Cervical cancer prevention in HIV-infected women using the "see and treat" approach in Botswana

Abstract

Background: Cervical cancer is a major public health problem in resource-limited settings, particularly among HIV-infected women. Given the challenges of cytology-based approaches, the efficiency of new screening programs need to be assessed.

Setting: Community and hospital-based clinics in Gaborone, Botswana.

Objective: To determine the feasibility and efficiency of the "see and treat" approach using visual inspection acetic acid (VIA) and enhanced digital imaging (EDI) for cervical cancer prevention in HIV-infected women.

Methods: A 2-tier community-based cervical cancer prevention program was implemented. HIV-infected women were screened by nurses at the community using the VIA/EDI approach. Low-grade lesions were treated with cryotherapy on the same visit. Women with complex lesions were referred to our second tier specialized clinic for evaluation. Weekly quality control assessments were performed by a specialist in collaboration with the nurses on all pictures taken.

Results: From March 2009 through January 2011, 2175 patients were screened for cervical cancer at our community-based clinic. Two hundred fifty-three patients (11.6%) were found to have low-grade lesions and received same-day cryotherapy. One thousand three hundred forty-seven (61.9%) women were considered to have a normal examination, and 575 (27.3%) were referred for further evaluation and treatment. Of the 1347 women initially considered to have normal exams, 267 (19.8%) were recalled based on weekly quality control assessments. Two hundred ten (78.6%) of the 267 recalled women, and 499 (86.8%) of the 575 referred women were seen at the referral clinic. Of these 709 women, 506 (71.4%) required additional treatment. Overall, 264 cervical intraepithelial neoplasia stage 2 or 3 were identified and treated, and 6 microinvasive cancers identified were referred for further management.

Conclusions: Our "see and treat" cervical cancer prevention program using the VIA/EDI approach is a feasible, high-output and high-efficiency program, worthy of considering as an additional cervical cancer screening method in Botswana, especially for women with limited access to the current cytology-based screening services.

Figure 1

Distribution of the number of HIV-infected women screened and treated by a “See-and-Treat” cervical prevention program, Botswana 2007–2011