Browsing by Author "Pfaendler KS"

Now showing 1 - 9 of 9

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.
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.
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 'see-and-treat' cervical cancer prevention services linked to HIV care in Zambia.
(2009-Mar-27) Mwanahamuntu MH; Sahasrabuddhe VV; Pfaendler KS; Mudenda V; Hicks ML; Vermund SH; Stringer JS; Parham GP; University Teaching Hospital, Ministry of Health, Lusaka, Zambia. mulindi.mwanahamuntu@cidrz.org; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
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.
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)
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.
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.