Integrating cervical cancer screening and preventive treatment with family planning and HIV‐related services

Cervical cancer is a leading cause of mortality in Sub‐Saharan Africa—in large part because of inadequate coverage of screening and preventive treatment services. A number of programs have begun integrating cervical cancer prevention services into existing family planning or HIV/AIDS service delivery platforms, to rapidly expand “screen and treat” programs and mitigate cervical cancer burden. Drawing upon a review of literature and our experiences, we consider benefits and challenges associated with such programs in Sub‐Saharan Africa. We then outline steps that can optimize uptake and sustainability of integrated sexual and reproductive health services. These include increasing coordination among implementing organizations for efficient use of resources; task shifting for services that can be provided by nonphysicians; mobilizing communities via trusted frontline health workers; strengthening management information systems to allow for monitoring of multiple services; and prioritizing an operational research agenda to provide further evidence on the cost‐effectiveness and benefits of integrated service delivery.

Theobjectiveofthispaperistodescribebothbenefitsandchallenges associatedwith integrated SRH programs in countrieswith a high cervical cancer burden in Sub-Saharan Africa. We also recom-mendactionsthatcanincreasecoverageforintegratedSRHservices.

| Integrating cervical cancer services and family planning programs
A total of six countries (Kenya, Nigeria, Tanzania, Uganda, Zambia, and Zimbabwe) were identified as having integrated cervical cancer services with existing family planning programs 8,9,17   initiallyfocusedonHIV-positivewomen,buttheproportionofHIVnegative women accessing screening services also increased-from 22%to38%-between2006and2011. 24 Thisincreaseduseofcervical cancer services by the general population was due to the sustained efforts of providers and community mobilizers to educate all womenwithinthetargetagegroup. 24 InEthiopia,programsthattar-getwomenlivingwithHIVforcervicalcancerscreeningreportedhigh serviceuptakeinthepilotphase,butalsorecognizedthechallengeof scalingupwithinthebroaderhealthsystem. 21

| Efficient and cost-effective use of resources and infrastructure
IntegratingcervicalcancerservicesintoexistingHIVandfamilyplanning programs promotes increased efficiencies through use of commonhealthpersonnelandinfrastructure,comparedwithverticalSRH programming. 11,12,16 Significant global investments have been made to increase provision of HIV testing, treatment, and care, and these investments can be maximized by adding cervical cancer prevention services. 4,12,16 In 2015, the Global Fund for AIDS, Tuberculosis andMalariaannouncedthatitwillallowcountriestoincludecervical cancerservicesintheirGlobalFundrequests, 27 openingthedoorto increasedfundingfortheseservices.

| Lack of availability of cervical cancer treatment services
Numerous Sub-Saharan African countries promote a single-visit approach for cervical screening and preventive treatment. If this approach is not feasible (e.g. if not all health facilities are outfitted withcryotherapyunits;orifthereisaneedforreferraltohigher-level facilities),clientsarereferredtootherfacilitiesfortreatmentservices.
The limited availability of treatment sites and lack of coordination amongtreatmentfacilitieshasanegativeimpactontreatmentrates. 25 Forwomenwhorequirehigher-levelcare(suchasbiopsy,surgery, or radiotherapy) the dearth of trained providers, lack of equipment, highcostofservices,andlackofastandardizedreferralsystemhave asignificantimpactonmorbidityandmortalityofwomen.InNigeria, nearly 70% of VIA-positive women were unable to access treatment services at tertiary facilities owing to high financial costs of treatment. 20 Often treatment for invasive cervical carcinoma is only availableatasingletertiaryfacility,locatedinthecapital. 19 Theavailability of higher-level services is even more critical for HIV-positive women,astheyaremorelikelytohaveextensivelesionsthatdonot meetthecriteriafortreatmentwithcryotherapy. 16,25,30

| Shortage of SRH commodities and equipment
Integratedservicedeliveryinevitablywillresultinincreaseddemand for multiple services, which in turn increases the need for a robust supply chain for all SRH-related goods and services. The ability to adequatelyforecast,plan,andmanageinventoryisessentialforintegratedservicedelivery.

| Limited access to target populations
In some settings, integration of cervical cancer services into stand-aloneHIVprogramscanlimitaccesstoscreeningservicesforwomen in the general population, resulting in sub-optimal coverage of the targetpopulation.ThiscanbeduetothestigmaofHIV,ortolackof awarenessofscreeningservices. 32 Inaddition,asalreadynoted,the target populations for family planning services only partially overlap withthoseforcervicalcancerscreening. 4,17

| RECOMMENDATIONS
The integration of cervical cancer services into existing family plan-ningandprogramsforHIVhasbeendocumentedacrossseveralcountries in Sub-Saharan Africa. This is a promising strategy to increase accessandcoverageofcervicalscreeningservices,aswellasuptake offamilyplanningandHIV-relatedservices.Thefollowingstepscan helptofurtherincreasecoverageforintegratedSRHservices.

| Increased coordination among existing implementers
National cervical cancer prevention programs are difficult to implementinmanylow-resourcesettingsowingtoalackoffinances,which results from competing health priorities, fragmented health infrastructure,lackoftrainedproviders,andlimitedphysicalaccesstothe targetpopulations.Althoughsomeinternationaldonorsareworking with government, private, and nongovernmental organizations in manyofthesamecountries,theseparateanddistinctfundingstreams received by each partner mean that cervical cancer programming is not routinely coordinated. By leveraging existing in-country programmaticcapacityforcervicalcancerservicedelivery,governments canidentifywheresynergiesorgapsexistandoptimizeresourcesto increaseaccesstocervicalcancerpreventionandtreatmentservices.

| Training of nonphysician service providers in higher-level treatment services (task shifting)
Thetrainingofnonphysicianprovidersincryotherapyhasbeenshown tobeasuccessfulapproachforincreasingtreatmentratesforprecancerouslesions. 2

| Introduction of robust health management information systems
Routine data collection capturing the number of services provided at the facility-level is often sufficient to meet donor requirements.
However, developing and collecting client-level indicators will allow effectivemonitoringandmeasuringofthescaleandqualityofintegratedservicedelivery.Thesedatacanthenbeusedbyprogrammanagerstosupportprogrammaticdecisionmaking,improvethequality ofservices,andidentifywhichSRHservicesarecommonentrypoints forclientsaccessingscreeningservicestofurtherincreasecoverage. Ms Shira Berman assisted in the formatting and copy editing of the finaldraftofthismanuscript.

CONFLICTS OF INTEREST
Theauthorshavenoconflictsofinteresttodeclare.