Opportunities and challenges for introducing HPV testing for cervical cancer screening in sub-Saharan Africa.

To protect women against cervical cancer, the World Health Organization recommends that women aged 30 to 49 years be screened with tests that detect human papillomavirus (HPV). If the countries that have the greatest burden of this disease-especially those in sub-Saharan Africa-are not to be left behind, we must understand the challenges they face and identify measures that can help them take full advantage now of innovations that are transforming screening services in wealthier countries. We reviewed policy documents and published literature related to Kenya, Tanzania, and Uganda, and met with key personnel from government and nongovernmental organizations. National policy makers understand the value of HPV testing in terms of its superior sensitivity and the programmatic advantages that could result from using self-collected samples. However, while these countries have national cervical cancer prevention strategies, and some have national departments or units for cervical cancer prevention, screening is rare, funding scarce, and quality low. Age guidelines are not strictly followed, with scarce resources being used to screen many women younger than the recommended ages. Published evidence of the benefits of HPV testing-including performance, safety, and cost-effectiveness-must be provided to ministry of health leaders, along with information on anticipated costs for training personnel, purchasing supplies, providing facility space, and maintaining test kits. Despite the obstacles, a joint effort on the part of global and national stakeholders to introduce molecular screening methods can bring better protection to the women who need it most.

Ending cervical cancer: A call to action.

The outlook for elimination of the scourge of cervical cancer is bright, because we now have the tools to achieve this goal. In recent years human papillomavirus (HPV) vaccination in high-income countries has resulted in dramatic decreases in HPV infection and associated cervical disease. If all countries with a substantial burden of disease introduce the vaccine nationally, we can protect the vast majority of women and girls most at risk. For women who are beyond the vaccination target age, progress has been made in screening and treatment for cervical precancer, but we must accelerate this momentum to reduce incidence and mortality worldwide to the very low rates found in wealthier countries. Human and financial resources must be increased and directed to programs that follow best practices and reach all women, including the marginalized or disadvantaged. Seven key actions are recommended. Now is the time for action at national, regional, and global levels.

The investment case for cervical cancer elimination.

We already know what causes cervical cancer, how to prevent it, and how to treat it, even in resource-constrained settings. Inequitable access to human papillomavirus vaccine for girls and screening and precancer treatment for women in low- and middle-income countries is unacceptable on ethical, social, and financial grounds. The burden of cervical cancer falls on the poor and extends beyond the narrow bounds of the family, affecting national economic development and community life, as family resources are drained and poverty tightens its grip. Proven solutions are available and the priorities for the next few years are clear, as shown by the papers in this Supplement. Sustained political commitment and strategic investments in cervical cancer prevention can not only save millions of lives over the next 10 years, but can also pave the way for the broader fight against all cancers.

Feasibility of delivering HPV vaccine to girls aged 10 to 15 years in Uganda.

BACKGROUND: Cervical cancer is a leading cause of mortality among women in Uganda. The availability of the human papillomavirus (HPV) vaccine presents an opportunity to prevent cervical cancer. The Government of Uganda conducted a demonstration project exploring the feasibility of two delivery strategies. OBJECTIVE: To explore the feasibility of two HPV vaccine delivery strategies: 1) a stand-alone school-based strategy that selected girls based on their enrolment in grade 5 (known as the "grade-based" strategy; and 2) an age-based strategy that delivered the HPV vaccine based on the girls' age (10-year-olds). This strategy combined the delivery of the vaccine with the distribution of deworming medication and vitamin A through an existing Child Days Plus program. METHODS: A qualitative study that explored the feasibility of the two delivery strategies from the perspective of health workers, district leaders, and staff of the Uganda National Expanded Programme on Immunization, utilizing in-depth interviews and focus group discussions. RESULTS: Coverage data showed that more girls (88%) were vaccinated using the grade-based strategy and completed all three doses compared to those (73%) vaccinated using the age-based strategy. Health workers and teachers indicated that determining vaccination eligibility was easier by grade than by age and there were minor disruptions to health services and school programs during vaccinations, as reported by health workers and teachers using the grade-based strategy. CONCLUSION: HPV vaccine delivery at schools using grade eligibility was more feasible than selecting girls by age. Lessons learned in Uganda could be relevant for countries considering implementing HPV vaccinations.

Qualitative study of the feasibility of HPV vaccine delivery to young adolescent girls in Vietnam: evidence from a government-implemented demonstration program.

