PEPFAR An Integrated Mobile Model Reaching Women in Remote Areas of Zambia by Building on HIV/AIDS Platforms for Cervical Cancer Services Delivery July.

PEPFAR

An Integrated Mobile Model

Reaching Women in Remote Areas of Zambia by Building on HIV/AIDS Platforms for Cervical Cancer

Services Delivery

July 24 2014

PEPFARCancer No. %

Cervical 632 35

Breast 157 8

Kaposi’s sarcoma 111 6

Prostate 90 5

Oesophagus 51 3

Lymphoma 46 3

Eye 40 2

Colorectal 30 1.6

Keloids 30 1.6

Bladder 29 1.5

Top Ten Cancers in Zambia

Treated at Cancer

Diseases Hospital

of Zambia in 2012

Background

• PCI implements comprehensive HIV and AIDS capacity building interventions in all 54 Zambia Defence Force (ZDF) units and surrounding communities

• Funded by PEPFAR through the US Department of Defense (DOD)

• Plus-up funding from the Pink Ribbon Red Ribbon (PRRR) Initiative

• Population of 300,000 – 90% civilians • Most military units are in hard-to-reach and

underserved rural Zambia• ZDF runs a parallel health system with primary health

facilities available in all the units • Program implemented August 2011-April 2014

Facilitating Factors For Rapid Adaptation and Scale Up

• Existing Ministry of Health cervical cancer screening program using the “Screen-and-Treat” model with integrated cervicography

• Existing ZDF mobile HIV testing and counseling (HTC) program • Existing system and tools for HIV behavior change communication

(BCC) programs• Buy-in from ZDF leadership

Trained nurses and clinical officers in VIA and CryotherapyTrained Obstetric Gynecologists in LEEP

Procured equipment and supplies

Trained drama groups and peer educators to implement demand creation interventions

Why An Integrated Mobile Model with Integrated Cervicography?

Generalized HIV epidemic and second highest incidence rate of cervical cancer globally

Association between HIV-related immunosuppression and a higher prevalence, incidence and persistence of HPV and progression to cervical lesions

Sensitivity of VIA with digital cervicography is higher than cervical cytology: 84% Vs 61% (Bateman et al, 2014)

Digital Cervicography: built-in quality assurance system and continuing education

Mobile model: Rural population has poor access to cervical cancer diagnosis, treatment and prevention services

The Integrated Mobile Model

VIA and Cryotherapy

Self referrals

ART and MCH clinics

Mobile HIV Counseling and Testing

The Integrated Mobile Model Cont’d

Peer educators and drama groups conduct pre-interventions campaigns

Mobile HIV counseling and testing provided in tents outside the health facility

Women are offered cervical cancer screening services

Cervical cancer screening provided to consenting women inside the health facility Intra-clinic and self referrals accepted and offered Provider Initiated Testing and Counseling (PITC)

On-site “Screen and Treat”

Screen: VIA

VIA positive

Offer same-day cryotherapy Refer for LEEP/Biopsy

VIA negative

Results: August 2011-April 2014Women screened

Year Total Women

screened

Tested HIV Positive

VIA Positive VIA Positive Treated with Cryotherapy

VIA Positive Referred for LEEP

n n % n % n % n %

2011 580 113 19.4 62 10.7 36 58.0 26 41.9

2012 1663 328 19.7 57 3.4 38 66.6 19 33.3

2013 2709 434 16.0 82 3.0 50 60.9 31 37.8

2014 1614 304 18.8 82 5.0 44 53.6 39 47.5

Total 6566 1179 17.9 283 4.3 168 59.3 115 40.6

Results: August 2011-April 2014

Results: August 2011-April 2014

Lessons LearnedPre-intervention demand creation activities really create demand and clear up misconceptions about cervical cancer screening

In settings with generalized HIV epidemics and high cervical cancer incidence rates, providing timely integrated screening and HIV testing and treatment services save women’s lives

Leadership involvement and buy-in result in seamless implementation of programs

Challenges

• Pulling health personnel from an already over-stretched system to participate in mobile services

• Referral mechanisms from LEEP services to diagnostic and treatment services weak

• Gas not always available and expensive

References• CANCER DISEASE HOSPITAL ZAMBIA (2012). Cancer Registry:

Cancer Disease Hospital • CENTRAL STATISTICAL OFFICE ZAMBIA (2010). Census of

Population Report: Central Statistical Office• CENTRAL STATISTICAL OFFICE ZAMBIA (2007). Demographic and

Health Survey: Central Statistical Office• DANGOU, J. (2014, June 18). Cancer and Chronic Respiratory

Diseases, WHO-AFRO. [PowerPoint slides]. Presented at the Africa Regional Conference on New Opportunities and Innovations in Cervical Cancer Prevention Lusaka.

• GLOBOCAN: Cancer incidence and mortality worldwide database (2012). Available at: http://globocan.larc.fr (accessed 3rd March 2014)

• PARHAM, G. (2014, June 18). VIA and Cryotherapy Accompanied by Cervicography. [PowerPoint slides]. Presented at the Africa Regional Conference on New Opportunities and Innovations in Cervical Cancer Prevention Lusaka.

Acknowledgments• The American People through PEPFAR funding to the United States

Department of Defence HIV /AIDS Prevention Program’ s (DHAPP) grant to PCI. Grant Number N00244-14-1-0007

• Zambia Defence Force Medical Services (DFMS) Management including Brigadier General F. Sikazwe, Brigadier General P. Njobvu, Brigadier General E. Malyangu, Brigadier General A. Mulela, Lieutenant Colonel F. Malasha and Colonel E.C. Chisoko

• The Mobile cervical cancer team including Colonel (Col) S. Banda, Col. E Banda, Major F. Banda, Major M. Sibindi, Major C. Mukwasa, M. Ngolwe, and G. Mulenga. We also thank Namwayi Membe for organizing and collating the data.

• The Zambia Ministry of Health and the Ministry of Community Development Mother and Child Health for providing referral LEEP services.

• Professor Groesbeck Parham and Dr. Sharon Kapambwe from the African Center of Excellence for Women’s Cancer Control, Center for Infectious Disease Research in Zambia (CIDRZ)

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THANK YOU!