A briefing note on cervical cancer screening practices in the Gwassi Division, Suba District, Nyanza Province, Kenya. Includes WHO guidelines, a pilot study in a neighboring region and interview and survey data from the community.

1. Cervical Cancer Screening (CCS)
in the Gwassi Division
A Briefing Note on Current Practices in the Region

2. Why is Cervical Cancer Screening
Important?
¤ Cervical cancer is the second most common type of
cancer among women, and was responsible for over
250,000 deaths in 2005, approximately 80% of which
occurred in developing countries.
¤ Without urgent action, deaths due to cervical cancer are
projected to rise by almost 25% over the next 10 years in
developing countries.
WHO. Comprehensive cervical cancer control: a guide to essential practice. www.who.int.
http://whqlibdoc.who.int/publications/2006/9241547006_eng.pdf. Published 2006

3. Why is Cervical Cancer Screening
Important?
¤ Cervical cancer and HIV infection represent synergistic
threats to women’s reproductive health and mortality.
¤ HIV infection increases the women’s risk of HPV infection,
cervical neoplasia and invasive cervical cancer.
¤ In Kenya, cervical cancer is the most common cancer
diagnosed among women and the most common cause
of cancer-related death
Palefsky J. Human papillomavirus-related disease in people with HIV. Curr Opin HIV AIDS.
2009;4(1):52–56.

4. Why is Cervical Cancer Screening
Important?
¤ From the time that cancer precursors (mild dysplasia) are
identified, it usually takes 10 to 20 years for invasive
cancer to develop.
¤ Cervical cancer control is possible through screening
and treatment.

5. Impact for the Community
¤ The Nyanza province is the region hardest hit by HIV within
Kenya, with infection rates ranging from 14% to 40% in
different districts. Estimates in Gwassi are around 22%.
¤ Additionally, women were more likely to be HIV infected
than men. In particular, young women aged 15-24 years
were four times more likely to be infected than young men
in the same age group, according to the 2007 Kenya AIDS
Indicator Survey.
¤ The wide availability of HIV care centers and ARV therapy in
the division is expected to increase the lifespan of women
living with HIV, but also to increase the lifetime risk of
developing cervical cancer.

6. WHO Guidelines for Developing
Countries
From the WHO Publication: Comprehensive Cervical Cancer
Control: a guide to essential practice

7. Recommended target ages of CCS
¤ New programmes should start screening women
aged 30 years or more, and include younger
women only when the highest-risk group has been
covered.
¤ Existing organized programmes should not include
women less than 25 years of age in their target
populations.
¤ If a woman can be screened only once in her
lifetime, the best age is between 35 and 45 years.

8. Factors for Screening Success
¤ High coverage (80%) of the population at risk
¤ Appropriate follow-up and management for those who
are positive on screening.
¤ Effective links between program components (e.g. from
screening to diagnosis and treatment)
¤ High quality of coverage, screening tests, diagnosis,
treatment, and follow-up
¤ Adequate resources

9. Screening Methods for Low Resource
Settings
¤ Cytology based programs can be difficult to implement
in low-resource setting, due to inherent requirements:
¤ highly trained personnel
¤ well equipped laboratories
¤ transport of specimens
¤ an effective system for collecting information and following
up patients
¤ Visual inspection methods show promise for replicating
the success of cytology-based programs but have not
been demonstrated in large scale studies.

10. Visual Screening Methods for Low
Resource Settings
¤ Two visual methods are available:
¤ visual inspection with acetic acid (VIA)
¤ visual inspection with Lugol’s iodine (VILI)
¤ Abnormalities are identified by inspection of the cervix
without magnification, after application of dilute acetic
acid (vinegar) (in VIA) or Lugol’s iodine (in VILI).
¤ Results are immediate and there is no reliance of
laboratory testing.

11. Evidence for the use of Visual
Screening Methods
¤ VIA and VILI are recommended by WHO only for use in pilot
settings, because the impact on cervical cancer incidence and
mortality is still unproven.
¤ In research settings, VIA has been shown to have an average
sensitivity for detection of precancer and cancer of almost 77%,
and a range of 56% to 94%. The specificity ranges from 74% to 94%
with an average of 86%.
¤ One study has shown that VILI can detect 92% of women with
precancer or cancer, a sensitivity considerably higher than that of
either VIA or cytology. Its ability to identify women without disease is
similar to that of VIA (85%), and lower than that of Pap smears.
¤ One study showed that VILI had a higher reproducibility than VIA.

