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      Advancing Cervical Cancer Prevention Initiatives in Resource-Constrained Settings: Insights from the Cervical Cancer Prevention Program in Zambia

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          Abstract

          Groesbeck Parham and colleagues describe their Cervical Cancer Prevention Program in Zambia, which has provided services to over 58,000 women over the past five years, and share lessons learned from the program's implementation and integration with existing HIV/AIDS programs.

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          HPV screening for cervical cancer in rural India.

          Rengaswamy Sankaranarayanan, Bhagwan M Nene, Surendra Shastri … (2009)
          In October 1999, we began to measure the effect of a single round of screening by testing for human papillomavirus (HPV), cytologic testing, or visual inspection of the cervix with acetic acid (VIA) on the incidence of cervical cancer and the associated rates of death in the Osmanabad district in India. In this cluster-randomized trial, 52 clusters of villages, with a total of 131,746 healthy women between the ages of 30 and 59 years, were randomly assigned to four groups of 13 clusters each. The groups were randomly assigned to undergo screening by HPV testing (34,126 women), cytologic testing (32,058), or VIA (34,074) or to receive standard care (31,488, control group). Women who had positive results on screening underwent colposcopy and directed biopsies, and those with cervical precancerous lesions or cancer received appropriate treatment. In the HPV-testing group, cervical cancer was diagnosed in 127 subjects (of whom 39 had stage II or higher), as compared with 118 subjects (of whom 82 had advanced disease) in the control group (hazard ratio for the detection of advanced cancer in the HPV-testing group, 0.47; 95% confidence interval [CI], 0.32 to 0.69). There were 34 deaths from cancer in the HPV-testing group, as compared with 64 in the control group (hazard ratio, 0.52; 95% CI, 0.33 to 0.83). No significant reductions in the numbers of advanced cancers or deaths were observed in the cytologic-testing group or in the VIA group, as compared with the control group. Mild adverse events were reported in 0.1% of screened women. In a low-resource setting, a single round of HPV testing was associated with a significant reduction in the numbers of advanced cervical cancers and deaths from cervical cancer. 2009 Massachusetts Medical Society
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            Expansion of cancer care and control in countries of low and middle income: a call to action.

            Julio J Frenk, Lincoln Chen, Douglas W Blayney … (2010)
            Substantial inequalities exist in cancer survival rates across countries. In addition to prevention of new cancers by reduction of risk factors, strategies are needed to close the gap between developed and developing countries in cancer survival and the effects of the disease on human suffering. We challenge the public health community's assumption that cancers will remain untreated in poor countries, and note the analogy to similarly unfounded arguments from more than a decade ago against provision of HIV treatment. In resource-constrained countries without specialised services, experience has shown that much can be done to prevent and treat cancer by deployment of primary and secondary caregivers, use of off-patent drugs, and application of regional and global mechanisms for financing and procurement. Furthermore, several middle-income countries have included cancer treatment in national health insurance coverage with a focus on people living in poverty. These strategies can reduce costs, increase access to health services, and strengthen health systems to meet the challenge of cancer and other diseases. In 2009, we formed the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries, which is composed of leaders from the global health and cancer care communities, and is dedicated to proposal, implementation, and evaluation of strategies to advance this agenda. Copyright © 2010 Elsevier Ltd. All rights reserved.
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              Rapid scale-up of antiretroviral therapy at primary care sites in Zambia: feasibility and early outcomes.

