The objective of cervical cancer screening is to reduce cervical cancer incidence and mortality by detecting and treating precancerous lesions. Conventional cytology is the most widely used cervical cancer screening test. Although cytology has been effective in reducing the incidence of and mortality from cervical cancer in developed countries in both opportunistic and--more dramatically--organized national programs, it has been less successful and largely ineffective in reducing disease burden in low-resource settings where it has been implemented. Liquid-based cytology, testing for infection with oncogenic types of human papillomaviruses, visual inspection with 3-5% acetic acid, magnified visual inspection with acetic acid, and visual inspection with Lugol's iodine have been evaluated as alternative tests. Their test characteristics, and the applications and limitations in screening, are discussed with an emphasis on the work of the Alliance for Cervical Cancer Prevention over the past 5 years.

Background: Despite being a preventable disease, cervical cancer claims the lives of almost half a million women worldwide each year. India bears one-fifth of the global burden of the disease, with approximately 130,000 new cases a year. In an effort to assess the need and potential for improving the quality of cervical cancer prevention and treatment services in Uttar Pradesh, a strategic assessment was conducted in three of the state's districts: Agra, Lucknow, and Saharanpur.

Cervical cancer can be successfully prevented if timely identification of precancerous lesions is followed by effective treatment. In many developing countries, treatment of precancer is neglected because therapeutic services are unavailable, inaccessible, inappropriate, or inadequately linked to screening services. One of the main focuses of the Alliance for Cervical Cancer Prevention (ACCP) has been to ensure that safe and effective methods of treatment for precancer are both available and accessible to women who need them. Cryotherapy, in use for the past 40 years, is a relatively simple, safe, effective, acceptable, and appropriate outpatient procedure for the treatment of precancer. ACCP studies conducted in more than a dozen developing countries show that cryotherapy for precancer can be performed safely and effectively as an outpatient procedure at all levels of health facilities by trained and competent midlevel providers, thus increasing availability and accessibility to precancer treatment services.

Cervical cancer remains a leading cause of death for women in many countries of the world. In Latin America and the Caribbean, cervical cancer has become the primary cause of cancer-related deaths among women despite the introduction of screening programs more than 30 years ago. Each year in Latin America and the Caribbean 52 000 new cases are diagnosed, and 25 000 women die of the disease (1). Bolivia has one of the highest cervical cancer incidence rates in the Americas (58.1/100 000 women) (2). An estimated 661 deaths per year in Bolivia are attributed to cervical cancer, equivalent to an agestandardized mortality rate of 22.2/100 000. This compares with 7.6/100 000 in Argentina and 12/ 100 000 for all of South America. These statistics are particularly noteworthy given that cervical cancer can be prevented by the timely identification and treatment of precancerous lesions (3, 4). Bolivia is one of the poorest countries in South America. Some 70% of Bolivians live in poverty, with limited access to adequate housing, sanitation, education, and health care. Surveys indicate that the public sector in Bolivia provides health care for 40%-60% of the population, and performs 70% of all the Pap smears done in the country for cervical cancer screening (5, 6). Various efforts related to cervical cancer prevention in Bolivia have yet to result in an appreciable decrease in morbidity and mortality from the disease. These efforts have included Pap smear screening, creating the Component for the Detection and Control of Women's Cancer (Componente de Detección y Control del Cáncer de la Mujer) (the "Women's Cancer Component") as a unit within the Ministry of Health and Social Welfare (MHSW) (Ministerio de Salud y Previsión Social), and developing national clinical norms for the prevention of cervical cancer. To identify the obstacles that have impeded the effectiveness of cervical cancer prevention, three organizations joined together in 2001 to coordinate an assessment of the existing cervical cancer prevention and treatment services and the development of appropriate intervention strategies. The three groups were the Women's Cancer Component, EngenderHealth (an international reproductive health organization based in New York City), and the Pan American Health Organization. These groups adapted the World Health Organization (WHO) three-stage "Strategic Approach" for strategic planning and reproductive health policy and program development (7, 8

This paper presents findings from a study conducted in 2007 and 2008 in two states in India: Andhra Pradesh and Gujarat. The objectives of the study were to: (i) design effective and appropriate HPV vaccine delivery systems for 10-to 14-year-old girls; (ii) design a communication strategy for HPV vaccine delivery; and (iii) devise an HPV vaccine advocacy strategy.The study populations included girls, parents, and local-, district-, and national-level stakeholders. A mixture of group discussions, visual representation techniques, face-to-face interviews, desk and health facility record reviews, field observations, and consultative workshops were used to collect the data.Study findings showed that the policymakers, health care providers, parents, and adolescents were aware and concerned about cervical cancer; would welcome vaccination if safe, effective, affordable, and accessible. Health systems did not require large infrastructure investments to introduce HPV vaccine; basic cold chain and logistic equipment were available. New outreach systems for adolescent girls need to be tested through demonstration projects. No policies would compromise the introduction of HPV vaccination.An HPV vaccine program, requiring public education and provider training, could be delivered. Policymakers' safety and vaccine efficacy concerns can be addressed through targeted advocacy efforts. Three broad approaches were suggested: (i) merge HPV vaccination with already established immunization services; (ii) package HPV immunization with adolescent health services or as a part of a cancer control service; and (iii) deliver HPV vaccinations through either routine immunization services or a campaign using schools as sites for school-going girls and anganwadi or village health centers for non-school-going girls.

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