At an ICAP-supported clinic in Kenya, Juliana, a 32 year-old mother of two, was diagnosed with a premalignant lesion covering at least a quarter of the surface of her cervix. Like many other HIV-positive women, Juliana was unaware of her risk for cervical cancer. “I thought I was dying of AIDS when I started experiencing repeated discharge. Little did I know I would be developing this type of problem.”

It was the nurse counselor at her HIV clinic who advised Juliana to receive cervical cancer screening. Through ICAP’s work expanding cervical cancer care in sub-Saharan Africa, the service was introduced recently at Juliana’s clinic and offered free of charge. The screening revealed extensive abnormal cervical cells, and Juliana received cryotherapy treatment—provided by the clinical officer—the same day. Two weeks later, in line with national cervical cancer guidelines, Juliana was seen by a gynecologist from the hospital and was doing well.

!{filedir_2}CCS.jpg(Juliana and the nurse counselor at an ICAP supported HIV clinic.)!

p=. *Juliana and the nurse counselor at an ICAP supported HIV clinic.*

In resource-limited countries, approximately 80 percent of cervical cancer cases go undiagnosed until the disease is at an advanced stage. Access to cervical cancer screening and treatment is limited throughout much of sub-Saharan Africa. Women living with HIV face a greater risk of developing aggressive precancerous cervical lesions and invasive cervical cancer.

ICAP is working urgently to close this gap in women’s health services and has developed and launched cervical cancer screening programs in Mozambique, Tanzania and Kenya.

h2. Mozambique

Since 2011, ICAP has been working in Mozambique to train health care workers to provide cervical cancer screening, increase linkages between HIV and women’s health care services, and disseminate clinical tools and materials all aimed at increasing awareness about the importance of cervical cancer screening and treatment. Since the start of the project, in collaboration with Maternal and Child Health Integrated Program (MCHIP), 65 health workers have been trained and equipped to perform screenings and treatment has been distributed to Gaza, Inhambane, Maputo City, Nampula and Zambezia provinces. Since activities began in October 2011, more than 10,000 screenings using visual inspections with acetic acid (VIA) were performed with referral to same-day treatment.

Despite an increase in cervical cancer services, significant challenges remain. Women with identified lesions or cellular changes should undergo treatment the same day, but because cryotherapy requires sexual abstinence for several weeks following the procedure, less than half of women chose to be treated the same day. Many report that they will discuss treatment with their partner, and unfortunately, do not return. The long-distances many women have to travel to the clinic is another obstacle and there remain challenges in communication between primary health facilities and provincial hospitals where patients with advanced needs are referred.

h2. Tanzania

ICAP is also working to scale up screening services in Tanzania. Since 2010, ICAP has collaborated with the Ministry of Health and partners to support the start-up of cervical cancer screening programs using VIA and treatment of precancerous lesions in a single visit. This includes providing support to obtain the necessary supplies and equipment, to train health workers, to train peer educators to mobilize HIV positive women to access these services, and to establish referral systems for those women who have large lesions and suspect cancer.

Using clinical and community-based strategies, ICAP has supported the establishment of cervical cancer screening services at 33 MOH health facilities with specialized HIV/AIDS care and treatment centers in Kigoma and Pwani Region of Tanzania. Since 2010, more than 16,000 women have been screened. This year, these services will be expanded to ten further sites in Kagera region, and ICAP hopes to support the continued expansion of cervical cancer screening in government health facilities and for HIV positive women, in particular.

h2. Kenya

ICAP in Kenya is supporting cervical cancer screening centers within HIV clinics at five high volume health facilities in Eastern South and five in Nynanza provinces. A clinical officer leads each Center of Excellence and coordinates all the cervical cancer training, supports nurses to screen at the sites, receives referrals from the smaller peripheral sites, and ensures referral of complicated cases to the regional gynecologist. To date, ten clinical officers have been hired and centers have received cryotherapy machines, gynecology examination beds, laboratory reagents and data collection tools. More than 100 health care workers have been trained in cervical cancer screening and treatment.

ICAP is also collaborating with the University of Nairobi to train nurses at smaller peripheral facilities to screen for premalignant lesions and refer those testing VIA/VILLI positive for treatment at the central facilities. Since September, 21 nurses have been trained using cost-efficient clinical training methods, rather than the conventional classroom-based training, and more than 3,000 women have received cervical cancer screening services.

The increasing support by several governments for cervical cancer screening programs in sub-Saharan African countries offers promise of early detection of cervical abnormalities and prevention of cervical cancer and its related morbidity and mortality. In addition, the growing interest in providing access to the vaccine for human papilloma virus for girls may also have substantial impact on future rates of cervical cancer across the continent.

With PEPFAR support and through its collaborative efforts with partners, ICAP will continue to support the expansion of cervical cancer screening services and care for women throughout the region, particularly the unmet needs of women living with HIV.