Zimbabwe Cervical Cancer Screening and Education Project – Executive Summary

A Cancer Prevention Initiative

Executive Summary

 Cervical cancer accounts for one-third of all cancer cases in Zimbabwe and is the leading cause of cancer death among Zimbabwean women. This high disease burden has been heavily influenced by the HIV epidemic. When woman arrive at rural hospitals with invasive, late-stage cervical cancer, little can be done for them. In practical terms, both treatment and palliation are unavailable, and these women usually die of their disease. In the absence of an HPV vaccine, cervical screening to detect and remove early, precancerous lesions is the most effective way to prevent the disease and the suffering it causes. Unfortunately, cervical screening is available to only a fraction of Zimbabwean women, particularly in rural areas.

Mr. Darrell Ward of Better Healthcare for Africa (BHA), Dr. Lowell Schnipper of the Beth Israel Deaconess Medical Center/Harvard Medical School and collaborators at St. Albert’s Mission Hospital, a rural mission hospital in Zimbabwe, are seeking funding to develop a hospital-based cervical-cancer screening and education program.

This “screen and treat” program uses a simple, inexpensive and proven method to detect precancerous lesions on the cervix, and a relatively simple and proven technology to remove those lesions and thereby prevent the development of invasive cervical cancer, for which few treatment options exist in rural Zimbabwe.

In brief, the program will establish a cervical screening clinic at the hospital that includes training in cervical cancer for staff and support a district-wide community cervical-cancer prevention campaign and weekly cervical-cancer screening at three of the hospital’s 11 outlying clinics. In brief, this project:

• Has the potential to screen an estimated 100 women per month at St. Albert’s hospital;
• Will offer education and rapid testing for the human immunodeficiency virus (HIV) to women of unknown HIV status;
• Will meet national standards set by Zimbabwe’s MOHCW for this screen and treat program;
• Includes program monitoring and evaluation at the hospital, patient and community levels.
• Could serve as a model for cervical-cancer screening initiatives at other rural hospitals in Zimbabwe.

Of key importance, the program will create an infrastructure for the seamless introduction of an HPV-vaccination program and for the introduction of a more accurate and effective screening test when they become affordable.

On behalf of the principles and the hospital engaged in this initiative, BHA is requesting approximately $150,000 to initiate and support the three- year project.

As proposed, the project builds on local expertise and international “best practices,” and is designed to contain costs and facilitate sustainability. Working with physicians and staff at St. Albert’s, the Centenary District Medical Officer, and incorporating recommendations from Zimbabwe’s Ministry of Health and Child Welfare (MOHCW) and the UN Population Fund (UNFPA), this low-cost, low-technology program uses existing infrastructure, facilities and staff, and gives immediate results. Additionally, the program will introduce cancer awareness for women and men in the 29 wards of the Centenary district a rural area of Zimbabwe with a population of 120,000.

The current proposal requests funding to initiate this cervical-cancer prevention activity at St. Albert’s Mission Hospital. Assuming a successful launch at St. Albert’s, we plan to seek additional funding to adopt this initiative at a second location, Muvonde Mission Hospital (see Annex 3 below) in a second phase of the project.

St. Albert’s Mission Hospital

St. Albert’s Mission Hospital is located 120 miles north of Harare in Mashonaland Central Province. It is the only hospital in the Centenary district, and it operates under the director of the Parish of Chinhoyi Diocese. The International Medical Association (IMA) is a Catholic lay women’s missionary society headquartered in Rome that is committed to the health and welfare of the desitute poor. This organization has provided medical care and other services at St. Albert’s Hospital for 40 years and continues doing so today. Currently, IMA members at St. Albert’s include two physicians – one is hospital director, the other a family therapist – and other staff.

BHA personnel have worked with the hospital since 2000, including five visits to the hospital for a week or more at time to experience and understand the hospital’s programs, patient population, capabilities and challenges. BHA’s past assistance to St. Albert’s hospital form the basis for the collaboration that underlies this cervical-cancer prevention initiative. This assistance has included:

• Purchasing equipment requested by the hospital, such as an anesthesia machine and X-ray film processor;
• Shipping donated medical supplies to the hospital;
• Emailing PDFs of World Health Organization (WHO) and Alliance for Cervical Cancer Prevention (ACCP) documents to help guide the hospital in developing its cervical cancer prevention efforts;
• Posting slideshows of the hospital and its outreach activities online to help in education and fundraising efforts (see the Annex for these links) to the online slideshows about the hospital).
• Assisting American nurses and doctors interested in visiting St. Albert’s Mission Hospital schedule and prepare for their trip, which usually includes carrying in donated medical supplies. Since 2006, BHA has provided nonmonetary assistance to eight nurses and one physician in spending one to three months at St. Albert’s, working with the doctors at St. Albert’s to coordinate the visit. Most recently, BHA helped coordinate a six-week visit to St. Albert’s by three nurses who recently graduated from the Yale nursing program.
• To help finalize this proposed cervical-cancer screening initiative, collaborators Dr. Schnipper and Mr. Ward visited St. Albert’s hospital in March 2013.
• Following this 2013 visit, BHA and Dr. Schnipper provided $1,250 to install dedicated internet service for the entire hospital, allowing Dr. Schnipper and BHA to maintain regular and consistent email and Skype contact with the physicians at St. Albert’s to confer with the physicians at the hospital and monitor progress.