12. Advantages and Disadvantages of
Visual Screening Methods
Advantages
¤ Relatively simple and can be
taught to nurses, nurse-midwives
and other health workers.
¤ Assessment is immediate. No
transport, laboratory equipment
or personnel, is needed.
¤ Likely to be less costly than other
approaches in routine use.
¤ Results are available
immediately, reducing loss to
follow-up.
Disadvantages
¤ Low positive predictive value of
the test increases the number of
women who test positive do not
have disease.
¤ Cannot be relied on in
postmenopausal women.
¤ No permanent record of the test
that can be reviewed later
¤ VIA has mostly been evaluated
as a once-in-a-lifetime screening
test, its performance in periodic
screening has not been assessed

13. Standard practice for diagnosis:
colposcopy and biopsy
¤ Biopsy performed with the aid of a colposcope is the
standard method for diagnosis of cervical precancer
and preclinical invasive cancer.
¤ Barriers to colposcopy and biopsy services
¤ Colposcopes are sophisticated, relatively expensive
instruments.
¤ Specialized training and experience are required to
maintain proficiency.
¤ Biopsy samples need to be transported to a histopathology
service, which may be difficult in low-resource settings.

14. Treatment Options for Precancer
¤ Precancer should be treated on an outpatient basis
whenever possible.
¤ Both cryotherapy and LEEP (loop electrosurgical excision
procedure) may be suitable for this purpose, depending
on eligibility criteria and available resources.

15. Advantages and Disadvantages of
Cryotherapy
Advantages
¤ High cure rate for small lesions
¤ Equipment simple and
relatively inexpensive, training
takes a few days
¤ Can be performed as an
outpatient procedure
¤ Fast
¤ Anesthesia not required
¤ Electricity not required
Disadvantages
¤ Less effective for larger lesions
(cure rates < 80% at one year)
¤ No tissue sample available for
histological examination
¤ Needs continuous supply of
carbon dioxide or nitrous oxide
¤ Causes prolonged and
profuse watery discharge

16. Advantages and Disadvantages of
LEEP
Advantages
¤ High cure rate
¤ Reliable histology specimen
obtained,
¤ Few complications
¤ Can be performed on an
outpatient basis at a
secondary level facility
¤ Fast and technically simple to
perform
Disadvantages
¤ Requires intensive training
¤ Postoperative bleeding in less
than 2% of treated women
¤ More sophisticated equipment
needed
¤ Requires electricity
¤ Requires local anesthesia

17. A Case Study of a Pilot Cervical
Cancer Screening Program
(initiated by FACES in the Nyanza province)
Huchko, M., Bukusi, E. and Cohen C., Building capacity for cervical cancer screening in outpatient HIV
clinics in the Nyanza province of western Kenya. Int J Gynaecol Obstet . 2011 August ; 114(2): 106–110.

18. Introduction
¤ Family AIDS Care and Education Services (FACES) is an
NGO providing HIV care and treatment in the Nyanza
province of Kenya.
¤ FACES developed a pilot program in Lumumba Hospital
in Kisumu, where they had a long established HIV care
program.
¤ The pilot study was conducted over three years, and
3,642 women underwent screening.
¤ Screening was offered as part of comprehensive HIV
care to all non-pregnant women aged over 25 years.

19. Screening Protocol
¤ The clinical protocol was developed on the basis of
recommendations from the WHO’s Comprehensive Guide to
Cervical Cancer Control for resource-limited settings, coupled with
relevant evidence from recent clinical trials.
¤ The protocol uses visual inspection with 3–5% acetic acid (VIA) as a
screening test, followed by colposcopy and biopsy to confirm
cervical intraepithelial neoplasia.
¤ Women with biopsy-proven CIN2/3 are offered treatment via loop
electrosurgical excision procedure (LEEP), performed by clinical
officers on-site.
¤ LEEP was chosen for treatment because it has has significantly
better outcomes in HIV-infected women than cryotherapy

20. FACESPilotProgramFlow

21. Training
¤ Clinical officers were provided specific training for competency in
VIA and colposcopy. For both techniques, training includes a week
of daily, 90-minute didactic sessions at the start or end of the
clinical day. A short test assesses their retention and understanding.
¤ The didactic training is followed by a predetermined number of
observed VIA and colposcopic examinations.
¤ The screening protocol relies on a confirmatory biopsy for treatment
decisions.
¤ To facilitate histology interpretation and tracking of results, a local
pathologist trained the laboratory staff in specimen processing.
¤ Pathology specimens are sent weekly to Nairobi, and the results are sent
back via email

22. Results from the Pilot Program
¤ During the 3-year pilot (2007-2010):
¤ 3642 women were screened for cervical neoplasia with VIA
(87% of the 4186 women offered screening).
¤ 531 (15%) underwent colposcopy for either positive or
unsatisfactory VIA.
¤ CIN2/3 was diagnosed and confirmed histologically in 259
women (7.1%)
¤ 243 LEEPs were performed, with no serious adverse events
requiring treatment or referral.
¤ Eight women (0.1%) were diagnosed with invasive cancer.

