BY

DR PAHE GAMB ROGO

ROLE CERVICAL CANCER

SCREENING IN INDENTIFYING

UNTREATED CHRONIC

CERVIVITIS AMONG HIV+

POSITIVE WOMEN

OUTLINE

BACKGROUND

OBJECTIVE

METHODOLOGY

RESULT

RECOMMENDATIONS/WAY FORWARD

BACKGROUNDThe Mater Comprehensive Care clinic(MCCC) was opened on October 2nd 2006

A charitable work of the Mater Hospital together with the Cardiac Program that offers heart surgeries to needy children. 70% of clients in the program resides in the surrounding densely populated Mukuru slums

Clinic currently has 3104 active patients on care of which adult population 64% are women

Cervical cancer is now recognized as an AIDS -defining illness in HIV infection and with HIV positive women receiving ART and living longer, cervical cancer becomes not only a life defining event but a disease that affects their quality of life.

BACKGROUND(2)The prevalence of HIV in invasive cervical cancer patients in Kenya is 15%which is double the national average of 7%. This provided the platform for which the HIV programme in Kenya is making efforts in integrating cervical cancer screening as part of the minimum comprehensive care package.

Cervicitis is described as an inflammation of the cervix, the lower, narrow end of your uterus that opens into the vagina.

It's possible to have cervicitis and not experience any signs or symptoms. Among the signs and symptoms women sometimes notice are bleeding between menstrual periods and changes in vaginal discharge.

Often, cervicitis results from a sexually transmitted infection, such as chlamydia or gonorrhea. Cervicitis can develop from noninfectious causes, too.

OBJECTIVE

To increase the proportion of women who

received cervical cancer screening from 5% in

2012 to 30% in 2013, for all women aged 18 -65

years who would be willing to receive the service

To increase the quality of life for HIV + women by

early diagnosis and treatment of precancerous

lesion and prevent progression to invasive

cervical cancer

To reduce morbidity and mortality associated with

cervical cancer

METHODOLOGYThe screening methods are recommended for the Kenya program as they meet the criteria for a good screening test are Visual Inspection with Acetic Acid (VIA),Visual Inspection with Lugol’s iodine ,Cytology using Conventional Pap smear and HPV testing.

We undertook testing using VIA/VILI given that we are resource limited as we are purely donor funded. We screened a total of 484 women over a 12 month period. The women were first taken through a series of health talks where certain aspects such as risk factors for cervical cancer and the rationale for screening were explained to them. Those who were willing to undergo the test were then reassured about the safety of the procedure, timeliness and the confidentiality of results.

Those with positive lesions were offered treatment such as Cryotherapy for early lesion and Colposcopic biopsy and referral for LEEP/ TAH depending on their histology results

VIA is visual examination of the ectocervix, TZ, and

cervical os with the naked eye (unmagnified) after an

acetic acid wash.

It allows identification of acetowhite areas that need

further management.

Visual Inspection With Acetic Acid

(VIA)

Normal squamous epithelium is light pink in color.

Normal columnar epithelium is red.

The color comes from the blood vessels in the

underlying stroma.

Abnormal epithelial tissue, especially cervical

intraepithelial neoplasia (CIN), turns white after

the application of acetic acid. This is called the

acetowhite reaction.

VIA—How It Works

VIA Positive

14

VIA Positive

VILI is also promising as a visual method to screen

for cervical cancer.

After the woman’s cervix is examined using VIA,

the cervix is painted with Lugol’s iodine solution

and examined again with the naked eye.

Visual Inspection With Lugol’s

Iodine

Normal squamous epithelial cells have substantial stores

of glycogen.

Glycogen stains mahogany-brown with iodine solution.

Abnormal areas of squamous epithelium (CIN or

inflammation) do not contain glycogen to the same

extent and do not stain brown.

How VILI Works

Normal Cervix: VILI Negative

VILI negative: The squamous epithelium is black due to uptake of iodine,

and the columnar epithelium is slightly discolored after iodine

application. The SCJ is fully visible and located closer to the external os.

Source: Reprinted from Sankaranarayanan,15 with permission.

(a) VIA-positive: A large acetowhite area around the os after

acetic acid application.

(b) VILI-positive: After Lugol’s iodine application, the lesion is

iodine-negative.

a b

VIA/VILI-POSITIVE

RESULT

Although the focus of the exercise women with

precancerous lesions, it also emerged that there

was a high prevalence of untreated chronic

cervicitis women with in this age group. These

women reported a longstanding history of lower

abdominal pains

Out of the women screened, 217(45% of the

women screened) had cervicitis at the time of

screening

Cervicitis was characterized by a greenish yellow

or mucopurulent discharge from the os or

cervicitis

WAY FORWARDAlthough donor funding is moving away from the area of cervical cancer screening, women who are HIV + still have a high prevalence of precancerous lesions

Screening for cervical cancer through VIA/VILI should be prioritized as it is not costly and does not need highly specialized technical skill and manpower requires.

It is an effective way of not only identifying precancerous lesions but also identifying and treating women with untreated cervicitis

Prompt treatment reduces chances of transmission of STIs as well as HIV to sexual partners.

This method is also proving to be effective in diagnosing chronic cervicitis and treating it which avoids morbidity in terms of disease progressing to Pelvic Inflammatory Disease and leading to complications such as infertility and future tubal pregnancies which could rupture and cause mortality where resources are scarce

This will improve the quality of life of HIV+ Women since a part of a woman's pride and legacy particularly in Africa is her ability to bear children.

In the bigger picture identifying chronic cervicitis and offering timely treatment will reduce maternal mortality from complications such as ruptured tubal pregnancies