova- mentioned that we have an implication on health tive strategies and really move forward. In Malawi, systems in our region, is the task-shifting in terms we are not yet there in terms of using smart phones of diagnostic and treatment, so to what percen- to support our prevention programs, but with sup- tage of agreement was there between nurses port, we can do it. All of us are using smart phones versus specialists, in terms of diagnosis? I am inte- in our daily lives, but we need support in terms of rested in that, since there are task-shifting implica- how can we do this, how to get resources, and im- tions as well in our region.” plement the policies, etc.” Dr Caroline Benski: “Since it’s still small study with Dr. Caroline Benski: “From my experience, m-health 3000 women, our objective is to look for the most cannot supply strategy for screen and treatment appropriate strategy for cervical cancer screening for example, for cervical cancer, but it shows that it and treatment, with a good association between can help to do task-shifting, which can be a solution screening, diagnosing and treatment, and also to have quality control and better communication to decrease the loss of follow-up problems. The between hospitals and health centers, hospitals and strategy from screening to treatment to follow-up experts in distance medicine, to also give more insu- in the same day, was the best one. The genexpert rance for local people and make it easier to answer with a good sensibility, HPV/DNA tests and VIA/ them.” VILI, then diagnosis and a treatment with thermal coagulation, eliminating the cases for further sur- Dr Oshira Ginsburg: “As far as cancer is concerned, gical intervention. We are now implementing that there hasn’t been much done until the advent of strategy, planning 6 to 12 months follow-ups to these mobile cervical projects. My group, as an aca- see if we really have a clearance of HPV and de- demic, actually we’re the only ones with a m-health creases in diseases of women.” program for breast cancer. We had this expe- rience in Bangladesh. The scale is an issue as well Dr Oshira Ginsburg: “There is a study specifically as funding to continue these projects after the pi- on this question: can mobile phones/smartphones lot phase, which is always a challenge. The hope is be used to enhance VIA in a successful way? What that we do it properly and rigorously, in our case we is the percentage of agreement, between the randomized control trials to really show the bene- gynecologist ‘far-away’ and the nurses who are fit of the phone because it is crucial to show what there? The outcome was 98% after a very short can be done and how cost-effective it can be. So we intervention. Then next step is to insure a conti- can move forward by publishing results, even when nuous medical education, and so the opportunities they’re negative, to learn from the experience”. to have refresher efforts building in are also very important. There’s always a follow-up after a few Dr Alisalad Abdikamal: NCD director, WHO months. The issue of maintaining the skill of those Regional Office for Africa: “What is the primary who are involved is a very important point”. 21 PAP SMEARS /DNA TESTS
Dr Uday Bodhankar: The Commonhealth As- Dr Caroline Benski: “Actually before implemen- sociation for Health and Disability COMHAD. ting these programs in Cameroon and Madagas- “When we do these projects in developing coun- car we initiated these projects in Geneva, trying tries, are we doing the same tests as in developed to reach the population that does not come for countries? We should drop Pap. Are we going screening, which means 30% of women. All over to discuss that? If you’re going to say ‘no, we’re the heterogeneous population of Geneva, we continuing with Pap smear, because….’ that’s not had a very good feedback strategy, with a door- good, this has always been a failure”. to-door outreach, distributing self-samples”.
Dr Oshira Ginsburg: “This is such an important Dr John Paul Bogers: “It’s the same in Belgium. point though, I’m really glad you raised it. One Actually the European guidelines for cancer scree- piece of the answer is that HPV/DNA testing is ning in Europe state that we go to HPV primary going to replace Pap tests everywhere. It’s on screening. its way in many countries, in Canada for instance If you look at Holland for instance, as they’re ins- we’re trying to find a way to afford it, like eve- talling the national program, the reason why they rywhere else, but we understand the utility of this. don’t do it, it’s because in our developed coun- In many ways, it indicates to us yet another time tries, we have an abundance of gynecologists in history, when the efforts of these so-called de- and pathologists, and they form political groups veloping countries efforts are leapfrogging from opposing these changes. So that is probably the anything we’re doing and we’re going to have to main reason it is not yet implemented in some learn from, as much as teach them, so it’s sharing. European and Western countries. But I’m sure The other issue is that DNA is usually done du- we will go through the same, and probably, as ring a colposcopy, so it’s not like it’s never been my colleague said, developing countries may go done before in Canada, Switzerland, etc., it’s just through the process faster than us, because of a different use in the absence of a cost-effective these political forces developed countries have solution that can be implemented properly and to face.” widely”.
