Cervical Cancer Screening: Jhpiego

Jean Anderson
Jhpiego, an affiliate of Johns Hopkins University The Johns Hopkins University School of Medicine

Jhpiego
An affiliate of Johns Hopkins University, founded 1973 A nonprofit organization primarily funded through USAID, CDC, PEPFAR, corporations, international donors and private foundations Currently working in more than 50 countries with about 1,600 host country staff and US-based staff
Historic Browns Wharf, Fells Point, Baltimore, Maryland

Where We Work Today

Core Expertise

Target for Screening and Flow Pattern

VIA 3050 years HIV-Positive/Unknown (high-prevalence areas) at any age RCH, OPD, GYN CLINIC, ART

Negative

Positive

Suspect Cancer

Follow-up 5 years (HIV-) Follow-up 3 years ( HIV+)

Treat Immediately Cryotherapy

Refer/Treat with LEEP

Repeat VIA after 1 year

Refer

Key Service Delivery Performance Indicators

Total number of clients screened with VIA Number of new clients screened with VIA Number (%) women screened with known HIV status Number (%) of new clients screened with VIA+ result Number (%) of VIA+ clients treated with cryo at same visit (SVA) Number (%) of clients treated with LEEP Number (%) of new clients with suspect cancer Number (%) of new clients referred for large lesions Number (%) offered PITC Number (%) accepting HTC Number (%) accepting HTC with HIV+ results

Jhpiego: Cervical Cancer Screening

Jan. 2000Dec. 2011 Thailand Philippines Indonesia Ghana Malawi # VIA Screened 105,484 17,320 45,050 19,503 10,142 # (%) VIA+ 4,596 (4.4%) 366 (2%) 816 (2%) 1,664 (8.5%) 1,021 (10%)

Jhpiego: Cervical Cancer Screening in HIV-Infected Women

Country Guyana # VIA/ HIV+ % 19,957/ 8% 14,338/ 66.2% 26,065/ 28% 72,818/ 386/ 12.7% 10,270/ 4.4% VIA+(%) 2,639 (13%) 960 (7%) 2,012 (8%) 4,990 (6.8%) 23 (6%) 892 (9%) VIA+/ HIV+ (%) 258 (16%) SVA 1,813 (84%) 460 (74%) 1,660 (94%) 3,333 (66.7%) 19 (82.6%) 460 (64%) Setting HIV Care Gen Med Clinic HIV Care FP/RCH FP OPD, PHC OPD Time Period 1/09 3/12 10/09 9/13 4/10 9/13 4/11 9/13 9/13 9/10 8/13

Cte dIvoire Tanzania Mozambique Zambia (DOD) Burkina Faso

810 (9%) 884 (12%) 897 (17.9%) 4 (8.2%) 892 (22%)

VIA and Cryotherapy Implementation Issues (1)

Health System Leadership NCD or RH Priority intervention Funding Service Delivery Model Stand-alone or integrated Opportunistic or organized screening Outreach and static Functional referral points for continuum of care Community mobilization

Technique Quality of acetic acid Standardization of VIA steps Infection prevention practices Training Trainer preparation Provider development Length of training Transfer of learning Caseload for hands-on practice Qualifying new and current providers

VIA and Cryotherapy Implementation Issues (2)

Quality Assurance Timely and appropriate supportive supervision Compliance to standards Resources for supervision Referral Resources Specialists and services Equipment Supply and logistics of consumables Monitoring and Evaluation Standardized monitoring tools Documentation and accuracy Data use to drive management Integration of tools into National Health Information Systems

Equipment, Supplies and Logistics for Cryotherapy Connectivity Reliability Durability Repairability and spare parts Maintenance Quality and access to CO2 Portability Cost

CO2

HIV-Related Issues
Larger proportion of large lesions (involving >75% of cervix) ineligible for cryotherapy Need for integration into HIV services and HCT (also to include HIV- women!) Need for LEEP training/implementation
Jhpiego has supported introduction of LEEP in Cte

dIvoire and Tanzania Who can perform? Can this be incorporated into SVA?

Role of HPV DNA testing

Integrated screening?

Screening and Treatment Outcomes by HIV Status, April 2012Sept. 2013

New clients screened with VIA Clients diagnosed with precancerous lesions (VIA+) among new clients screened
Clients diagnosed with large lesions among those identified with pre-cancerous lesions (VIA+) Clients diagnosed with large lesions among those screened Clients diagnosed with large lesions and received LEEP* HIV-Infected n 3,067 328 % 11 HIV Non-Infected or Status Unknown n 8,967 505 6 % n 12,034 833 Total % 7

82

25

49

10

131

16

82 80

3 98

49 35

0.5 71

131 115

1 88

Lessons Learned
Promote country ownership Implement sustainable, organized screening for scale-up
Design service delivery model to adapt to organized

screening Sustain a strong link from community to referral

Monitoring and assessment

Monitoring scale-up: Document results and outcomes Efficient use of limited resources

Powerful advocacy tool

Lessons Learned
Build capacity
Competency-based training
Develop/Sustain core team of qualified trainers and

supervisors Task shifting and task sharing Institutionalize

Maintain quality of care

Measure, monitor and reward

Acknowledgments
Jhpiego would like to thank the Ministries of Health of the following countries: Tanzania, Cte dIvoire, Guyana, Mozambique, Burkina Faso, Zambia, Indonesia, Thailand, Philippines, Ghana and Malawi Funding generously provided by The Bill & Melinda Gates Foundation, USAID and PEPFAR through USAID, CDC and DOD