EGPAF Fights the Double Burden of HIV and Cervical Cancer in Lesotho

By Heather Mason

Cervical cancer is the most common cause of cancer deaths among women in Lesotho, according to Oluwasanmi Akintade, M.D., EGPAF’s director of reproductive health.

Heather Mason/EGPAF

Two years ago, cervical cancer was a death sentence for women in Lesotho.

In this mountainous country, 50 percent of the population lives below the poverty line and the number of gynecologists can be counted on one hand. Pap smears—the conventional screening method for cervical cancer— are out of reach for most women. Until recently a pap smear was the only way to detect cervical cancer early, when it can still be treated.

For those lucky enough to receive a pap smear, accessing the test results is another challenge. Cytologists, the technicians who analyze pap smears for abnormalities, are scarce and overburdened in Lesotho. It can take weeks or months, even a year, for the results of a pap smear to be processed and delivered.

To make matters worse, women living with HIV are at especially high risk for cervical cancer. The human papilloma virus (HPV)—the extremely common sexually transmitted infection that causes cervical cancer— replicates quickly and easily in women with compromised immune systems.

Oluwasanmi Akintade, M.D., director of reproductive health for the Elizabeth Pediatric AIDS Foundation (EGPAF) in Lesotho, explains that an HIV-positive woman who contracts HPV is four to five times more likely than an HIV-negative woman to develop invasive cervical cancer. This deadly combination explains why cervical cancer is the most common female cancer, and the biggest cause of cancer deaths, among women in Lesotho. “HIV is a major problem in Lesotho. National prevalence is 23 percent among the adult population,” says Akintade. “Among women who are living with HIV, cervical cancer is an opportunistic disease. So it’s like a double-burden.”

“Women usually develop cervical cancer in middle age, 40 years and above,” says Appolinaire Tiam, M.D., country director for EGPAF-Lesotho. “But with the high prevalence of HIV in Lesotho, more and more we’ve been seeing young women who are developing invasive cancer well before the age of 25. EGPAF feels that you cannot talk about HIV without talking about cervical cancer in women.”

The World Health Organization has classified cervical cancer as an AIDS-defining illness. This means that when an HIV-positive woman is diagnosed with cervical cancer, she has officially developed AIDS.

Combine all of these challenges with the fact that Lesotho, one of the most resource-limited countries in the world, does not have the capacity to treat women with cervical cancer. Women in Lesotho who are diagnosed with cervical cancer must be transferred to a hospital in Bloemfontein—135 kilometers away in neighboring South Africa—for treatment, costing the government an average of $13,000 per woman. The financial cost is great, as is the physical, mental, and emotional cost for a woman and her family.

“For women benefiting from the EGPAF prevention of mother-to-child transmission of HIV [PMTCT] program, screening for cervical cancer becomes necessary,” Akintade explains. “If they have a precancerous lesion—even if they continue with their ARVs [antiretroviral drugs]—it is only a matter of time before they develop cancer of the cervix. The majority of them will wind up dying from cancer of the cervix. So the baby that we have saved [through PMTCT] may end up losing his or her mother from cervical cancer.”

Today, a new cervical cancer screening program in Lesotho is making headway against this deadly epidemic. Lesotho’s National Cervical Cancer Prevention Program at the Senkatana Centre of Excellence, pioneered by EGPAF in partnership with the U.S. Agency for International Development (USAID) and the Lesotho Ministry of Health, is using simple, innovative methods to identify cervical cancer in its earliest stages and cure the disease before it can progress.

A One-Stop Shop for Cervical Cancer Screening and Treatment

Lerato, 30, sits in a counseling room at Senkatana, Lesotho’s oldest and largest HIV/AIDS care and treatment center, located in the capital city of Maseru. Lerato, who is HIV-positive, heard about Senkatana’s cervical cancer prevention program on the radio and decided to come in for screening. A precancerous lesion was discovered during her screening; she is about to have the lesion removed.

“I had a friend who died from [cervical] cancer,” Lerato says. “As she was ill, I saw that it was a terrible disease. I didn’t want to reach that point.”

Lerato explains that she arrived at Senkatana’s cervical cancer center, located in a prefab building adjacent to the HIV care and treatment and tuberculosis treatment centers, and received a warm welcome from the staff. “There was somebody who was teaching about HPV. That allayed my anxiety. I went into the consulting room for screening and I was relaxed.”