              Tedd V. Ellerbrock, Richard G Marlink, Alwyn Mwinga … (2006)
              The Zambian Ministry of Health has scaled-up human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) care and treatment services at primary care clinics in Lusaka, using predominately nonphysician clinicians. To report on the feasibility and early outcomes of the program. Open cohort evaluation of antiretroviral-naive adults treated at 18 primary care facilities between April 26, 2004, and November 5, 2005. Data were entered in real time into an electronic patient tracking system. Those meeting criteria for antiretroviral therapy (ART) received drugs according to Zambian national guidelines. Survival, regimen failure rates, and CD4 cell response. We enrolled 21,755 adults into HIV care, and 16,198 (75%) started ART. Among those starting ART, 9864 (61%) were women. Of 15,866 patients with documented World Health Organization (WHO) staging, 11,573 (73%) were stage III or IV, and the mean (SD) entry CD4 cell count among the 15,336 patients with a baseline result was 143/microL (123/microL). Of 1142 patients receiving ART who died, 1120 had a reliable date of death. Of these patients, 792 (71%) died within 90 days of starting therapy (early mortality rate: 26 per 100 patient-years), and 328 (29%) died after 90 days (post-90-day mortality rate: 5.0 per 100 patient-years). In multivariable analysis, mortality was strongly associated with CD4 cell count between 50/microL and 199/microL (adjusted hazard ratio [AHR], 1.4; 95% confidence interval [CI], 1.0-2.0), CD4 cell count less than 50/microL (AHR, 2.2; 95% CI, 1.5-3.1), WHO stage III disease (AHR, 1.8; 95% CI, 1.3-2.4), WHO stage IV disease (AHR, 2.9; 95% CI, 2.0-4.3), low body mass index (<16; AHR,2.4; 95% CI, 1.8-3.2), severe anemia (<8.0 g/dL; AHR, 3.1; 95% CI, 2.3-4.0), and poor adherence to therapy (AHR, 2.9; 95% CI, 2.2-3.9). Of 11,714 patients at risk, 861 failed therapy by clinical criteria (rate, 13 per 100 patient-years). The mean (SD) CD4 cell count increase was 175/microL (174/microL) in 1361 of 1519 patients (90%) receiving treatment long enough to have a 12-month repeat. Massive scale-up of HIV and AIDS treatment services with good clinical outcomes is feasible in primary care settings in sub-Saharan Africa. Most mortality occurs early, suggesting that earlier diagnosis and treatment may improve outcomes.
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                Author and article information

                Journal
                Journal ID (nlm-ta): PLoS Med
                Journal ID (publisher-id): PLoS
                Journal ID (pmc): plosmed
                Title: PLoS Medicine
                Publisher: Public Library of Science (San Francisco, USA )
                ISSN (Print): 1549-1277
                ISSN (Electronic): 1549-1676
                Publication date Collection: May 2011
                Publication date (Print): May 2011
                Publication date (Electronic): 17 May 2011
                Volume: 8
                Issue: 5
                Electronic Location Identifier: e1001032
                Affiliations
                [1 ]Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
                [2 ]University Teaching Hospital, Lusaka, Zambia
                [3 ]Vanderbilt University, Nashville, Tennessee, United States of America
                [4 ]University of Cincinnati, Cincinnati, Ohio, United States of America
                [5 ]University of Alabama at Birmingham, Birmingham, Alabama, United States of America
                [6 ]Michigan Cancer Institute, Pontiac, Michigan, United States of America
                Author notes

                Conceived and designed the experiments: MHM VVS SK KSP CC GM VM MLH SHV JSS GPP. Wrote the first draft: VVS MHM GPP. Wrote the manuscript: MHM VVS SK KSP CC GM VM MLH SHV JSS GPP. ICMJE criteria for authorship read and met: MHM VVS SK KSP CC GM VM MLH SHV JSS GPP. Agree with the manuscript's results and conclusions: MHM VVS SK KSP CC GM VM MLH SHV JSS GPP.

                Article
                Publisher ID: PMEDICINE-D-10-00336
                DOI: 10.1371/journal.pmed.1001032
                PMC ID: 3096609
                PubMed ID: 21610859
                SO-VID: a50b52a5-fce4-47dc-92bf-3d4544130294
                Copyright © Mwanahamuntu et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
                History
                Page count
                Pages: 5
                Categories
                Subject: Health in Action
                Subject: Viral Diseases
                Subject: HIV
                Subject: Human Papillomavirus Infection
                Subject: Gynecologic Cancers
                Subject: Cancer Prevention
                Subject: Medicine
                Subject: Global Health
                Subject: Infectious Diseases
                Subject: Obstetrics and Gynecology
                Subject: Oncology

                ScienceOpen disciplines: Medicine
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                ScienceOpen disciplines: Medicine

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