Browsing by Author "Kapambwe S"

Now showing 1 - 18 of 18

Advancing cervical cancer prevention initiatives in resource-constrained settings: insights from the Cervical Cancer Prevention Program in Zambia.
(2011-May) Mwanahamuntu MH; Sahasrabuddhe VV; Kapambwe S; Pfaendler KS; Chibwesha C; Mkumba G; Mudenda V; Hicks ML; Vermund SH; Stringer JS; Parham GP; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Groesbeck Parham and colleagues describe their Cervical Cancer Prevention Program in Zambia, which has provided services to over 58,000 women over the past five years, and share lessons learned from the program's implementation and integration with existing HIV/AIDS programs.
Assessing capacity and readiness to manage NCDs in primary care setting: Gaps and opportunities based on adapted WHO PEN tool in Zambia.
(2018) Mutale W; Bosomprah S; Shankalala P; Mweemba O; Chilengi R; Kapambwe S; Chishimba C; Mukanu M; Chibutu D; Heimburger D; University of Zambia, School of Public Health, Lusaka, Zambia.; Department of Biostatistics, School of Public Health, University of Ghana, Legon, Accra, Ghana.; Ministry of Health, Lusaka, Zambia.; Vanderbilt University, Nashville, Tennessee, United States of America.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
INTRODUCTION: Sub-Saharan Africa is experiencing an epidemiological transition as the burden of NCDs overtake communicable diseases. However, it is unknown what capacity and gaps exist at primary care level to address the growing burden of NCDs. This study aimed to assess the Zambian health system's capacity to address in NCDs, using an adapted WHO Essential Non Communicable Disease Interventions (WHO PEN) tool. METHODOLOGY: This was a cross-sectional facility survey in the three districts conducted from September 2017 to October 2017. We defined facility readiness along five domains: basic equipment, essential services, diagnostic capacity, counseling services, and essential medicines. For each domain, we calculated an index as the mean score of items expressed as percentage. These indices were compared to an agreed cutoff at 70%, meaning that a facility index or district index below 70% off was considered as 'not ready' to manage NCDs at that level. All analysis were performed using Stata 15 MP. RESULTS: There appeared to be wide heterogeneity between facilities in respect of readiness to manage NCDs. Only 6 (including the three 1st level hospitals) out of the 46 facilities were deemed ready to manage NCDs. Only the first level hospitals scored a mean index higher than the 70% cut off; With regard to medications needed to manage NCDs, urban and rural health facilities were comparably equipped. However, there was evidence that calcium channel blockers (p = 0.013) and insulin (p = 0.022) were more likely to be available in urban and semi-urban health facilities compared to rural facilities. CONCLUSION: Our study revealed gaps in primary health care capacity to manage NCDs in Zambia, with almost all health facilities failing to reach the minimum threshold. These results could be generalized to other similar districts in Zambia and the sub-region, where health systems remain focused on infectious rather than non-communicable Disease. These results should attract policy attention and potentially form the basis to review current approach to NCD care at the primary care level in Zambia and Sub-Saharan Africa.
Cervical cancer screening outcomes in Zambia, 2010-19: a cohort study.
