Cervical cancer is a major cause of female cancer death in sub-Saharan Africa: Malawi has the highest global incidence. A ‘screen and treat’ approach using visual inspection with acetic acid (VIA) has government support but actual screening provision is limited due to lack of infrastructure, trained personnel, and the cost and availability of gas for cryotherapy. Recently, thermo-coagulation (also known as cold coagulation) has been acknowledged as a safe and acceptable procedure in this setting. We describe the setting up of a screening programme using VIA and thermo-coagulation for the treatment of low grade lesions coupled with appropriate, sustainable pathways of care for women with high grade lesions and cancers in Nkhoma CCAP Hospital and ten associated health centres in central Malawi.
Following approvals from the Ministry of Health and from regional and village chiefs, clinics were set up, staff trained and educational resources in the local language developed. At Nkhoma Hospital screening has been integrated within an existing Reproductive Health Unit. Attendance at the Malawian Ministry of Health VIA course is a prerequisite for all providers and is supplemented by additional theoretical and practical training in VIA interpretation and treatment using thermo-coagulation at Nkhoma Hospital. Bespoke standard operating procedures and assessment tools, and a training manual, were developed.
13,424 previously unscreened women attended VIA clinics between October 2013 and September 2015. Screening clinics were held daily in the hospital and weekly in eight health centres. In two health centres a mobile clinic was set up. Overall VIA positivity was 6.2%, but this varied by age, HIV status and clinic location. The majority of VIA-positive women received same-day treatment: in some health centres treatment is provided to VIA positive women on a monthly basis, and the need for partner consent also contributed to postponed treatment for a minority of women. A one-year cure rate of over 90% is observed, comparable to reported rates with cryotherapy. Women with suspected cancer at the health centres were referred to Nkhoma Hospital for further investigation.
Although high staff turnover and/or low staff levels provide challenges to maintenance of service levels in some health centres, a cervical screening programme has been set up, capitalising on already established trust between the hospital and health centres. Shared continued professional development sessions support an environment of mutual learning to strengthening the cadre of trained providers to implement the service more widely.
Campbell C et al. Use of thermo-coagulation as an alternative treatment modality in a ‘screen and treat’ programme of cervical screening in rural Malawi. IJC 2016; in press