The Senkatana Centre, in addition to housing Lesotho’s first cervical cancer screening program, is the first health clinic in the country to use visual inspection with acetic acid (VIA) to screen a woman’s cervix for precancerous lesions. In contrast to a pap smear, in which a health care worker scrapes a sample of cells from a woman’s cervix and sends the sample away to be tested, VIA yields a visual diagnosis within minutes. VIA also costs only a few cents, compared to $10-$15 per pap smear. When using VIA, a health care worker applies acetic acid—a technical term for white vinegar—to the woman’s cervix and visually scans the cervix for abnormalities. If the woman is infected with HPV and has a precancerous lesion, the lesion appears white when it comes into contact with vinegar. In the time it takes to apply vinegar and visually inspect the cervix, the health care worker can accurately diagnose a precancerous cervical lesion.

At Senkatana, women diagnosed with precancerous lesions through VIA can have the lesions removed immediately after their screenings.

“We offer [treatment] there and then, if the patient finds it comfortable,” says Nurse Mantsane Sole, EGPAF’s PMTCT and reproductive health officer based at Senkatana. Sole is responsible for ensuring that Senkatana’s PMTCT, HIV care and treatment, and cervical cancer prevention services are fully integrated. “Ninety-nine percent of our [VIA] clients are treated immediately.”

The Senkatana Centre offers two types of treatment for precancerous cervical lesions. Smaller lesions are removed using cryotherapy, a method in which nurses use extremely cold nitrous oxide to “freeze” the cancerous cells from the woman’s cervix. Larger lesions require a loop electrosurgical excision procedure (LEEP), a slightly more complex procedure performed by one of the clinic’s two physicians. Both procedures, in addition to being relatively simple, are lifesaving in that they permanently remove cervical lesions before they become cancerous.

“Before EGPAF intervened, people [in Lesotho] who had these precancerous lesions…their wombs would be taken out to try to avoid the risk of it developing into cancer,” says Sole. “But now we screen and treat them immediately. It is free; people don’t pay a single cent. It’s a wonderful program.”

Thanks to the National Cervical Cancer Prevention Program, women like Mpho,  who is 29 years old and has a ten-year-old son, have a new chance at life. Mpho was referred to Senkatana for treatment after being diagnosed with a precancerous lesion. Instead of undergoing a hysterectomy, as she would have two years ago, Mpho’s lesion was removed with a LEEP. Today, she is visiting the clinic for her one-month follow-up.

“They told me there is a pre-cancer [lesion], but that I can be cured if I do everything they tell me to do. I did everything. I can be cured,” Mpho says. “I want to thank [the Senkatana staff] with all my heart. They are good people.”

“Lives Are Being Saved”

Under Akintade’s passionate leadership, EGPAF founded the National Cervical Cancer Prevention Program in January 2013 with financial support from USAID and in partnership with the Lesotho Ministry of Health. Getting the program off the ground wasn’t easy; a program like this had never existed before in Lesotho, and several organizations had already tried and failed to establish cervical cancer screening programs. But with these three organizations working together, the EGPAF project gained the momentum it needed to take off. The results speak for themselves.

Between February 2013 and April 2014, 2,324 women were screened at Senkatana; 1,782 of whom were screened using VIA. Of those, 190 women screened “VIA-positive,” meaning precancerous lesions were discovered through visual inspection with acetic acid. All 190 women were treated at Senkatana, either via cryotherapy or a LEEP.

“More than 10 percent of women had precancerous lesions, and all of them received treatment. Every single one of them who came to the center was treated at the center,” says Tiam. “This is the most positive outcome.”

According to Akintade, the success rate for treatment of precancerous lesions is between 75 and 95 percent.

Now that the program at Senkatana has been established, EGPAF is working with the Ministry of Health to roll out the program to the rest of Lesotho. EGPAF has already developed guidelines and trained health care workers from each of Lesotho’s ten districts on how to screen patients using VIA. Currently, patients outside Maseru who screen positive for precancerous lesions are referred to Senkatana for treatment. But plans are in place to establish treatment programs in each district by the end of 2015.

EGPAF’s cervical cancer prevention program is also operating in conjunction with a nationwide HPV vaccination campaign. All girls in Lesotho between the ages of 9 and 13 now receive the HPV vaccine at school, protecting them against infection with HPV before they become sexually active. Lesotho is the first African country to achieve nationwide coverage with its HPV vaccination campaign.

“Before, people were progressing to cancer. But now there is a campaign, and lives are being saved,” says Sole. “If we screen every woman from every corner of this country, I don’t think we will ever have people with cancer anymore. We would like to eradicate it in the near future. Women won’t die from cancer of the cervix.”

This article is made possible by the generous support of the American people through the United States Agency for International Development (USAID) and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). The contents are the responsibility of the Elizabeth Glaser Pediatric AIDS Foundation and do not necessarily reflect the views of USAID or the United States government.