23. Future of the Pilot Program
¤ This program was funded through a seed grant, and
therefore depends heavily on the existing infrastructure of
the HIV clinic.
¤ Universal access to cervical cancer screening will require
programs that can be scaled up to more remote areas that
have even fewer resources and lower levels of staffing.
¤ Sustainability will depend on the validation of low-cost
screening tests among HIV-infected women to determine
whether the time, expense, and infrastructure requirements
of colposcopy can be removed, and screening can be
paired with same-day treatment to reach more remote sites.

24. Current Practices in Gwassi Division
As of July|August 2013

25. Facilities offering CCS
¤ There are currently three facilities offering CCS in the Gwassi
division:
¤ Nyandiwa Dispensary
¤ Magunga Health Center
¤ Kisegi Sub-District Hospital
¤ All programs are supported by FACES
¤ Only VIA screening is offered. Colposcopy is referred to the
district hospital in Sindo.
¤ In most cases, CCS is the only time a woman will have
undergone a gynecological examination, as a result, health
workers report some discomfort among older women (40
and above), but see immediate uptake among younger
women (20-30)

26. Nyandiwa Dispensary
¤ Nyandiwa initiated their screening program in July 2012
¤ In 2012 (July –December), 131 women were screened
¤ In 2013 (January -July), 42 women were screened
¤ During the life of the program, 9 women had positive results
and were referred to the district hospital in Sindo for
colposcopy.
¤ Nyandiwa does not screen on a fixed schedule, but offers
screening on demand. They do not push the service due to
heavy workload, but perform when requested.

27. Magunga Health Centre
¤ Magunga initiated their screening program in June 2012
¤ In 2012 (June – December), 95 women were screened
¤ In 2013 (January -July), 25 women were screened
¤ Screening is offered two days per week
¤ Since initiation, no positive findings have been reported
¤ Due to the heavy workload, the staff report difficulty
accommodating screening on demand.

28. Kisegi Sub-District Hospital
¤ Kisegi initiated their screening program in July 2012
¤ In 2012 (July – December), 71 women were screened
¤ In 2013 (January -July), 47 women were screened
¤ Screening is recommended on Fridays, but also performed
on demand
¤ Since initiation, one positive finding has been reported
¤ There is only one female staff trained in CCS which increase
demand on days she is in the facility. Women state a strong
preference for a female health worker.

29. Responses from Community Health
Survey regarding CCS
¤ A community health survey was conducted over two days in
Nyandiwa.
¤ Participants were asked questions about their health, their
health seeking behavior and attitudes and thoughts on the
status of health in the community.
¤ The questionnaire was response guided, women were asked
questions to gauge awareness of CCS programs, their
purpose, and their participation.
¤ The survey was conducted in English which biases the
literacy and educational levels of the sample.
¤ The following data reflects the responses of 28 women.

30. Demographic Information
Age and Marital Status
0
2
4
6
8
10
12
15-19 20-24 25-29 30-34 35-39 Over 40
NumberofRespondents
Age Bracket
Single Married (monogamous) Married (Polygamous)

31. Demographic Information
HIV Status
82%
14%
4%
HIV Status
HIV -
HIV +
Prefer Not to State

32. Demographic Information
Childbearing and Level of Education
50%50%
Have Children
Yes No
25% 29%
46%
0%
10%
20%
30%
40%
50%
Level of Education

33. General CCS Awareness
57%
43%
Have you heard about Cervical Cancer
Screening?
Yes
No

34. Perceptions of Cervical Cancer
¤ Selected responses from the question: “What do you
know about Cervical Cancer?”
¤ “it is brought about by the males”
¤ “it is a dangerous disease” (3 respondents)
¤ “it leads to barrenness”
¤ “there is no cure, it leads to death”
¤ “it can be treated/cured” (3 respondents)
¤ “nothing” (3 respondents)

35. Screening Prevalence
21%
79%
Have You Ever Been Screened?
Yes
No

36. Frequency and Recency of CCS
0
1
2
3
4
5
Within the last
6 months
Within the last
year
How long ago were
you screened?
0
1
2
3
4
5
One Time More than One
Time
How many times have
you been screened?
No women who had been screened reported any positive findings.

37. Stated Reasons for Not Having Been
Screened
¤ For women who had heard about cervical cancer
screening, but had not been screened, they were then
asked “Why have you not been screened?”
¤ Selected responses:
¤ “never had any problems” (2 responses)
¤ “never been to the clinic/where the screening takes
place” (2 responses)
¤ “because screening is done by a male health worker”
¤ “have never been offered” (2 responses)
¤ “lack of money”

38. Level of Interest Among Unscreened
82%
14%
4%
If screening was offered,
would you be interested?
Yes
No
Maybe
¤ Reasons given for negative
responses:
¤ “I might die”
¤ “No reason”
¤ “If you thought there
were no problems, then
you wouldn’t be
screened”
¤ “I don’t like to be
screened”