(2021-Jun) Pry JM; Manasyan A; Kapambwe S; Taghavi K; Duran-Frigola M; Mwanahamuntu M; Sikazwe I; Matambo J; Mubita J; Lishimpi K; Malama K; Bolton Moore C; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Department of Internal Medicine, School of Medicine, Washington University, St Louis, MO, USA. Electronic address: jakepry@cidrz.org.; Ministry of Health, Lusaka, Zambia; University Teaching Hospital, Women and Newborn Hospital, Lusaka, Zambia.; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; The Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.; Ministry of Health, Lusaka, Zambia.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Joint IRB-BSC-CRG Program in Computational Biology, Institute for Research in Biomedicine, The Barcelona Institute of Science and Technology, Barcelona, Spain; Ersilia Open Source, Cambridge, UK.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: Globally, cervical cancer is the fourth leading cause of cancer-related death among women. Poor uptake of screening services contributes to the high mortality. We aimed to examine screening frequency, predictors of screening results, and patterns of sensitisation strategies by age group in a large, programmatic cohort. METHODS: We did a cohort study including 11 government health facilities in Lusaka, Zambia, in which we reviewed routine programmatic data collected through the Cervical Cancer Prevention Program in Zambia (CCPPZ). Participants who underwent cervical cancer screening in one of the participating study sites were considered for study inclusion if they had a screening result. Follow-up was accomplished per national guidelines. We did descriptive analyses and mixed-effects logistic regression for cervical cancer screening results allowing random effects at the individual and clinic level. FINDINGS: Between Jan 1, 2010, and July 31, 2019, we included 183 165 women with 204 225 results for visual inspection with acetic acid and digital cervicography (VIAC) in the analysis. Of all those screened, 21 326 (10·4%) were VIAC-positive, of whom 16 244 (76·2%) received treatment. Of 204 225 screenings, 92 838 (45·5%) were in women who were HIV-negative, 76 607 (37·5%) were in women who were HIV-positive, and 34 780 (17·0%) had an unknown HIV status. Screening frequency increased 65·7% between 2010 and 2019 with most appointments being first-time screenings (n=158 940 [77·8%]). Women with HIV were more likely to test VIAC-positive than women who were HIV-negative (adjusted odds ratio 3·60, 95% CI 2·14-6·08). Younger women (≤29 years) with HIV had the highest predictive probability (18·6%, 95% CI 14·2-22·9) of screening positive. INTERPRETATION: CCPPZ has effectively increased women's engagement in screening since its inception in 2006. Customised sensitisation strategies relevant to different age groups could increase uptake and adherence to screening. The high proportion of screen positivity in women younger than 20 years with HIV requires further consideration. Our data are not able to discern if women with HIV have earlier disease onset or whether this difference reflects misclassification of disease in an age group with a higher sexually transmitted infection prevalence. These data inform scale-up efforts required to achieve WHO elimination targets. FUNDING: US President's Emergency Plan for AIDS Relief.
Clinical performance of digital cervicography and cytology for cervical cancer screening in HIV-infected women in Lusaka, Zambia.
(2014-Oct-01) Bateman AC; Parham GP; Sahasrabuddhe VV; Mwanahamuntu MH; Kapambwe S; Katundu K; Nkole T; Mulundika J; Pfaendler KS; Hicks ML; Shibemba A; Vermund SH; Stringer JS; Chibwesha CJ; *Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; †University of North Carolina at Chapel Hill, Chapel Hill, NC; ‡University Teaching Hospital, Lusaka, Zambia; §Vanderbilt University, Nashville, TN; ‖University of Cincinnati, Cincinnati, OH; and ¶Michigan Cancer Institute, Pontiac, MI.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Although there is a growing literature on the clinical performance of visual inspection with acetic acid in HIV-infected women, to the best of our knowledge, none have studied visual inspection with acetic acid enhanced by digital cervicography. We estimated clinical performance of cervicography and cytology to detect cervical intraepithelial neoplasia grade 2 or worse. Sensitivity and specificity of cervicography were 84% [95% confidence interval (CI): 72 to 91) and 58% (95% CI: 52 to 64). At the high-grade squamous intraepithelial lesion or worse cutoff for cytology, sensitivity and specificity were 61% (95% CI: 48 to 72) and 58% (95% CI: 52 to 64). In our study, cervicography seems to be as good as cytology in HIV-infected women.
Death, contagion and shame: The potential of cancer survivors' advocacy in Zambia.
(2018-May) Wigginton B; Farmer K; Kapambwe S; Fitzgerald L; Reeves MM; Lawler SP; a The University of Queensland, School of Public Health , Brisbane , Queensland , Australia.; b Ministry of Health, The Centre for Infectious Disease Research in Zambia , Lusaka , Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Cancer has become a global health concern with marked differences in the incidence and mortality rates between developing and developed countries. Understanding the factors that shape uptake of preventative and screening services is the key. We use in-depth interviews with 13 Zambian urban-based female cancer survivors to explore the facilitators and barriers to screening, diagnosis and treatment, with a particular focus on cultural influences. We identified a central theme (i.e. a story told about cancer) in all of the interviews: 'cancer is a death sentence'. Most women referenced this theme to describe their own, their family members', or community members' reactions to their diagnosis, along with references to cancer as 'contagious' and 'a shameful illness'. We also identified a theme entitled 'survivors as advocates', within which women described engaging in advocacy work to challenge stigma, misconceptions and misinformation about cancer; and advocating early detection and diagnosis, compliance with medical treatment and the sharing of success stories. This analysis points to the need for survivors to be front and center of preventative efforts. Their personal experiences, legitimacy and connections in the community, and their enthusiasm in helping others should be fostered, particularly in low-resource settings.
eC3--a modern telecommunications matrix for cervical cancer prevention in Zambia.
