Integrating cervical screening services and HIV care to save women's lives
Dr. Judith Auma shows how integrated HIV and cervical screening clinics in Uganda increased screening from 31% to nearly 80% in one year and her recommendations for introducing this into the region.
Although cervical cancer is one of the best-understood cancers, preventable through vaccination and regular cervical screening, it remains the leading cause of cancer deaths among women in sub-Saharan Africa.
HIV is a significant risk factor for cervical cancer, so working in Uganda, we sought to implement and test a ‘one-stop shop’ approach using integrated HIV and cervical screening services. Our study took an action research approach with research and ‘action’ (intervention) taking place in cycles and informing each other in an iterative fashion to create an evidence-base for, and optimise, impact. We were delighted to receive support from the Royal Society of Tropical Medicine and Hygiene (RSTMH) small grant funded by NIHR.
Cervical cancer is a preventable problem
Currently, screening for cervical cancer in Uganda is patchy, and absent in certain parts of the country. From my own experience providing cervical cancer prevention services in Uganda, cervical screening and HIV care services are not well integrated. For example, an audit of the screening service of one of these health facilities from June 2017 to August 2019 found that less than one third of eligible women using HIV services were screened for cervical cancer, and that less than 20% of those who were screened attended follow-up screenings.
This challenged me to explore how to effectively integrate cervical screening into the normal routine HIV care services of this health facility, to optimise screening coverage and follow-up amongst HIV positive women in care in timely ways.
What we did, what we found and recommendations for improvement
We designed cervical screening cards, similar to the cards being used in HIV care to monitor patients’ viral loads. These were attached in each patient’s file in order to enable vigilance and notification of the clinicians about the cervical screening plan for each of the women.
We also introduced the use of an appointment book to offer health care providers prior notification of the women due for screening and their appointment dates.
These helped develop a system of ‘call and recall’ of women due for screening, resulting in an exponential increase in timely screening of HIV positive women in care: from 31% to nearly 80% (recommended target for any screening programme) in ten months of the integration. The success of this integrated approach has also promoted an increased rate of screening and follow-up amongst HIV positive women in the region (most of these women are being referred to the case facility for screening).
In order to expand this integrated approach of service delivery to other health facilities in the region, we conducted a door- to-door community awareness-raising survey on cervical cancer prevention and trained over 50 health professionals in cervical screening and treatment. We have also set up more screening clinics in the region so hopefully, we can now also formally integrate screening into the HIV care of these facilities.
We discovered that overall, both health care providers and women have positive attitudes towards cervical screening, and appreciate the need for its integration with HIV care in well-structured ways. So how can we achieve this?
Our main recommendations for sustainable and effective integration are:
- Comprehensive health education
- Shifting the task of health talks from health professionals to expert clients and community health workers
- Government support in terms of more screening facilities and staffing
- Better screening follow-up mechanism - a notification or a reminding system to alert both the clinicians and the women about their screening appointments.
Reduce the minimum age for screening to catch cervical cancer among younger women
Finally, there is a critical issue of the minimum age for screening amongst the HIV positive women in integrated clinics. According to the new WHO screening guidelines, it recommends for HIV positive women to be screened starting from the age of 25 years.
However in our experience, many of the HIV positive women who test positive for cervical precancerous lesions are aged 18-25. Pry et al., 2021 also found that younger women with HIV aged 20–29 years had the highest predictive probability of being screened positive for precancerous lesions followed very closely by those younger than 20 years. It would therefore seem appropriate to screen women with HIV at an earlier age than 25, to prevent progression to cancer. We need more studies to be conducted to define an evidence-based minimum set of age-specific screening targets in this group.
Find out more information about The-cervical-screening-project and our work.
The NIHR’s Small Grants Programme in partnership with the Royal Society for Tropical Medicine and Hygiene (RSTMH) offers early career researchers and global health professionals based anywhere in the world the opportunity to apply for funding in a topic related to tropical medicine and global health.
Dr. Judith Auma, Medical Officer Knowledge4change (K4C)
Find out more about the Global Health Research programme
The views and opinions expressed in this blog are those of the authors and do not necessarily reflect those of the NIHR or the Department of Health and Social Care.