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Access to Loop Electrosurgical Excision Procedure (LEEP) in Cervical Cancer Prevention Is Critical for HIV-Endemic Settings: Experiences from

Tanzania
by: Giulia Besana, Mary Rose Giattas, Marya Plotkin, Mariam Mohammed, Christina Makene and Kelly Curran3,4 affiliate: 1Jhpiego, an affiliate of Johns Hopkins University/Tanzania; 2Ministry of Health and Social Welfare (MOHSW), Iringa Region; 3 Jhpiego, an affiliate of Johns Hopkins University/USA; 4Johns Hopkins Bloomberg School of Public Health

Background n The USAID-funded Mothers and Infants,

Screening and treatment outcomes by HIV status, April 2012September 2013


HIV-Infected n New clients screened with VIA Clients diagnosed with pre-cancerous lesions (VIA+) among new clients screened Clients diagnosed with large lesions among those identified with pre-cancerous lesions (VIA+) Clients diagnosed with large lesions among those screened Clients diagnosed with large lesions and received LEEP* 3,067 328 82 82 80 % 11 25 3 98 HIV Non-Infected or Status Unknown n 8,967 505 49 49 35 % 6 10 0.5 71 .009 < 0.000 < 0.000 < 0.000 p-value n 12,034 833 131 131 115 Total % 7 16 1 88

n HIV-infected women have a higher

Safe, Healthy and Alive (MAISHA) program is working with the MOHSW to improve the quality of maternal, newborn, and reproductive health in Tanzania. Since 2009, MAISHA program is expanding access to low-cost cervical cancer screening services by providing health facilities with equipment and training for staff. The program uses a Jhpiego-pioneered screening method, the single visit approach, and immediate treatment with cryotherapy for small pre-cancerous or the Loop Electrosurgical Excision Procedure (LEEP) for large pre-cancerous lesions and/or lesions that extend into the endocervical canal. prevalence, incidence and persistence of human papillomavirus (HPV) infection, can be from 212 times more likely to develop pre-cancerous lesions than HIVnegative women, and are at increased risk of developing or dying from cervical cancer (CaCx). n This includes increased risk of
developing larger lesions that cannot be treated with cryotherapy.

Background (cont.) Overview of cryotherapy and LEEP as components of service delivery


Cryotherapy (CO2 or N2O gas required) Cure rate of single treatment Proportion of clients with minor side effects Provider authorized to provide service Anesthesia required? Tissue obtained? > 90% 13% Nurse or Clinician No No LEEP (Electrosurgical unit and power required) > 90% 15% Clinician Yeslocal Yes

Results

Overall, among all clients screened, 3% of HIV-infected compared to 0.5% of non-HIV infected women were diagnosed with large lesions and referred for LEEP services (p < 0.000). HIV-infected women who had pre-cancerous lesions were more than twice as likely to present with larger lesions compared to nonHIV-infected women and need the referral to LEEP services (25% compared to 10%) (p < 0.000). Overall, 88% of all women diagnosed with large lesions received LEEP treatment, even though in many cases this entailed travel paid for by the client:

Tanzania Service Delivery Guidelines for Cervical Cancer Prevention and Control, 2011.

n Despite the increased risk, globally only

n In Tanzania, CaCx is the most common

an estimated 20% of HIV-infected women are screened for CaCx and less than 10% receive appropriate treatment. cancer in women. Annually, there are 51 cases and 38 deaths per 100,000 women; this rate is likely to be disproportionately higher in HIV-positive women, who represent 6.2% of adult women. visual inspection with acetic acid (VIA) as the primary screening method as part of CaCx prevention. n Treatment options include cryotherapy
for small pre-cancerous lesions (occupying < 75% of the cervix), and LEEP for large pre-cancerous lesions (occupying 75% of the cervix).

Methods n Morogoro and Iringa regions, supported

n The Tanzanian MOHSW has adopted

n The analysis is drawn from de-identified

by the MAISHA program, have integrated LEEP into cervical cancer prevention services; data from these two regions are presented here. The regional hospitals, trained in LEEP in April and September 2012, have been providing LEEP services for an average of 16 months. client-level data, from the months when LEEP service was offered at the facility. Data are entered into a database on-site.

n 98% of the HIV-positive women received


the LEEP service. the LEEP service. 62% of clients referred for LEEP were diagnosed in a facility not providing LEEP and traveled to another facility to get the service.

n 71% of the HIV-negative women received

Conclusions n LEEP is an important part of a

LEEP Equipment

n Women who are HIV-infected are at

comprehensive cervical cancer prevention and treatment program in developing countries. higher risk of large intraepithelial lesions and thus will need increased availability of LEEP. While LEEP will not be available as readily as cryotherapy (more expensive to maintain, performed by clinicians), it is vital that cervical cancer prevention programs incorporate LEEP into their service delivery package to serve the needs of HIV-infected women: n Countries with high HIV prevalence
will encounter much higher (these data suggest up to twice as high) rates of large lesions among HIV-infected women.

n Coverage of CaCx screening and

n Results presented here are from

treatment options for pre-cancer are still very limited in the country the MOHSW estimates that there are more than 100 facilities providing CaCx screening and treatment of pre-cancerous lesions out of close to 6,000 health care facilities in the country. Currently, five tertiary health care facilities in Tanzania provide LEEP. the MAISHA program, working in collaboration with the MOHSW and supported by USAID. The program supports provision of CaCx prevention services in 15 health facilities, in two regions of Tanzania. n All sites offer both VIA screening and
cryotherapy, and LEEP is available on a referral basis at the regional hospital. Women with suspected cancer are referred to the national referral hospital.

LEEP Tray

n Findings from this analysis show that

when LEEP is made available at the regional referral hospital, there is a high uptake, even when this involves some cost to the client:

n Uptake varied (not significantly) by HIV

status, with more HIV-infected women referred actually accessing the service. This finding needs to be investigated further.

References

Chirenje ZM. Best Pract Res Clin Obstet Gynaecol 2005:19 :269276. Anderson et al. Cervical Cancer Screening and Prevention for HIVInfected Women in the Developing World. In: Georgakilas AG, editor. Cancer Prevention From Mechanisms to Translational Benefits, 2012.

Morogoro Iringa

E2Pi, Evidence to Policy Initiative, The Global Health Group. September 2012 Policy Brief, Integrating cervical cancer screening into HIV services in Sub-Saharan Africa.

We thank the Tanzanian Ministry of Health and Social Welfare for their support and collaboration.

This poster was funded by the Presidents Emergency Plan for AIDS Relief (PEPFAR) through USAID's Mothers and Infants, Safe, Healthy, Alive Program through Cooperative Agreement #621-A-00-08-00023-00. The opinions herein are those of the authors and do not necessarily reflect the views of PEPFAR or USAID.