(2010-Jul) Parham GP; Mwanahamuntu MH; Pfaendler KS; Sahasrabuddhe VV; Myung D; Mkumba G; Kapambwe S; Mwanza B; Chibwesha C; Hicks ML; Stringer JS; Center for Infectious Disease Research in Zambia, Lusaka, Zambia. groesbeck.parham@cidrz.org; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
OBJECTIVES: Low physician density, undercapacitated laboratory infrastructures, and limited resources are major limitations to the development and implementation of widely accessible cervical cancer prevention programs in sub-Saharan Africa. MATERIALS AND METHODS: We developed a system operated by nonphysician health providers that used widely available and affordable communication technology to create locally adaptable and sustainable public sector cervical cancer prevention program in Zambia, one of the world's poorest countries. RESULTS: Nurses were trained to perform visual inspection with acetic acid aided by digital cervicography using predefined criteria. Electronic digital images (cervigrams) were reviewed with patients, and distance consultation was sought as necessary. Same-visit cryotherapy or referral for further evaluation by a gynecologist was offered. The Zambian system of "electronic cervical cancer control" bypasses many of the historic barriers to the delivery of preventive health care to women in low-resource environments while facilitating monitoring, evaluation, and continued education of primary health care providers, patient education, and medical records documentation. CONCLUSIONS: The electronic cervical cancer control system uses appropriate technology to bridge the gap between screening and diagnosis, thereby facilitating the conduct of "screen-and-treat" programs. The inherent flexibility of the system lends itself to the integration with future infrastructures using rapid molecular human papillomavirus-based screening approaches and wireless telemedicine communications.
Implementation and Operational Research: Age Distribution and Determinants of Invasive Cervical Cancer in a "Screen-and-Treat" Program Integrated With HIV/AIDS Care in Zambia.
(2015-Sep-01) Kapambwe S; Sahasrabuddhe VV; Blevins M; Mwanahamuntu MH; Mudenda V; Shepherd BE; Chibwesha CJ; Pfaendler KS; Hicks ML; Vermund SH; Stringer JS; Parham GP; *Center for Infectious Disease Research in Zambia, Lusaka, Zambia; †University of Zambia, Lusaka, Zambia; ‡Vanderbilt University, Nashville, TN; §University of North Carolina at Chapel Hill, Chapel Hill, NC; ‖University of Cincinnati, Cincinnati, OH; ¶Michigan Cancer Institute, Pontiac, MI.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: Cervical cancer screening efforts linked to HIV/AIDS care programs are being expanded across sub-Saharan Africa. Evidence on the age distribution and determinants of invasive cervical cancer (ICC) cases detected in such programs is limited. METHODS: We analyzed program operations data from the Cervical Cancer Prevention Program in Zambia, the largest public sector programs of its kind in sub-Saharan Africa. We examined age distribution patterns by HIV serostatus of histologically confirmed ICC cases and used multivariable logistic regression to evaluate independent risk factors for ICC among younger (≤35 years) and older (>35 years) women. RESULTS: Between January 2006 and April 2010, of 48,626 women undergoing screening, 571 (1.2%) were diagnosed with ICC, including 262 (46%) HIV seropositive (median age: 35 years), 131 (23%) HIV seronegative (median age: 40 years), and 178 (31%) of unknown HIV serostatus (median age: 38 years). Among younger (≤35 years) women, being HIV seropositive was associated with a 4-fold higher risk of ICC [adjusted odds ratio = 4.1 (95% confidence interval: 2.8, 5.9)] than being HIV seronegative. The risk of ICC increased with increasing age among HIV-seronegative women and women with unknown HIV serostatus, but among HIV-seropositive women, the risk peaked around age 35 and nonsignificantly declined with increasing ages. Other factors related to ICC included being married (vs. being unmarried/widowed) in both younger and older women, and with having 2+ (vs. ≤1) lifetime sexual partners among younger women. CONCLUSIONS: HIV infection seems to have increased the risk of cervical cancer among younger women in Zambia, pointing to the urgent need for expanding targeted screening interventions.
Implementation of cervical cancer prevention services for HIV-infected women in Zambia: measuring program effectiveness.
