Mary Rose Giattas Marya Plotkin Giulia Besana Maryjane Lacoste Safina Yuma Robert Kamala Mainza Lukobo-Durrell Megan Wysong Harris Sharon Kibwana Kelly Curran Cervical Cancer Screening in HIV-Positive Clients in Tanzania: Creating Linkages to Reduce Cancer-Related Deaths

Cervical Cancer and HIV  Cervical cancer is the leading cause of cancer deaths among women in Tanzania:  Tanzania has the highest cervical cancer burden in East Africa, with ASR incidence rate of 50.9 cases per 100,000 women (GLOBOCAN  Compelling evidence has shown that HIV-positive women are at greater risk for developing cervical cancer:  Higher incidence and longer persistence of HPV infection, the main cause of cervical cancer  Higher risk of developing precancerous lesions  More rapid progression to invasive cervical cancer (Branca 2003, DeVuyst 2008, Parham 2006) 2

HIV Prevalence in Tanzania 3 Iringa Morogoro National – Adult HIV prevalence: 5.7% National – Women 15–49 years HIV prevalence: 6.1% Morogoro Region Women 15–49 years, HIV prevalence: 7.1% Iringa Region Women 15–49 years, HIV prevalence: 18.6% Source: 2007/08 Tanzania HIV/AIDS and Malaria Indicator Survey (THMIS)

Single Visit Approach (SVA) in Tanzania Client reaches RCH clinic Client is offered cervical cancer screening Client is offered PITC if status is unknown Visual inspection of the cervix using acetic acid Client is VIA+ (large lesion) Client is VIA+ (pre-cancerous lesions) Client has suspect cancer Client is VIA- If client is HIV+, counseled to return after 1 yr Immediate cryotherapy offered Client counseled to return after 1 yr Referred for LEEP Referred for suspect cancer If client is HIV-, counseled to return after 5 yrs Postponed cryotherapy Client returns for postponed cryotherapy

Benefits of SVA with VIA  VIA is a cost-effective, safe, feasible and acceptable alternative, with sensitivity comparable to cytology (Goldie 2005,Sankaranarayanan 2007)  Links screening for precancerous lesions with immediate treatment (cryotherapy) in the same visit:  Reduces loss to follow-up  Practical approach that can be scaled up 5 Negative Positive

Jhpiego Support for CECAP in Tanzania  Jhpiego is providing (USAID-funded) technical assistance to MOHSW:  National service delivery guidelines  HMIS tools  Training resource package  IEC materials  Technical assistance to partners for scale-up  Supporting service delivery rollout in 10 facilities in Morogoro and Iringa Regions:  Services targeted but not limited to HIV-positive women  Services provided in RCH, HIV-positive women referred from CTC and PMTCT (all providers oriented) 6

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CECAP Program in Tanzania  SVA approach using VIA has been endorsed by MOHSW  CECAP services provided through RCH services  CECAP screening and treatment is for all women 8

Adaptations for High HIV Prevalence Setting  Opt-out PITC for clients whose HIV status is unknown:  HIV-positive clients (through PITC) linked to CTC services  2551 clients accepted PITC ; 92% of those offered accepted  4% of clients test HIV-positive at PITC (110 clients)  Strong linkage from Care and Treatment Center (CTC) to CECAP screening  LEEP machines to be provided to regional hospitals and training to providers 9

Methods  Nationally approved client form for CECAP is entered into a client-level database stripped of identifiers. These data are analyzed by Jhpiego to provide feedback to the MOHSW on programmatic achievements:  A non-research determination has been obtained from Johns Hopkins University for secondary analysis of these data.  Client-level routine service delivery data from 10 sites, April 2010– September 2011, are presented. 10

VIA Screened, April 2010–Sept 2011 (10 sites) 11 HIV Status HIV-positive (n=1,074) HIV status negative or unknown (n=4,026) Totalp Value N% (of HIV +)N% (of HIV -) Total VIA screened 1,074--4,026--5,100-- Total VIA- positive %1994.9% * Total referred for large lesions 282.6%240.5% Total suspect cancer 151.3%992.4%

VIA Screening April 2010–Sept Expansion to 10 facilities

Provider-Initiated Testing and Counseling 13 2,551 women have been screened via PITC, of whom 5% were positive in Iringa and 4% were positive in Morogoro

Source of Information of HIV-Positive Status 14

Rates of VIA-Positive Clients and Large Lesions 15

Conclusion  Provision of CECAP services in high HIV setting must take into consideration needs arising from both HIV- positive and HIV-negative populations  Need for locating services where all can access  Need for targeting for women at high risk of morbidity  Need for integrating testing for HIV  Need for strengthening of referrals both ways  Need for LEEP for all women but especially HIV-positive women who will have higher rate of large lesions 16

Challenges  Referral of CTC clients to CECAP still low:  More orientation of CTC providers needed  Location of CECAP in RCH has advantages and disadvantages  PITC consistency hampered by national-level shortages of test kits 17

Recommendations 18  Strong linkages between HIV care and treatment and CECAP:  Providers oriented and supervision provided  CTC providers consistently referring enrolled female clients  PITC on an opt-out basis  Availability of LEEP services