“I was scared cervical cancer screening could be a long procedure and painful. However, I found it to be a simple procedure. They detected the case in a matter of minutes,” said Alem Abera, a cervical cancer patient in Dessie, Ethiopia. “I was treated with cryotherapy in about 10 minutes. No pain and no complication, it was a simple and swift process.”
In Ethiopia, cervical cancer is the leading cause of cancer deaths among women. Although highly preventable, limited access to screening services and a need for greater awareness of cancer signs and symptoms contribute to 80% of cervical cancer cases diagnosed at advanced stages, when little can be done to treat the disease. For women living with HIV, the risk of cervical cancer is especially stark. In Ethiopia, women living with HIV are four to five times more likely to develop cervical cancer than those without HIV infection. To raise awareness about cervical cancer and reach more women who need access to screening and treatment, ICAP supported the Ministry of Health to bring low-cost, safe, and effective cervical cancer services to 505 health facilities across six regions of the country.
At Dessie Comprehensive Specialized Hospital – a major referral hospital in the Amhara region with high volumes of cervical cancer cases – ICAP launched a project to increase screening services among eligible women.
“As a first step, we formed a quality improvement (QI) team involving health care workers from the HIV unit, gynecology clinic, and hospital management team, forging strong linkages and collaboration between the anti-retroviral therapy (ART) and gynecology clinics,” said Dr Haymanot Ayele, the Medical Director of Dessie Comprehensive Specialist Hospital.
Using a systematic approach, the QI team conducted an analysis to identify key barriers preventing individuals from using the cervical cancer services. The investigation revealed patients feared stigma for seeking services and identified a need for greater coordination between ART and gynecology units, increased patient awareness of cancer signs and symptoms, proper supplies and equipment, and training of health care providers.
With funding from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC), ICAP helped establish a designated space for cervical cancer services within the HIV services clinic, providing necessary screening equipment such as speculums, and training health workers and support staff on how to use them. By integrating the services, women no longer needed to visit a different area of the hospital.
“Bringing the cervical cancer screening and treatment rooms physically closer to the ART services, as well as enhanced counselling services, was a key strategy to address women’s fears of stigma and increase confidentiality and privacy,” said Dr. Hezkiel Petros, cervical cancer program manager at ICAP in Ethiopia.
Once the rooms were equipped and health care providers were trained, ICAP led an analysis of electronic medical records that identified more than 3,000 eligible patients, which included sexually active women between 15-49 years old who have never been screened or were screened more two years ago. The QI team also developed tracking tools to capture information on screening and treatment status, creating a necessary resource to track and verify if referred clients have undergone screening.
Thanks to intensive campaign-style calling by case managers, 1600 women were screened for cervical cancer – a twelve-fold increase from the previous year. “Before the initiative, we used to screen one or two women in a week. After we started implementing the project, there were times where we were able to screen 50 to 80 women a day,” said Fikirte Kebede, a comprehensive nurse, cervical cancer focal person and coordinator of the gynecology ward.
Of the women screened, 137 women who screened positive for precancerous lesions, 135 were treated with cryotherapy, while two hysterectomies were performed for advanced cases. “The screening and treatment of precancerous lesion is simple. That can be performed in a matter of minutes; however, the outcome is lifetime and lifesaving.” said Dr Hezkiel Petros, cervical cancer Program Manager at ICAP in Ethiopia.
“The achievement of the quality improvement project at Dessie Hospital to increase the number of women living with HIV screened for pre-cervical cancer is remarkable.” said Takelech Moges, national coordinator for cervical cancer screening and management at the Ministry of Health in Ethiopia. “By taking such an important lesson, the Ministry of Health in partnership with ICAP is expanding the quality improvement project to other cervical cancer screening and management program sites in the country.”
A major global health organization that has been improving public health in countries around the world for nearly two decades, ICAP works to transform the health of populations through innovation, science, and global collaboration. Based at Columbia Mailman School of Public Health, ICAP has projects in more than 30 countries, working side-by-side with ministries of health and local governmental, non-governmental, academic, and community partners to confront some of the world’s greatest health challenges. Through evidence-informed programs, meaningful research, tailored technical assistance, effective training and education programs, and rigorous surveillance to measure and evaluate the impact of public health interventions, ICAP aims to realize a global vision of healthy people, empowered communities, and thriving societies. Online at icap.columbia.edu