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Cervical Cancer Prevention in Africa: The Future Nelly Yatich, DrPH University of California San Francisco July 19th, 2016 #AIDS2016 | @AIDS_conference DISCLOSURE • I have no financial or other conflicts of interest to declare #AIDS2016 | @AIDS_conference Magnitude of cervical cancer • Globally 528,000 cases diagnosed per year • ~ 85% of global burden in the developing world • Accounts for ~ 12% of all female cancers in the developing world • High ASRs >30 per 100,000, include E. Africa (42.7), Melanesia (33.3), Southern (31.5) and Middle (30.6) Africa • Remains the most common cancer in women in Eastern and Middle Africa • Globally 266,000 deaths per year • Accounts for 7.5% of all female cancer deaths • Almost 87% cervical cancer deaths occur in developing countries • Rates of > 20 per 100,000 in in Melanesia (20.6), Middle (22.2) and Eastern (27.6) Africa Globocan, 2012 #AIDS2016 | @AIDS_conference Cervical cancer burden in HIV/AIDS HIV Prevalence 2014 (UNAIDS) #AIDS2016 | @AIDS_conference Cervical cancer incidence (Globocan, 2012) Cervical cancer in women with HIV • Increased longevity of patients on ART may: – Increase risk of exposure to HPV – Provide the time required for progression to cervical cancer • HIV-positive women are more likely to have: – – – – – – Human Papilloma Virus (HPV) infection Persistent infection with high risk HPV An increased risk of developing precancerous lesions A recurrence of precancerous lesions after treatment Precancerous lesions that progress rapidly to cervical cancer Higher risk of developing cervical cancer than HIV(-) women #AIDS2016 | @AIDS_conference Model of HPV–related CIN and cervical cancer with ART Palefsky, Current Opinion in Oncology, 2003 #AIDS2016 | @AIDS_conference Screening for cervical cancer • Cytological screening of women has resulted in a decline in cervical cancer deaths in wealthier countries • High mortality in the developing world due to shortage of highquality precancer screening and treatment programs • Most developing countries lack infrastructure and trained personnel for cytology • VIA has been reported to have sensitivity values comparable to Pap and provides opportunity to “see and treat” • VIA Accuracy: – Depends on provider experience – May miss small or endocervical lesions – Requires pelvic exam (space, supplies, fear by clients) #AIDS2016 | @AIDS_conference The future – HPV screening • Precision oncology: Interventions concentrated on those who will benefit, sparing expense and side effects for those who will not • HPV testing is: – Etiology-based – Has been shown to be more sensitive, with higher positive and negative predictive value than cytology – Is more readily exportable to low resource settings • 2013 WHO guidelines recommend: – HPV over VIA, where possible – Treatment based on screening results alone – Cryotherapy as standard treatment, LEEP at referral centers #AIDS2016 | @AIDS_conference • Cluster RCT of 52 villages in India (131,746 women) • Random assignment to – HPV testing – Cytology – VIA – Standard Care • Outcome: Cervical cancer incidence or death #AIDS2016 | @AIDS_conference India Trial, Results • Test positivity rates: – HPV: 10%, Cytology 7%, VIA 14% • Detection rate for CIN1 was higher in the VIA group • Detection rate for CIN 2 and 3 similar across all three groups #AIDS2016 | @AIDS_conference #AIDS2016 | @AIDS_conference #AIDS2016 | @AIDS_conference The future – HPV Vaccination • • • • • Gardasil® (Merck) and Cervarix ®(GSK) Efficacy 96-98% in prevention of cervical pre-cancers Both vaccines appear to offer cross-protection against other HPV types Vaccine most effective if given before 1st sexual contact Administered as a series of 3 injections over a 6-month period at 0, 1-2, and 6 months Challenges for developing countries: • Health care infrastructure • Capacity for initiating and sustaining an immunization program for adolescents • Affordability and cost-effectiveness of vaccination relative to other programs competing for resources • Cultural acceptability • Political will #AIDS2016 | @AIDS_conference Research Priorities • Optimal screening strategies for cervical cancer precursors in Africa – – – – Role of HPV testing Role of self-collection Testing at community settings Point of care treatment • Integration of HPV vaccine with screening in developing countries • Second generation of prophylactic HPV vaccines #AIDS2016 | @AIDS_conference How can evidence-based strategies be successfully implemented? • Systematic assessment of the barriers and facilitators to implementation of the interventions • Partnership with the communities and stakeholders to develop feasible and sustainable strategies • Ensure that strategies as implemented remain faithful to original intervention • Cost effectiveness analysis #AIDS2016 | @AIDS_conference Community-based HPV testing • Outreach and education: – Use a brief educational module validated in this setting for use by CHWs – Provide outreach, education and screening in most accessible location • Screening: – Low-cost HPV screening available – Self-collected specimens eliminate many barriers to VIA/screening • Notification of results: – Text message, phone call results with follow-up information • Treatment: – Cryotherapy, with LEEP for larger lesions – Linkage strategies to be developed with communities #AIDS2016 | @AIDS_conference Conclusion • Cervical cancer remains a huge burden of disease for women in resource-limited settings • HIV infection is associated with higher incidence of cervical cancer and CIN/SIL • Alternatives to cytology, such as HPV testing, are critical to ensure adequate coverage and appropriate interventions • Community partnership is key • Although current vaccines are highly effective in women, implementation of HPV vaccination in developing countries remains a challenge #AIDS2016 | @AIDS_conference