BACKGROUND: Introduction of human papillomavirus (HPV) vaccine in national programs has proceeded apace since 2006, mostly in high-income countries. Recently concluded pilots of HPV vaccination in low-income countries have provided important lessons learned for these settings; however, rigorous evaluations of the feasibility of these delivery strategies that effectively reach young adolescents have been few. This paper presents results from a qualitative evaluation of a demonstration program which implemented school-based and health center-based HPV vaccinations to all girls in grade 6, or 11 years of age, for two years in four districts of Vietnam. METHODS: Using semi-structured interviews of 131 health and education staff from local, district, province, and national levels and 26 focus-group discussions with local project implementers (n = 153), we conducted a qualitative two-year evaluation to measure the impact of HPV vaccinations on the health and education systems. RESULTS: HPV vaccine delivery at schools or health centers was made feasible by: a. close collaboration between the health and education sectors, b. detailed planning for implementation, c. clearly defined roles and responsibilities for project implementers, d. effective management and supervision of vaccinations during delivery, and e. engagement with community organizations for support. Both the health and education systems were temporarily challenged with the extra workload, but the disruptions were short-lived (a few days for each of three doses) and perceived as worth the longer-term benefit of cervical cancer prevention. CONCLUSION: The learning from Vietnam has identified critical elements for successful vaccine delivery that can provide a model for other countries to consider during their planning of national rollout of HPV vaccine.

Why the time is right to tackle breast and cervical cancer in low-resource settings.

The health concerns of women in their mid-adult years - when the prime age of reproduction has passed - have been traditionally given little or no attention by health systems and donors, despite the heavy burden that diseases such as breast and cervical cancer impose on women and their families. The risk of sexually transmitted infections that accompanies sexual relations and the risk of death and morbidity associated with pregnancy have long been recognized and have stimulated major control efforts that are finally yielding positive results. Much less attention has been focused, however, on how experiences in early life can affect women's health in adulthood. Breast and cervical cancers kill more women than any other types of cancer in all parts of the developing world. In most of Asia and Latin America and some African countries, deaths from these two forms of cancer now outnumber pregnancy-related deaths. There are five compelling reasons for focusing on these cancers now to try to reverse these epidemiologic trends: (i) the burden of breast and cervical cancer is large and is growing; (ii) effective screening and treatment are available; (iii) research is generating new knowledge; (iv) there are opportunities for synergy with other health programmes; and (v) noncommunicable diseases are the focus of much current interest.

Les problèmes de santé des femmes au milieu de l'âge adulte (une fois passé le premier âge de la reproduction) ont traditionnellement bénéficié de peu d'attention ou ont été ignorés par les systèmes de santé et les donateurs, malgré le lourd fardeau que constituent les maladies, comme le cancer du sein et du col de l'utérus pour les femmes et leurs familles. Le risque d'infections sexuellement transmissibles qui accompagne les relations sexuelles, et le risque de mortalité et de morbidité associé à la grossesse sont reconnus depuis longtemps et ont guidé d'importants efforts de lutte, qui finissent par donner des résultats positifs. Beaucoup moins d'attention a cependant été accordée à la façon dont les expériences en début de vie peuvent affecter la santé des femmes à l'âge adulte.Les cancers du sein et du col de l'utérus tuent plus de femmes que tout autre type de cancer dans tous les pays du monde en voie de développement. Dans la plupart des pays d'Asie, d'Amérique latine et dans certains pays d'Afrique, les décès résultant de ces deux formes de cancer sont maintenant plus nombreux que les décès liés à la grossesse. Il y a cinq raisons impérieuses de se concentrer maintenant sur ces cancers afin d'essayer d'inverser ces tendances épidémiologiques: (i) le fardeau du cancer du sein et du cancer du col de l'utérus est toujours plus lourd; (ii) un dépistage et des traitements efficaces sont disponibles; (iii) la recherche génère de nouvelles connaissances; (iv) il existe des possibilités de synergie avec d'autres programmes de santé; et (v) les maladies non transmissibles génèrent beaucoup d'intérêt actuellement.

