Cervical cancer prevention in countries with the highest HIV prevalence: a review of policies

Abstract

Introduction Cervical cancer (CC) is the leading cause of cancer-related death among women in sub-Saharan Africa. It occurs most frequently in women living with HIV (WLHIV) and is classified as an AIDS-defining illness. Recent World Health Organisation (WHO) recommendations provide guidance for CC prevention policies, with specifications for WLHIV. We systematically reviewed policies for CC prevention and control in sub-Saharan countries with the highest HIV prevalence. Methods We included countries with an HIV prevalence ≥ 10% in 2018 and policies published between January 1st 2010 and March 31st 2022. We searched Medline via PubMed, the international cancer control partnership website and national governmental websites of included countries for relevant policy documents. The online document search was supplemented with expert consultation for each included country. We synthesised aspects defined in policies for HPV vaccination, sex education, condom use, tobacco control, male circumcision,cervical screening, diagnosis and treatment of cervical pre-cancerous lesions and cancer, monitoring mechanisms and cost of services to women while highlighting specificities for WLHIV. Results We reviewed 33 policy documents from nine countries. All included countries had policies on CC prevention and control either as a standalone policy (77.8%), or as part of a cancer or non-communicable diseases policy (22.2%) or both (66.7%). Aspects of HPV vaccination were reported in 7 (77.8%) of the 9 countries. All countries (100%) planned to develop or review Information, Education and Communication (IEC) materials for CC prevention including condom use and tobacco control. Age at screening commencement and screening intervals for WLHIV varied across countries. The most common recommended screening and treatment methods were visual inspection with acetic acid (VIA) (88.9%), Pap smear (77.8%); cryotherapy (100%) and loop electrosurgical procedure (LEEP) (88.9%) respectively. Global indicators disaggregated by HIV status for monitoring CC programs were rarely reported. CC prevention and care policies included service costs at various stages in three countries (33.3%). Conclusion Considerable progress has been made in policy development for CC prevention and control in sub Saharan Africa. However, in countries with a high HIV burden, there is need to tailor these policies to respond to the specific needs of WLHIV. Countries may consider updating policies using the recent WHO guidelines for CC prevention, while adapting them to context realities.

Impact of the 2013 WHO guidelines for screening and treatment of cervical precancerous lesions on women’s screening rates, by HIV-status, in East and Southern Africa: A regression discontinuity design analysis

“…Although the guidelines recommended screening sexually active girls and women immediately after they tested HIV-positive, decision-makers might not have prioritized screening AGYWLHIV. They might have only screened them if AGYWLHIV or their providers requested the screening (11,15). AGYWLHIV might have not been aware of their HIV-positive status and less likely to access ART, and associated services including cervical cancer screening than older WLHIV (20,21).…”

“…This group includes women aged 30__49 years, and WLHIV aged 25__49 for whom the WHO recommended screening for cervical pre-cancer (5). We identified, in the literature, that the countries’ cervical pre-cancer screening programmes were rule-based; they followed the WHO cervical pre-cancer screening recommendations before and after the 2013 WHO guidelines were issued, including the age to start screening women (4,11,12,13,14).…”

Facility-Based Indicators to Manage and Scale Up Cervical Cancer Prevention and Care Services for Women Living With HIV in Sub-Saharan Africa: a Three-Round Online Delphi Consensus Method

“…9,12,13 Several studies have taken this approach to evaluating the performance of CC control programs for WLHIV in SSA, [14][15][16][17][18][19][20] but they did not use standardized indicators, so it is difficult to compare their findings. [14][15][16][17][18][19][20] Indicators that consider HIV status are often omitted from cancer control policies, even in countries with high HIV burden, 21 where they are most necessary. 22 Most cancer control polices in these countries advice leveraging existing infrastructure and integrating CC prevention and care services into existing HIV programs to facilitate access to and scale up of these services and eventually significantly reduce CC incidence and mortality.…”

“…[23][24][25][26][27] But today, data on access to and uptake of services for women attending HIV clinics in SSA are limited or rare, although electronic data systems are widely available. 21,22,28 We urgently need standardized indicators for each step in the CC prevention and care cascade to measure and compare access with the quality of the services offered to girls and WLHIV, so we used a Delphi process to bring experts to consent on facility-based indicators for monitoring, managing, and scaling up the CC prevention and care cascade through which girls and women attending HIV clinics in SSA progress.…”

“…23–27 But today, data on access to and uptake of services for women attending HIV clinics in SSA are limited or rare, although electronic data systems are widely available. 21,22,28…”