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Greater than 80% of the world's new cases and deaths due to cervical cancer occur in the developing world . No more than 5% of women in these settings are screened for cervical cancer even once in their lifetimes . Earlier attempts to establish population-based cervical cancer prevention programs using cytology screening in resource-limited settings have inevitably fallen short or failed [3–5]. Although many of the reasons for failure can be attributed to lack of resources and trained manpower, the multiple visit requirements of cytology-based screening programs jeopardizes success and sustainability.
HIV infection is associated with higher incidence, more rapid progression, and increased recurrence rates of human papillomavirus (HPV)-associated cervical intraepithelial neoplasia (CIN) and invasive cervical cancer, an AIDS-defining disease [6–14]. The last decade has seen a global push for increasing access to affordable antiretroviral therapy (ART) for HIV-infected individuals in the developing world. Programs such as the US President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria, have substantially upgraded healthcare infrastructures in many parts of sub-Saharan Africa and elsewhere at a scale never experienced in history [15,16]. Zambia has one of the world's highest cervical cancer incidence rates (53.7/100 000 women/year) and also a national adult HIV seroprevalence rate of 16% (23% in Lusaka, the capital city) [1,17]. Through PEPFAR-supported programs, greater than 100 000 people (50% women) are now (September 2008) accessing ART in Zambia . This care is largely delivered through partnerships between the public sector, nonprofit organizations, development agencies, and academic institutions.
Through support from the US Centers for Disease Control and Prevention (CDC)-PEPFAR program and other charitable resources, we launched an innovative program for cervical cancer prevention targeting, but not limited to, HIV-infected women in Lusaka, Zambia [19,20]. To our knowledge, this is the first effort within PEPFAR-supported programs to undertake cervical cancer prevention as a component of HIV care. We describe some of the major lessons learned through our experiences in the field operationalization of this program:
Over the past two and a half years, our program has screened over 20 000 women through services offered in 15 primary care clinics and one referral Gynecologic Cancer Prevention Clinic (Fig. 3). Our experience has shown that linking cervical cancer prevention services with HIV care and treatment services has potentiated the impact of initiatives such as PEPFAR by preventing cervical cancer in women living longer on ART and who have never been screened. We believe that HIV-targeted funds can and should address closely allied health concerns whose neglect may reduce the long-term success of HIV programs. This holds the promise of both saving lives and ensuring the strengthening of the broader primary care context so essential for sustaining HIV programs beyond the PEPFAR/Global Fund era.
The authors wish to acknowledge and thank Dr Moses Sinkala, Dr Bushimbwa Tambatamba, Dr Velepi Mtonga, Dr Ann Chao, and Mr Fresher Mapiri for their contributions to the program described herein; and Mr. Alain Degroot (CIDRZ) for his contribution to the data collection system. None of them received compensation.
The program was conceptualized and designed by G.P.P., M.H.M., V.V.S., S.H.V. and J.S.A.S. Clinical/laboratory training was provided by G.P.P., M.H.M., K.S.P., V.M. and M.L.H. Data were analyzed, interpreted, and managed by V.V.S., G.P.P., M.H.M., S.H.V. and J.S.A.S. The manuscript was drafted by M.H.M., V.V.S. and G.P.P., and critical revision of the manuscript for important intellectual content was provided by S.H.V., K.S.P., J.S.A.S., V.M. and M.L.H. Funding for the program was obtained by J.S.A.S. and G.P.P. Administrative and technical support was provided by J.S.A.S., G.P.P. and M.H.M. The program was led and supervised by G.P.P. and M.H.M.
This study was supported by the President's Emergency Plan for AIDS Relief grant through the Elizabeth Glaser Pediatric AIDS Foundation from the Centers for Disease Control and Prevention Global AIDS Program with additional support from the National Institutes of Health (NIH) through the Center for AIDS Research at UAB (NIH grant P30AI027767), the International Clinical Research Scholars/Vanderbilt-UAB AIDS International Training and Research Program (NIH grant D43TW001035 and R24TW007988), Career Development award (NIH grant K23AI01411), and an Elizabeth Glaser Pediatric AIDS Foundation Clinical Scholars Award.