THE U.N. JOINT PROGRAM
Dr Oshira Ginsburg: “It’s a five year program, and published and well understood.” the number of countries will depend on the fun- ding, but we’re planning for eight to ten countries, Civil society: Walter Gyger, president of the Ro- three starting with what we’re calling an ‘inten- tary International in Geneva: “As you may know, tion mission’ this summer. So we’re getting going Rotary clubs have invested a lot in the last couple with an opportunity for other regions to present of years, on cervical cancer. One approach is that to us. We select the countries with the scoring every club is doing its own project, is finding ano- UN system, including the standardized morta- ther club, or really I try other areas and bring ro- lity rates for cervical cancer, and then looking at tary into a global strategy, in coherence with fast everything from health system capacity, political changes. But how could this is done? We need will and governments’ interest, and also the other to have specific cases, specific sectors, regarding agencies involved in the program to assist. So polio medication, so could we get this going?”. right now we’re getting advices from our regional colleagues and then go from there. It’s going to Dr Oshira Ginsburg “Civil society is key in brin- be transparent and we will have the methodology ging up this conversation. We did discuss so far
22 with some of the groups all about cervical cancer, HPV vaccination and screening. This model in- but we want to extend this discussion to other cludes the different motions and sensitive analy- organizations that assist them in health develop- sis. Hopefully, we will be using some of that data, ment more broadly. For example, with Rotary we to assist us at WHO in flashing out what we call certainly need a discussion. At this point, we are Appendix 3. This is the NCD global action plan, trying to sort out exactly how we’re going to en- with an Appendix with what we call the ‘best gage agencies interested in participating. Very buys’, which are very cost-effective interventions shortly, once the countries are selected, we will for NCDs. There were only two things related to ask them about their critical needs, and more cancer in the initial version: Hepatitis-B vaccina- about their cervical cancer control, ongoing pro- tion and screen/treating cervical cancer/precan- jects, challenges and gaps. There are a number cer. of initiatives also coming from other sub-societies We are certainly hoping HPV vaccination will be and organizations in relation with our WHO col- there. NCDs are going to be costed in a way that laborative center, which is the US NCI - National they’ll be presented as a menu of intervention Cancer Institute - and the director happens to be options for the Ministries to look at and decide. with us. Anyway there’s still a lot to be done, even Comprehensive cancer control is very cost-effec- if we screened and provided saving treatment for tive and we don’t need to argue about that any- all women, and HPV vaccination for all girls, we’d more, it’s a question of how we do screening, and still be seeing women within the grasps of cervical vaccination”. cancer and for that reason, pathology, diagnos- tic pathology, will be still very important towards “As the UN Secretary General this year made a controlling other types of cancers”. statement on the World Cancer Day, which was very exciting for us in the cancer world, and at the “One of our partners, the American Cancer So- end of this statement, he called for the elimina- ciety has commissioned reports with the Harvard tion of cervical cancer as a public health concern. University, on comprehensive packages of HIV, Hopefully, we can move toward together on this.”
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23 CONCLUSION
The round table was a very interesting exchange of field experiences related to the screening and the treatment of cervical cancer. In general, African countries may not always have considered cervix screening as a top priority The discussion showed that this issue should be first on the poli- tical agenda and that local efforts should be devoted to create the enabling environment to move forward the cervical cancer programs, through a better decentralization of the activities and their integration into existing programs, especially HIV/Aids screening and treatment. Among the main insights, the experts underlined the need for further support and research to help countries be- nefit from innovative tools and strategies and from on-going pilot screening methods as well as treatment.
