Project title –      Family Focused HIV Prevention, Care and Treatment (FFHPCT) Services

Demand Creation for Cervical Cancer Screening among Women Living with HIV in Ethiopia

Cervical cancer in Ethiopia

Cervical cancer incidence and mortality has been drastically reduced in high resource countries during the last decades. This can be largely attributed to the implementation of screening programs for the detection of precancerous lesions and HPV and improved therapy. Yet in low- and middle income countries where access to such measures is limited, cervical cancer remains a significant health problem. The vast majority of an estimated number of 311.000 cervical cancer deaths worldwide occur in less developed regions.

In Ethiopia, where almost 6.300 new cases are diagnosed annually, about 4.884 women die from cervical cancer each year. This makes cervical cancer the second-most common cancer in the country, and the second-most deadly cancer among Ethiopian women.

One of the most important prognostic factors is stage at diagnosis, linking early-stage diagnosis with better chances of survival; still most cervical cancer patients present at advanced stages in Ethiopia. Studies examining predictors of late and advanced stage presentation of cervical cancer patients in low- and middle-income countries have been scarce. The relationship between HIV-infection and cervical cancer and the question of whether HIV-infection leads to more advanced cancer stages is discussed controversially. The timespan between symptom onset and diagnosis has been associated with stage at diagnosis, but other studies could not confirm this. However, these studies were conducted in high-income countries where time to diagnosis is considerably shorter. It is unclear whether these results likewise apply to low-income countries such as Ethiopia, where time to diagnosis is long and patients present at advanced stages. Tragically, in a previous study of a hospital cohort of 1.059 cervical cancer patients receiving oncologic treatment in Addis Ababa, Ethiopia, we found long periods of time between diagnosis and the beginning of cancer treatment. This led to stage-migration and thus decreased chances of survival

Studies also shows that HIV-infection was associated with more advanced cancer stages at time of diagnosis compared to patients with a negative or unknown HIV-status. The association of HIV and HPV is well-known, and previous studies repeatedly linked HIV-infection with a higher prevalence, incidence and persistence of HPV-infection and its progression into precancerous lesions (especially for patients with low CD4 cell counts). However, the association between HIV and invasive cervical cancer is less clear. Published data indicate a 1.6 to 2.4 increased risk of developing invasive cervical cancer for HIV-positive women. The effect of sero-prevalence of HIV on cancer stage at time of diagnosis in comparable settings is similarly hard to establish.

Cervical cancer screening enables the detection of abnormal cervical cells, including precancerous cervical lesions, as well as early stage cervical cancers. Routine cervical screening has been shown to reduce both the incidence and mortality of the disease. However, over 80% of invasive cervical cancers worldwide occur in developing countries, largely as a result of the challenges in establishing effective screening programs. The World Health Organization estimates that only about 5% of women have been screened for cervical cancer in resource-poor countries, compared to 40–50% in the developed world. In Sub Sharan Africa, there have been efforts to improve awareness and the availability of cervical screening services. However, the coverage still remains low and the incidence and mortality rates associated with the disease are high in this region.

Ethiopia is one of the Sub-Saharan countries in which cervical cancer is the second most frequently diagnosed cancer among women, next to breast cancer. The WHO 2012 report showed that the estimated incidence of cervical cancer in Ethiopia was 17.3%, with a mortality of 16.5%. The age-standardized incidence rate of 26.4 per 100, 000 women was estimated in 2012. Studies have shown that the practice of screening is followed by knowledge of cervical cancer and screening. However, in Ethiopia, the overall coverage of cervical cancer screening was found to be 0.8% according to the ICO Information Centre on HPV and Cancer 2017. A study from the Northeast part of the country showed that only 57.7% of women had ever heard of cervical cancer, and 51.9% had sufficient knowledge of the disease. Nevertheless, 11% had undergone cervical screening at least once in their lifetime. In Mekelle, in the north of the country, among eligible women, 19.8% had been screened for cervical cancer, while in the northwest part of Ethiopia, a study showed that only 14.7% of women with knowledge of cervical cancer screening had undergone cervical cancer screening. The study also found that knowledge of the risk factors, symptoms and preventive options regarding cervical cancer were very low; a study in Addis Ababa found that only 6.5% of the respondents had experienced a Pap smear test.

As it is well known, NNPWE in partnership with Project Hope has been engaged on creating awareness about cervical cancer and creating demand for screening among women living with HIV and the community. Promising results have been registered so far. Thus, NNPWE would like to extend its activities to additional 4 associations and strengthen the on-going demand creation activities through its associations.

General objective – The general objective of this service level agreement (FSLA) is to continue and expand the awareness creation activities on cervical cancer screening and treatment among WLHIV who are members of NNPWE WPLHIV association at and other women focused organizations (CBOs, CSO, etc…) in CHCT target areas and provide referral services to HFs for eligible and consenting WLHIVs.

Specific objectives

–          To create awareness and knowledge among WLHIV about cervical cancer and its treatment through demand creation materials

–          To build the capacity for Women PLHIV associations and other actors to do cervical Cancer demand creation

–          To initiate WLHIV to screen for cervical cancer and to facilitate referral linkage of eligible and consenting WLHIV for cervical cancer screening to service providing health facilities

Activities and intervention strategies

–          Facilitate sensitization events on Cx Ca

–          Recruit and train  additional volunteer women among WLHIV Associations

–          Deploy volunteers to create awareness about cx ca among WLHIV associations and their community  

–          Prepare and distribute various demand creation materials

–          Work closely with USAID FFHPCT activity implementing LIPs.

–          Monitor and evaluate the progress of the activity  periodically

Major activities performed so far

–          Cervical cancer demand creation strategy and material development – NNPWE in partnership with Project HOPE has developed brochure, poster, radio spot and TV spot. The materials were distributed among NNPWE’s associations and USAID Local Implementing Partners (LIPS) to create awareness among women living with HIV and other community members to understand about cervical cancer and to get screening services. The radio spot has been on air for about 20 days on EBC (national radio station).

–          Capacity building for demand creation and referral of WLHIV for cervical cancer screening to services providing health facilities – NNPWE has trained 39 volunteers among 12 associations and deployed to create awareness among their association members and their community. So far, 2,892women are reached with the message whereas 489women were screened at various government based health facilities.

–          Conduct cervical cancer demand creation at community level – NNPWE has been creating an orientation session about cervical cancer to different local non-governmental organizations, community based organizations and women associations, non-women specific PLHIV associations and grass root organization as well as government offices to use their platforms to cascade the message and facilitate the screening for cervical cancer among women.