(2010) Parham GP; Mwanahamuntu MH; Sahasrabuddhe VV; Westfall AO; King KE; Chibwesha C; Pfaendler KS; Mkumba G; Mudenda V; Kapambwe S; Vermund SH; Hicks ML; Stringer JS; Chi BH; University of Cincinnati, OH, USA.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia ; University Teaching Hospital, Lusaka, Zambia.; University of Alabama at Birmingham, AL, USA ; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia ; University Teaching Hospital, Lusaka, Zambia.; Vanderbilt University, TN, USA.; Michigan Cancer Institute, MI, USA.; University of Michigan, MI, USA.; University Teaching Hospital, Lusaka, Zambia.; University of Alabama at Birmingham, AL, USA ; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Vanderbilt University, TN, USA ; National Cancer Institute, MD, USA.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: Cervical cancer kills more women in low-income nations than any other malignancy. A variety of research and demonstration efforts have proven the efficacy and effectiveness of low-cost cervical cancer prevention methods but none in routine program implementation settings of the developing world, particularly in HIV-infected women. METHODS: In our public sector cervical cancer prevention program in Zambia, nurses conduct screening using visual inspection with acetic acid aided by digital cervicography. Women with visible lesions are offered same-visit cryotherapy or referred for histologic evaluation and clinical management. We analyzed clinical outcomes and modeled program effectiveness among HIV-infected women by estimating the total number of cervical cancer deaths prevented through screening and treatment. RESULTS: Between 2006 and 2008, 6572 HIV-infected women were screened, 53.6% (3523) had visible lesions, 58.5% (2062) were eligible for cryotherapy and 41.5% (1461) were referred for histologic evaluation. A total of 75% (1095 out of 1462) of patients who were referred for evaluation complied. Pathology results from 65% (715 out of 1095) of women revealed benign abnormalities in 21% (151), cervical intraepithelial neoplasia (CIN) I in 30% (214), CIN 2/3 in 33% (235) and invasive cervical cancer in 16.1% (115, of which 69% were early stage). Using a conditional probability model, we estimated that our program prevented 142 cervical cancer deaths (high/low range: 238-96) among the 6572 HIV-infected women screened, or one cervical cancer death prevented per 46 (corresponding range: 28-68) HIV-infected women screened. CONCLUSION: Our prevention efforts using setting-appropriate human resources and technology have reduced morbidity and mortality from cervical cancer among HIV-infected women in Zambia. Financial support for implementing cervical cancer prevention programs integrated within HIV/AIDS care programs is warranted. Our prevention model can serve as the implementation platform for future low-cost HPV-based screening methods, and our results may provide the basis for comparison of programmatic effectiveness of future prevention efforts.
Innovative approaches to promoting cervical health and raising cervical cancer awareness by use of existing cultural structures in resource-limited countries: experiences with traditional marriage counseling in Zambia.
(2013-Dec) Kapambwe S; Parham G; Mwanahamuntu M; Chirwa S; Mwanza J; Amuyunzu-Nyamongo M; 1.Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
The Cervical Cancer Prevention Program in Zambia (CCPPZ) has increasingly used community-level structures to increase the uptake and ensure the sustainability of the program. Traditional marriage counselors, the alangizi, who have existed in the Zambian society for many years, are one of the structures used by the program to impart cervical cancer knowledge and increase access to screening and care using an existing community structure. Several steps were followed in developing this intervention: (a) ensuring the alangizi understood the process of screening by encouraging them to go through the screening process; (b) workshops were arranged for the alangizi to meet and share experiences during which lessons were given on cervical cancer by health workers as well; and (c) eight alangizi were chosen to help document the lessons as part of ensuring that cervical cancer information is accurate and passed in a consistent manner. Over 70 alangizi, who had undergone cervical cancer screening, were trained by CCPPZ. A 'Cervical Cancer Training Manual for Marriage Counsellors' was developed to help the alangizi integrate cervical cancer lessons in their routine teachings. An evaluation was conducted during the training of the alangizi that forms the basis for this paper. The results show that although the alangizi face key challenges in their work (e.g. changing social contexts), they are still considered relevant by most communities in Zambia and are potentially an important avenue for cervical cancer and other health information. This paper shows that it is possible to integrate sexual and reproductive health messages into existing structures in the community. However, it is important to design culturally specific and sensitive healthcare strategies that embrace locally accepted good practices.
