January 13, 2009 The Pump Handle 0Comment

By Leslie Mancuso

Imagine being diagnosed with a preventable disease in a country where access to quality health care services is not available to you. Not because you live in a remote area or because people don’t care, but because the training was not available for the skilled healthcare providers treating you. 

Now imagine being an HIV positive woman in this country.  You may be getting sophisticated antiretroviral therapy, but suffer without knowing it from another disease that can kill you if left untreated: cervical cancer.

As a leader in international health, I see these women facing this situation far too often. Globally, 473,000 new cases and more than 250,000 deaths due to cervical cancer are reported each year. More than 85 percent of those cases occur in low-resource countries where fewer than 5 percent of women have ever had a Pap test. Women living with HIV are particularly vulnerable to infection by the human papillomavirus (HPV) that causes cervical cancer. The good news is that there are innovative, low-cost solutions to this problem.

According to a recent study in Clinical Infectious Diseases, “low and middle-resource countries, where women have been hit hardest by the AIDS epidemic, have historically also had a high prevalence of human papillomavirus (the virus that causes cervical cancer).” In HIV positive women, HPV develops faster and progresses more quickly to cancer. The problem is that these women are not usually screened for cervical cancer when they are in HIV/AIDS treatment programs. While we are literally saving the lives of women with HIV with antiretroviral therapy and other care services, they are at risk of dying from an easily preventable cancer.

Screening and treating women can prevent cervical cancer, and it doesn’t have to be expensive. For more than ten years, my organization has been working with low-resource countries around the world to provide them with low-cost, effective solutions to help women get screened. One approach, known as VIA, uses vinegar and visual inspection to detect precancerous lesions on the cervix, and it can be followed by cryotherapy treatment to freeze any identified lesions in the same visit. Evidence shows that this simple, low-cost approach can have an important impact in reducing mortality rates from cervical cancer.

Developing a cadre of competent and highly motivated health workers is essential for ensuring the successful implementation of a national cervical cancer prevention program. However, health systems in many low-resource settings are challenged by shortages, poor deployment and low retention of skilled health professionals, particularly specialists who traditionally have been trained for cervical cancer prevention and control.  For example, in a country of about 13.5 million, Malawi has a small number of obstetricians-gynecologists who are based largely in its major urban centers. Pathologists who can read pap smears are even more rare. Task shifting is an approach that has been used to successfully address some of the human resource challenges. Specific tasks are moved where appropriate, from expert health workers to health workers with shorter training and less expertise, in order to make more efficient use of the available human resources for health.
Jhpiego has demonstrated in Thailand and Ghana that mid-level providers such as nurses, midwives, and health officers can provide screening using VIA and treatment with cryotherapy, and maintain a high level of competence and performance. This eases the burden on the limited number of physicians, and allows for successful scale-up of screening activities. The combination of a practical screen and treat approach coupled with task shifting has provided Thailand the means to reach close to 400,000 women since the program was started in 2000.

January is Cervical Cancer Awareness Month. As we pause this month to commemorate women suffering from cervical cancer, we recognize that it is an international health challenge that affects all of us. Our goal should be to keep women around the world healthy and productive-not just for their families, but for their countries.  It takes an integrated approach to women’s health to do this, including the testing and treating women for cervical cancer as well as HIV.  We can save women’s lives today.


Leslie Mancuso, PhD, RN, FAAN is the President and CEO of Jhpiego, an international non-profit health organization affiliated with Johns Hopkins University that works to break down barriers to high-quality health care for the world’s most vulnerable populations.

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