Los problemas de salud de las mujeres de mediana edad, una vez han pasado la plenitud de la edad reproductora, han recibido tradicionalmente poca o ninguna atención por parte de los sistemas sanitarios y donantes, a pesar de la gran carga que enfermedades como el cáncer de mama o de cuello uterino representan para las mujeres y sus familias. El riesgo de enfermedades de transmisión sexual a través de relaciones sexuales, y el riesgo de muerte y enfermedad asociados con el embarazo han sido reconocidos y se han impulsado intentos de control a gran escala que al fin están dando resultados positivos. Sin embargo, se ha prestado mucha menos atención a cómo las experiencias en las primeras etapas de la vida pueden afectar la salud de las mujeres en la vida adulta. En el mundo desarrollado, los cánceres de mama y de cuello uterino matan a más mujeres que ningún otro tipo de cáncer. En la mayor parte de Asia y América Latina y algunos países africanos, las muertes por estos dos tipos de cáncer superan en número a las muertes relacionadas con el embarazo. Hay cinco razones de peso para centrar la atención en estos tipos de cáncer con objeto de intentar revertir estas tendencias epidemiológicas: (i) la carga de los cánceres de mama y de cuello uterino es muy elevada, y sigue creciendo; (ii) existen controles y tratamientos eficaces; (iii) la investigación está proporcionando conocimientos nuevos; (iv) existen oportunidades de sinergia con otros programas sanitarios y (v) las enfermedades no transmisibles reciben gran parte de la atención actual.

Overcoming barriers and ensuring access to HPV vaccines in low-income countries.

The inequitable burden of cervical cancer falls on women in poorer countries, due primarily to a disparity in access to screening services. To ensure that access to the new human papillomavirus ("HPV") vaccines is not similarly skewed toward higher-income populations, it is important to understand the appropriate priority group for receiving vaccines, the potential barriers to reaching that group, and the options for overcoming those barriers. Based on vaccine efficacy data, the likelihood of achieving high coverage with various groups, and the resultant cost-effectiveness ratios, it is widely agreed that young adolescent girls should be the primary recipients. Potential barriers include the fact that young adolescents are not currently reached by many health services; that there might be stigma attached to a vaccine for a sexually transmitted infection; that financing for the vaccine must be allocated; and that there is limited political commitment to women's health, to cancer prevention, or to this particular vaccine when so many other new vaccines are also becoming available. Despite these very real challenges, there is reason to be cautiously optimistic that those most in need of an HPV vaccine can receive it in programs that are affordable, effective, and acceptable to girls, their families, and their societies.

Appropriate technology to prevent maternal mortality: current research requirements.

Maternal mortality involves a complex mixture of clinical, infrastructural and social issues and will require a multifaceted approach if we are to see meaningful reductions occur. That includes thoughtful attention to appropriate technologies for low-resource countries. An international group of specialists meeting in Bellagio, Italy, in 2003 identified important needs and opportunities related to new and underutilized technologies to reduce pregnancy-related mortality. Research to fill in critical information gaps was a recurrent theme. Research, whether it is for product development, for building the evidence base about effectiveness and safety or for helping refine introduction strategies and guide practice, plays a critical role in the development and widespread use of technologies. Priority research needs related to the five major causes of maternal mortality-haemorrhage, puerperal sepsis, unsafe abortion, pre-eclampsia and eclampsia and obstructed labour-have been identified. Appropriate collaborations of investigators and other stakeholders and adequate financial resources are urgently needed to move the research agenda forward.

Using technology to reduce maternal mortality in low-resource settings: challenges and opportunities.

Technology--consisting of equipment, supplies, procedures, and techniques--can play a central role in the management of pregnancy-related complications. Implementing proven interventions in developing countries and low-resource settings has been difficult, however, because skilled human and financial resources are constrained, and the physical and epidemiological environments are challenging. This article examines the limitations and challenges affecting health technologies in low-resource settings and suggests a framework for characterizing specific technology-based solutions. It also provides examples of pregnancy-related problems in which the introduction of new or modified technologies (drugs for prevention and management of postpartum hemorrhage, infection treatment, manual vacuum aspiration, preeclampsia detection and eclampsia management, partograms, and vacuum extraction) could help save women's lives. The authors call for a more complete assessment of the technology needs associated with pregnancy-related problems in low-resource settings, including evaluating alternative technology-based possibilities, carefully synthesizing and disseminating existing information, and characterizing the nature of current challenges. When accompanied by appropriate provider knowledge and skills, practice guidelines, financing and distribution systems, and community support, technology-based solutions can contribute to a significant reduction in maternal morbidity and mortality around the world.