Managing multiple funding streams and agendas to achieve local and global health and research objectives: lessons from the field.
(2014-Jan-01) Holmes CB; Sikazwe I; Raelly RL; Freeman BL; Wambulawae I; Silwizya G; Topp SM; Chilengi R; Henostroza G; Kapambwe S; Simbeye D; Sibajene S; Chi H; Godfrey K; Chi B; Moore CB; *Centre for Infectious Disease Research in Zambia; †School of Medicine, University of North Carolina, Chapel Hill, NC; ‡School of Medicine, University of Alabama, Birmingham, AL; and §Division of Acquired Immunodeficiency Syndrome, National Institutes of Allergy and Infectious Diseases.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Multiple funding sources provide research and program implementation organizations a broader base of funding and facilitate synergy, but also entail challenges that include varying stakeholder expectations, unaligned grant cycles, and highly variable reporting requirements. Strong governance and strategic planning are essential to ensure alignment of goals and agendas. Systems to track budgets and outputs, as well as procurement and human resources are required. A major goal of funders is to transition leadership and operations to local ownership. This article details successful approaches used by the newly independent nongovernmental organization, the Centre for Infectious Disease Research in Zambia.
Monitoring the performance of "screen-and-treat" cervical cancer prevention programs.
(2014-Jul) Mwanahamuntu MH; Sahasrabuddhe VV; Blevins M; Kapambwe S; Shepherd BE; Chibwesha C; Pfaendler KS; Mkumba G; Vwalika B; Hicks ML; Vermund SH; Stringer JSA; Parham GP; Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, USA.; Center for Infectious Disease Research in Zambia, Lusaka, Zambia.; Michigan Cancer Institute, Pontiac, USA.; Department of Obstetrics and Gynecology, University Teaching Hospital, Lusaka, Zambia.; Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, USA.; Department of Medicine, Vanderbilt University School of Medicine, Nashville, USA.; Department of Obstetrics and Gynecology, University of Cincinnati, Cincinnati, USA.; Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, USA.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Myths and misconceptions about cervical cancer among Zambian women: rapid assessment by peer educators.
(2010-Jun) Chirwa S; Mwanahamuntu M; Kapambwe S; Mkumba G; Stringer J; Sahasrabuddhe V; Pfaendler K; Parham G; Center for Infectious Disease Research in Zambia, Plot 5977 Benekale Road, Northmead, Lusaka, Zambia. groesbeck.parham@cidrz.org; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
OBJECTIVE: To make a rapid assessment of the common myths and misconceptions surrounding the causes of cervical cancer and lack of screening among unscreened low-income Zambian women. METHODS: We initiated a door-to-door community-based initiative, led by peer educators, to inform unscreened women about the existence of a new see-and-treat cervical cancer prevention program. During home visits peer educators posed the following two questions to women: 1. What do you think causes cervical cancer? 2. Why haven't you been screened for cervical cancer? The most frequent types of responses gathered in this exercise were analyzed thematically. RESULTS: Peer educators contacted over 1100 unscreened women over a period of two months. Their median age was 33 years, a large majority (58%) were not educated beyond primary school, over two-thirds (71%) did not have monthly incomes over 500,000 Zambian Kwacha (US$100) per month, and just over half (51%) were married and cohabiting with their spouses. Approximately 75% of the women engaged in discussions had heard of cervical cancer and had heard of the new cervical cancer prevention program in the local clinic. The responses of unscreened low-income Zambian women to questions posed by peer educators in urban Lusaka reflect the variety of prevalent 'folk' myths and misconceptions surrounding cervical cancer and its prevention methods. CONCLUSION: The information in our rapid assessment can serve as a basis for developing future educational and intervention campaigns for improving uptake of cervical cancer prevention services in Zambia. It also speaks to the necessity of ensuring that programs addressing women's reproductive health take into account societal inputs at the time they are being developed and implemented. Taking a community-based participatory approach to program development and implementation will help ensure sustainability and impact.
Partnering with traditional Chiefs to expand access to cervical cancer prevention services in rural Zambia.