Zimbabwe Cervical Cancer Screening and Education Project in Brief

Research and the Alliance for Cervical Cancer Prevention have determined that visual inspection with acetic acid (VIA) is an efficient and cost-effective strategy for detecting and treating cervical cancer precursors in low-resource settings. For low-income countries, studies of visual screening confirm that these methods offer a low-cost, effective option until affordable HPV DNA testing technologies become more widely available and cost-effective and medically effective in resource-limited settings.

The Zimbabwe MOHCW has given a high priority to the prevention of cervical cancer by scaling up cervical screening services as part of the government’s National Health Strategy (2009-2013). With financial and technical support from the UNFPA and the World Health Organization, the MOHCW has initiated a national program for cervical cancer screening and management using visual inspection with acetic acid plus cervicography (VIAC). Cervicography is incorporated into the program to facilitate review of observed lesions. Those identified as precancerous are treated by expert gynaecologists to assure the highest level of performance of the screening procedure. The Zimbabwe government/UNFPA initiative, however, is being implemented only at the level of national and provincial hospitals. Resources are not available to extend the program to rural hospitals or clinics, where the need is acute.

The Cervical Cancer Screening and Awareness Project described in this proposal will support cervical-cancer screening using VIAC in the rural district served by St. Albert’s Mission Hospital.

• The program will be supervised and implemented by obstetrician and gynecologist Dr. Neela Naha, FRCOG, at St. Albert’s, assisted by Matron Sr. Ronica Changata.
• Women diagnosed with precancerous lesions – i.e., cervical intraepithelial neoplasia (CIN) 2 – by VIAC will be treated using cryosurgery to remove these early lesions, abrogating their progression to invasive cervical cancer. Women found to have invasive carcinoma will be referred to the Parirenyatwa Hospital in Harare.
• The hospitals propose to screen all sexually active women aged 21 to 65 years, except those who are pregnant, who come to the hospitals’ outpatient or women’s health clinics. Pregnant women will be screened in the post-partum period.
• St. Albert’s personnel who perform VIAC will receive standardized training in the technique by the MOHCW to ensure that the hospital conforms to the VIAC standards established by the MOHCW.
• The St. Albert’s program will build capacity by providing basic cancer education of staff at the hospital and at 11 outlying clinics.
• After establishing the VIAC clinic at St. Albert’s, a trained nurse will travel to three outlying clinics once a week to perform VIAC. Women with confirmed or suspected precancerous lesions or with cervical cancer will be referred to St. Albert’s hospital for follow-up.
• Shortly after establishing the VIAC clinic, the hospital’s outreach program will begin a Cervical Cancer Community Awareness Initiative in the district’s 29 wards. The awareness program was designed by Dr. Naha and hospital staff who have more than 12 years’ experience in building community public-health awareness related to HIV/AIDS, TB and malaria. The initiative involves three hospital-organized groups: Volunteer Community Health Workers, Secondary Caregivers, and People Living with HIV. See Annex 2 for details of the cervical cancer prevention awareness program.
• Metrics: This program will assess the following:
  • Number of women reached through educational outreach at the hospitals and surrounding villages;
  • Number of women screened, among those screened the number of women who are HIV positive;
  • Number of abnormal VIAC findings;
  • True and false positives for CIN;
  • Number of invasive cancers.
• Since prevention is possible employing a vaccine that protects against HPV, we, with our collaborators in Zimbabwe, will investigate the possibility of providing HPV vaccinations through contacts in the pharmaceutical industry.
• This effort by BHA and Dr Schnipper is also receiving guidance from Dr. Tsungai Chipato, Professor of Obstetrics and Gynaecology, at the University of Zimbabwe, who has experience with cervical cancer screening in Zimbabwe. We have held several conference calls with Dr. Chipato and have met with him personally during the 2013 planning visit to Zimbabwe.

For more information or to request a copy of the complete proposal, please contact Mr. Darrell Ward at dward@betterhealthcareforafrica.org or Dr. Lowell Schnipper at lschnipp@bidmc.harvard.edu