As for the VIA, it is not expensive and can be done by healthcare workers but it is a very subjective method, while pap smears require structure and trained staff and for women to come back for the result. Regarding DNA testing, countries may need further guidelines to help them choose between a wide variety of those promising tests available, according to their local needs, their in- frastructure, the cost and their national policy’s goals on cervical cancer. New technologies, such as mobile screening should be efficient to help in that direction, improving existing programs, including the data collection and the quality control, but they still require further reference gui- delines.
The Joint UN program to eliminate the cervical cancer as a public health concern by 2025 should provide the expected momentum to all partners for joining efforts to reach the objectives. “Our roundtable was aimed at bringing its contribution to the discussion. HPV vaccination, although a crucial part of the program and a key success factor, was not on our agenda at this occasion, due to time constraints.” said Therese Lethu, “We hope to pursue the discussion about this issue with all the partners involved soon. As regional cooperation has been identified as a promising strategy, we will have other opportunities soon to actively participate in raising mutually benefi- cial collaboration”.
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24 Organizers
Global Health Objectives (GHO), is an NGO based in Geneva, dedicated to creating an enabling envi- ronment for increasing access to health care and prevention, including with the use of digital technologies, regardless of the socioeconomic factors are (age, education, income, place of living/country...). Thus GHO focuses on training, information, studies towards empowering target groups, health professionals and po- litical leaders, and on supporting the needed cultural changes. In addition, GHO contributes to exchanges experiences on eHealth between Swiss key players, at local, national, as well as international level, inclu- ding R & D projects in the South. “The success of the present roundtable with the active participation of representatives of Geneva major organizations, WHO and HUG Geneva, is very much encouraging. That way, we should also contribute to leverage “the International Geneva” and create synergies to reach our common objectives.”: said Therese Lethu, the executive director and founder of GHO. Contact: [email protected]
Université Numérique Francophone Mondiale (UNFM) aims at the creation and dissemination of quality education in low-income settings through the Internet and an extensive use of the new communication tech- nologies. The training programs are devoted to health care workers and are mostly delivered by experts of the recipient countries as such courses are field oriented. UNFM completes the training programs offered by the International Organization of the Francophonie, a key partner in the French speaking countries. The main focuses include NCDs, mother and children health, health crisis, among others. The UNFM will co-or- ganize the rst Master Course Francophone of the Union for International Cancer Control during the World Cancer Congress in late October 2016, in Paris. “We are willing to join efforts towards strengthening local health capacities to eliminate cervical cancer as a public health concern, through an improved collaboration and a quality continuous training and exchange of experiences between the French and English African speaking countries”, said Dr Line Kleinrebreil, vice president of the UNFM. “We will reinforce local and regio- nal networks, South-South, South- North, and North -South”. Contact: [email protected]
Afya Health Management Associates (AHMA): a Swaziland based organization that seeks to stimulate innovative thinking and promote simple solutions to transform the health sector. “We believe that focu- sing on demand-side interventions and harnessing the strengths of both the public and private healthcare sector will result in a more responsive and robust health system.” Contact: [email protected]
Acknowledgements
Our sincere thanks to the Hologic Humancare team who helped make this roundtable happen through an unconditional grant to the organization. Ho- logic Humancare is a leading global healthcare and diagnostics fund which supports access to heath, especially those in greatest need in low- income settings, through various activities, including training and empowerment of local health professionals. To achieve this objective, Hologic Humancare col- laborates with leading medical experts in diverse fields to develop and im- prove programs that will expand knowledge and skills of local professionals. Among those initiatives, the WAKA/ HPV program benefitted from the sup- port of Hologic Humancare to extend local research capacities, creating a dynamic referral center and an active regional research network.
Contact: [email protected] WAKA Program : The aim of the project is to set up a HPV reference centre and establishment of HPV research network within the African countries. It is a multi-country project. Several universities from different countries within Africa collaborate in this project.
© UNFM - Novembre 2016 -