R4D - Advancing Cervical Cancer Screening in HIV-Positive Women (ACCHIVe) – The Cervical Cancer Prevention and Care Cascade

Background:

Substantial disparities in cervical cancer (CC)-related incidence and mortality persist between high and low-income countries. In Sub-Saharan Africa (SSA), CC continues to be the leading cause of cancer related death in women. This overlaps with a high prevalence of HIV in the region. Although the introduction of antiretroviral treatment (ART) has reduced the risk of some cancers in those living with HIV, the incidence of CC has not decreased. Prevention strategies are considered the most effective for reducing CC-related morbidity and mortality.

Differences in availability and quality of prevention strategies are likely to contribute to disparities in mortality. Although vaccination programs have gained momentum in SSA, they are not yet widely implemented and their positive effects will not emerge for decades. Screening programs for early detection and treatment of pre-cancerous cervical lesions remain fundamental to the prevention of CC. Screening programs in high-income countries have effectively reduced incidence and mortality by up to 80%. However, these models are far from being replicable in low and middle-income settings where resources are scarce amidst competing health priorities. Despite the challenges, many countries in Africa have initiated CC screening programs and these are commonly integrated in ART programs.

In these settings, few studies report health outcomes of all women who were screened, including those who were treated and those who were not. This highlights the comparative lack of patient and data management systems, which hinder systematic implementation, monitoring and evaluation of CC screening programs and provision of and care services to women living with HIV (WLHIV).

To improve effectiveness, it is critical to develop monitoring and evaluation tools, which can increase program performance and ultimately reduce CC morbidity and mortality. This will contribute to achieving World Health Organization’s (WHO) most recent targets for CC elimination.

Aims and objectives:

Our overarching aim is to contribute to reducing inequalities in morbidity and mortality from CC by developing a Cervical Cancer Prevention and Care Cascade framework and monitoring tool for CC screening programs in SSA for WLHIV. To this aim, we will develop the CC Prevention and Care Cascade based on a standardized minimum data set for monitoring CC programs for WLHIV in SSA.

Our specific objectives are as follows: 

Objective 1: Develop an internationally agreed-upon CC Prevention and Care Cascade to monitor scale-up of CC screening across SA ART programs that integrate CC screening service

Objective 2: Test the CC Prevention and Care Cascade at a sentinel program in Zambia, where we will study the full continuum of CC service provision, and identify gaps in care

Objective 3: Conduct an in-depth, multifaceted analysis of the sentinel program in Zambia to identify bottlenecks, facilitators, and barriers to providing CC care in Zambia.

Relevance

Our Cascade framework and tool will ultimately:

• Improve existing HIV programs integrating CC screening and assist other SSA initiate similar programs for patient screening and follow-up.
• Improve CC outcomes for HIV-positive women in SSA. 
• Reduce CC-related inequities for women in SSA and high-income countries. 
• Identify gaps and bottlenecks in the prevention and care cascade, and provide evidence-based recommendations for setting goals to strengthen and scale-up CC screening programs for HIV-positive women in SSA and tailoring CC screening strategies in an efficient manner, attaining the greatest possible public health impact with available limited resources

Asangbeh-Kerman S.L, Davidović M, Taghavi K, Kachingwe J, Rammipi K.M, Muzingwani L, Pascoe M, Jousse M, Mulongo M, Mwanahamuntu M, Tapela N, Akintade O, Basu P, Dlamini X, Bohlius J. Cervical cancer prevention in countries with the highest HIV prevalence: a review of policies. BMC Public Health. 2022;22:1530. DOI: 10.1186/s12889-022-13827-0

Taghavi K, Mandiriri A, Shamu T, Rohner E, Bütikofer L, Asangbeh S, Magure T, Chimbetete C, Egger M, Pascoe M, Bohlius J. Cervical cancer screening cascade for women living with HIV: a cohort study from Zimbabwe. PLoS Glob Public Health Action. 2022;2(2):e0000156. DOI: 10.1371/journal.pgph.0000156

Davidović M. Cervical cancer prevention and care indicators for women living with HIV in Sub-Saharan Africa: Delphi Method: eCancer, 2022. Link: https://ecancer.org/en/video/10813-cervical-cancer-prevention-and-care-indicators-for-women-living-with-hiv-in-sub-saharan-africa-delphi-method

Davidović M. The Cervical Cancer Prevention and Care Cascade for women living with HIV in sub-Saharan Africa: Delphi Consensus Process: AfricArXiv, 2023. Virtual Stakeholder Meeting 2021 (online). DOI: 10.6084/m9.figshare.23615079.v1

Asangbeh-Kerman S.L. A facility-based survey of cervical cancer prevention and control programs in sub-Saharan Africa: AfricArXiv, 2023. Virtual Stakeholder Meeting 2021 (online). DOI: 10.6084/m9.figshare.23615067.v2

Dhokotera T, Asangbeh S, Bohlius J, Singh E, Egger M, Rohner E, Ncayiyana J.R, Clifford G.M, Olago V, Sengayi-Muchengeti M. Cervical cancer in women living in South Africa: a record linkage study of the National Health Laboratory Service and the National Cancer Registry. Ecancermedicalscience. 2022;16:1348. DOI: 10.3332/ECANCER.2022.1348

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