(2019-Mar) Kapambwe S; Mwanahamuntu M; Pinder LF; Chisele S; Chirwa SC; Parham GP; Ministry of Health, Republic of Zambia, Lusaka, Zambia.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Department of Obstetrics and Gynecology, Women and Newborn Hospital, Lusaka, Zambia.; Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
OBJECTIVE: To evaluate how the influence of traditional Chiefs can be leveraged to promote access to cervical cancer prevention services in rural Zambia. METHODS: A retrospective review of outcome data was conducted for all screening outreach events that occurred in Zambian Chiefdoms between October 4, 2015, and October 3, 2016. Members of the health promotion team of the Cervical Cancer Prevention Program in Zambia visited local Chiefs to inform them of the importance of cervical cancer prevention. The local Chiefs then summoned adults living within their Chiefdoms to assemble for cervical cancer prevention health talks. Screen-and-treat services were implemented within each of the Chiefdoms over a 1-week period. RESULTS: VIA-enhanced digital imaging of the cervix (digital cervicography) was offered to 8399 women in ten Chiefdoms as part of a village-based screening (VBS) program. In all, 419 (4.9%) women had positive screening test results. Of these women, 276 (65.8%) were treated immediately with thermocoagulation and 143 (34.1%) were referred to provincial government hospitals to undergo either the loop electrosurgical excision procedure/large loop excision of the transformation zone (n=109, 26.0%) or punch biopsy (n=34, 8.1%). CONCLUSION: The influence of traditional Chiefs was leveraged to facilitate access to cervical cancer prevention services in rural Zambia.
Population-level scale-up of cervical cancer prevention services in a low-resource setting: development, implementation, and evaluation of the cervical cancer prevention program in Zambia.
(2015) Parham GP; Mwanahamuntu MH; Kapambwe S; Muwonge R; Bateman AC; Blevins M; Chibwesha CJ; Pfaendler KS; Mudenda V; Shibemba AL; Chisele S; Mkumba G; Vwalika B; Hicks ML; Vermund SH; Chi BH; Stringer JS; Sankaranarayanan R; Sahasrabuddhe VV; Center for Infectious Disease Research in Zambia, Lusaka, Zambia; University of California, Irvine, Irvine, California, United States of America.; Center for Infectious Disease Research in Zambia, Lusaka, Zambia; University of Zambia, Lusaka, Zambia.; International Agency for Research on Cancer, Lyon, France.; Vanderbilt University, Nashville, Tennessee, United States of America; National Cancer Institute, Bethesda, Maryland, United States of America.; Center for Infectious Disease Research in Zambia, Lusaka, Zambia; University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.; Michigan Cancer Institute, Pontiac, Michigan, United States of America.; University of Zambia, Lusaka, Zambia.; Vanderbilt University, Nashville, Tennessee, United States of America.; Center for Infectious Disease Research in Zambia, Lusaka, Zambia; University of Zambia, Lusaka, Zambia; University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America; International Agency for Research on Cancer, Lyon, France.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: Very few efforts have been undertaken to scale-up low-cost approaches to cervical cancer prevention in low-resource countries. METHODS: In a public sector cervical cancer prevention program in Zambia, nurses provided visual-inspection with acetic acid (VIA) and cryotherapy in clinics co-housed with HIV/AIDS programs, and referred women with complex lesions for histopathologic evaluation. Low-cost technological adaptations were deployed for improving VIA detection, facilitating expert physician opinion, and ensuring quality assurance. Key process and outcome indicators were derived by analyzing electronic medical records to evaluate program expansion efforts. FINDINGS: Between 2006-2013, screening services were expanded from 2 to 12 clinics in Lusaka, the most-populous province in Zambia, through which 102,942 women were screened. The majority (71.7%) were in the target age-range of 25-49 years; 28% were HIV-positive. Out of 101,867 with evaluable data, 20,419 (20%) were VIA positive, of whom 11,508 (56.4%) were treated with cryotherapy, and 8,911 (43.6%) were referred for histopathologic evaluation. Most women (87%, 86,301 of 98,961 evaluable) received same-day services (including 5% undergoing same-visit cryotherapy and 82% screening VIA-negative). The proportion of women with cervical intraepithelial neoplasia grade 2 and worse (CIN2+) among those referred for histopathologic evaluation was 44.1% (1,735/3,938 with histopathology results). Detection rates for CIN2+ and invasive cervical cancer were 17 and 7 per 1,000 women screened, respectively. Women with HIV were more likely to screen positive, to be referred for histopathologic evaluation, and to have cervical precancer and cancer than HIV-negative women. INTERPRETATION: We creatively disrupted the 'no screening' status quo prevailing in Zambia and addressed the heavy burden of cervical disease among previously unscreened women by establishing and scaling-up public-sector screening and treatment services at a population level. Key determinants for successful expansion included leveraging HIV/AIDS program investments, and context-specific information technology applications for quality assurance and filling human resource gaps.
