PEPFAR An Integrated Mobile Model Reaching Women in Remote Areas of Zambia by Building on HIV/AIDS Platforms for Cervical Cancer Services Delivery July

PEPFAR CancerNo.% Cervical63235 Breast1578 Kaposi’s sarcoma1116 Prostate905 Oesophagus513 Lymphoma463 Eye402 Colorectal301.6 Keloids301.6 Bladder291.5 Top Ten Cancers in Zambia Treated at Cancer Diseases Hospital of Zambia in 2012

Background PCI implements comprehensive HIV and AIDS capacity building interventions in all 54 Zambia Defence Force (ZDF) units and surrounding communities Funded by PEPFAR through the US Department of Defense (DOD) Plus-up funding from the Pink Ribbon Red Ribbon (PRRR) Initiative Population of 300,000 – 90% civilians Most military units are in hard-to-reach and underserved rural Zambia ZDF runs a parallel health system with primary health facilities available in all the units Program implemented August 2011-April 2014

Facilitating Factors For Rapid Adaptation and Scale Up Existing Ministry of Health cervical cancer screening program using the “Screen-and-Treat” model with integrated cervicography Existing ZDF mobile HIV testing and counseling (HTC) program Existing system and tools for HIV behavior change communication (BCC) programs Buy-in from ZDF leadership Trained nurses and clinical officers in VIA and Cryotherapy Trained Obstetric Gynecologists in LEEP Procured equipment and supplies Trained drama groups and peer educators to implement demand creation interventions

Why An Integrated Mobile Model with Integrated Cervicography? Generalized HIV epidemic and second highest incidence rate of cervical cancer globally Association between HIV-related immunosuppression and a higher prevalence, incidence and persistence of HPV and progression to cervical lesions Sensitivity of VIA with digital cervicography is higher than cervical cytology: 84% Vs 61% (Bateman et al, 2014) Digital Cervicography: built-in quality assurance system and continuing education Mobile model: Rural population has poor access to cervical cancer diagnosis, treatment and prevention services

The Integrated Mobile Model VIA and Cryotherapy Self referrals ART and MCH clinics Mobile HIV Counseling and Testing

The Integrated Mobile Model Cont’d Peer educators and drama groups conduct pre-interventions campaigns Mobile HIV counseling and testing provided in tents outside the health facility Women are offered cervical cancer screening services Cervical cancer screening provided to consenting women inside the health facility Intra-clinic and self referrals accepted and offered Provider Initiated Testing and Counseling (PITC)

On-site “Screen and Treat” Screen: VIA VIA positive Offer same-day cryotherapy Refer for LEEP/BiopsyVIA negative

Results: August 2011-April 2014 Women screened YearTotal Women screened Tested HIV Positive VIA PositiveVIA Positive Treated with Cryotherapy VIA Positive Referred for LEEP nn%n%n%n% Total

Results: August 2011-April 2014

Lessons Learned Pre-intervention demand creation activities really create demand and clear up misconceptions about cervical cancer screening In settings with generalized HIV epidemics and high cervical cancer incidence rates, providing timely integrated screening and HIV testing and treatment services save women’s lives Leadership involvement and buy-in result in seamless implementation of programs

Challenges Pulling health personnel from an already over-stretched system to participate in mobile services Referral mechanisms from LEEP services to diagnostic and treatment services weak Gas not always available and expensive

References CANCER DISEASE HOSPITAL ZAMBIA (2012). Cancer Registry: Cancer Disease Hospital CENTRAL STATISTICAL OFFICE ZAMBIA (2010). Census of Population Report: Central Statistical Office CENTRAL STATISTICAL OFFICE ZAMBIA (2007). Demographic and Health Survey: Central Statistical Office DANGOU, J. (2014, June 18). Cancer and Chronic Respiratory Diseases, WHO-AFRO. [PowerPoint slides]. Presented at the Africa Regional Conference on New Opportunities and Innovations in Cervical Cancer Prevention Lusaka. GLOBOCAN: Cancer incidence and mortality worldwide database (2012). Available at: (accessed 3 rd March 2014) PARHAM, G. (2014, June 18). VIA and Cryotherapy Accompanied by Cervicography. [PowerPoint slides]. Presented at the Africa Regional Conference on New Opportunities and Innovations in Cervical Cancer Prevention Lusaka.

Acknowledgments The American People through PEPFAR funding to the United States Department of Defence HIV /AIDS Prevention Program’ s (DHAPP) grant to PCI. Grant Number N Zambia Defence Force Medical Services (DFMS) Management including Brigadier General F. Sikazwe, Brigadier General P. Njobvu, Brigadier General E. Malyangu, Brigadier General A. Mulela, Lieutenant Colonel F. Malasha and Colonel E.C. Chisoko The Mobile cervical cancer team including Colonel (Col) S. Banda, Col. E Banda, Major F. Banda, Major M. Sibindi, Major C. Mukwasa, M. Ngolwe, and G. Mulenga. We also thank Namwayi Membe for organizing and collating the data. The Zambia Ministry of Health and the Ministry of Community Development Mother and Child Health for providing referral LEEP services. Professor Groesbeck Parham and Dr. Sharon Kapambwe from the African Center of Excellence for Women’s Cancer Control, Center for Infectious Disease Research in Zambia (CIDRZ)

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