Scaling up proven innovative cervical cancer screening strategies: Challenges and opportunities in implementation at the population level in low- and lower-middle-income countries.
(2017-Jul) Holme F; Kapambwe S; Nessa A; Basu P; Murillo R; Jeronimo J; Centro Javeriano de Oncologia, Hospital Universitario San Ignacio, Bogota, Colombia.; PATH, Seattle, WA, USA.; Faculty of Medicine, Pontificia Universidad Javeriana, Bogota, Colombia.; International Agency for Research on Cancer, Lyon, France.; Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh.; Ministry of Health of Zambia and Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
The problem of cervical cancer in low- and lower-middle-income countries (LLMICs) is both urgent and important, and calls for governments to move beyond pilot testing to population-based screening approaches as quickly as possible. Experiences from Zambia, Bangladesh, Guatemala, Honduras, and Nicaragua, where scale-up of evidence-based screening strategies is taking place, may help other countries plan for large-scale implementation. These countries selected screening modalities recommended by the WHO that are within budgetary constraints, improve access for women, and reduce health system bottlenecks. In addition, some common elements such as political will and government investment have facilitated action in these diverse settings. There are several challenges for continued scale-up in these countries, including maintaining trained personnel, overcoming limited follow-up and treatment capacity, and implementing quality assurance measures. Countries considering scale-up should assess their readiness and conduct careful planning, taking into consideration potential obstacles. International organizations can catalyze action by helping governments overcome initial barriers to scale-up.
The burden of cervical pre-cancer and cancer in HIV positive women in Zambia: a modeling study.
(2015-Jul-24) Bateman AC; Katundu K; Mwanahamuntu MH; Kapambwe S; Sahasrabuddhe VV; Hicks ML; Chi BH; Stringer JS; Parham GP; Chibwesha CJ; University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. professorparham@gmail.com.; Michigan Cancer Institute, Pontiac, MI, USA. mrhicks2@comcast.net.; University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. Benjamin.Chi@cidrz.org.; University of Zambia, Lusaka, Zambia. mulindim@gmail.com.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. mulindim@gmail.com.; University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. Jeffrey_Stringer@med.unc.edu.; Vanderbilt University, Nashville, Tennessee, USA. vikrant.sahasrabuddhe@vanderbilt.edu.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. Katundu.Katundu@cidrz.org.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. sharon.kapambwe@cidrz.org.; University of Zambia, Lusaka, Zambia. professorparham@gmail.com.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. Carla.Chibwesha@cidrz.org.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. Benjamin.Chi@cidrz.org.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. bateman.allen@gmail.com.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. professorparham@gmail.com.; University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. bateman.allen@gmail.com.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: HIV infection is associated with a higher incidence of precancerous cervical lesions and their progression to invasive cervical cancer (ICC). Zambia is a global epicenter of HIV and ICC, yet the overall burden of cervical pre-cancer [cervical intraepithelial neoplasia 3 (CIN3)] and ICC among its HIV positive adult female population is unknown. The objective of this study was to determine the burden of cervical disease among HIV positive women in Zambia by estimating the number with CIN3 and ICC. METHODS: We conducted a cross-sectional study among 309 HIV positive women attending screening in Lusaka (Zambia's most populated province) to measure the cervical disease burden by visual inspection with acetic acid enhanced by digital cervicography (DC), cytology, and histology. We then used estimates of the prevalence of CIN3 and ICC from the cross-sectional study and Spectrum model-based estimates for HIV infection among Zambian women to estimate the burden of CIN3 and ICC among HIV positive women nationally. RESULTS: Over half (52 %) of the study participants screened positive by DC, while 45 % had cytologic evidence of high grade squamous intraepithelial lesions (SIL) or worse. Histopathologic evaluation revealed that 20 % of women had evidence of CIN2 or worse, 11 % had CIN3 or worse, and 2 % had ICC. Using the Spectrum model, we therefore estimate that 34,051 HIV positive women in Zambia have CIN3 and 7,297 have ICC. CONCLUSIONS: The DC, cytology, and histology results revealed a large cervical disease burden in this previously unscreened HIV positive population. This very large burden indicates that continued scale-up of cervical cancer screening and treatment is urgently needed.
The use of thermal ablation in diverse cervical cancer "screen-and-treat" service platforms in Zambia.
(2022-Apr) Mwanahamuntu M; Kapambwe S; Pinder LF; Matambo J; Chirwa S; Chisele S; Basu P; Prendiville W; Sankaranarayanan R; Parham GP; Zambia Ministry of Health, Cancer Control, Lusaka, Zambia.; Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA.; International Agency for Research on Cancer, WHO Screening Group, Early Detection and Prevention Section, Lyon, France.; Center for Infectious Disease Research in Zambia, Cervical Cancer Prevention Program, Lusaka, Zambia.; Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.; Department of Obstetrics and Gynecology, Women and Newborn Hospital, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
OBJECTIVE: Thermal ablation (TA) was implemented in public sector cervical cancer prevention services in Zambia in 2012. Initially introduced as a treatment modality in primary healthcare clinics, it was later included in mobile outreach campaigns and clinical research trials. We report the feasibility, acceptability, safety, and provider uptake of TA in diverse clinical contexts. METHODS: Screening services based on visual inspection with acetic acid were offered by trained nurses to non-pregnant women aged 25-59 years. Women with a type 1 transformation zone (TZ) were treated with same-visit TA. Those with a type 2 or 3 TZ, or suspicious for cancer, were managed with same-visit electrosurgical excision or punch biopsy, respectively. A provider survey was conducted. RESULTS: Between 2012 and 2020, 2123 women were treated with TA: primary healthcare clinics, n = 746; mobile outreach clinics, n = 1127; research clinics, n = 250. Of the 996 women treated in primary healthcare and research clinics, 359 (48%) were HIV positive. Mild cramping during treatment was the most common adverse effect. No treatment interruptions occurred. No major complications were reported in the early (6 weeks) follow-up period. Providers expressed an overwhelming preference for TA over cryotherapy. CONCLUSION: TA was feasible, safe, and acceptable in diverse clinical contexts. It was the preferred ablation method of providers when compared with cryotherapy.
Utilization of cervical cancer screening services and trends in screening positivity rates in a 'screen-and-treat' program integrated with HIV/AIDS care in Zambia.
(2013) Mwanahamuntu MH; Sahasrabuddhe VV; Blevins M; Kapambwe S; Shepherd BE; Chibwesha C; Pfaendler KS; Mkumba G; Vwalika B; Hicks ML; Vermund SH; Stringer JS; Parham GP; Center for Infectious Disease Research in Zambia, Lusaka, Zambia ; University Teaching Hospital, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: In the absence of stand-alone infrastructures for delivering cervical cancer screening services, efforts are underway in sub-Saharan Africa to dovetail screening with ongoing vertical health initiatives like HIV/AIDS care programs. Yet, evidence demonstrating the utilization of cervical cancer prevention services in such integrated programs by women of the general population is lacking. METHODS: We analyzed program operations data from the Cervical Cancer Prevention Program in Zambia (CCPPZ), the largest public sector programs of its kind in sub-Saharan Africa. We evaluated patterns of utilization of screening services by HIV serostatus, examined contemporaneous trends in screening outcomes, and used multivariable modeling to identify factors associated with screening test positivity. RESULTS: Between January 2006 and April 2011, CCPPZ services were utilized by 56,247 women who underwent cervical cancer screening with visual inspection with acetic acid (VIA), aided by digital cervicography. The proportion of women accessing these services who were HIV-seropositive declined from 54% to 23% between 2006-2010, which coincided with increasing proportions of HIV-seronegative women (from 22% to 38%) and women whose HIV serostatus was unknown (from 24% to 39%) (all p-for trend<0.001). The rates of VIA screening positivity declined from 47% to 17% during the same period (p-for trend <0.001), and this decline was consistent across all HIV serostatus categories. After adjusting for demographic and sexual/reproductive factors, HIV-seropositive women were more than twice as likely (Odds ratio 2.62, 95% CI 2.49, 2.76) to screen VIA-positive than HIV-seronegative women. CONCLUSIONS: This is the first 'real world' demonstration in a public sector implementation program in a sub-Saharan African setting that with successful program scale-up efforts, nurse-led cervical cancer screening programs targeting women with HIV can expand and serve all women, regardless of HIV serostatus. Screening program performance can improve with adequate emphasis on training, quality control, and telemedicine-support for nurse-providers in clinical decision making.