Jan Bradley EngenderHealth

1. Delivering acceptable cervical cancer prevention services in low resource settings: looking at women’s experiences with new technologies and strategies Jan Bradley EngenderHealth

2. ACCP Studies • Countries: India, South Africa, Thailand, Ghana, El Salvador, Peru, Kenya, Romania, Bulgaria, Bolivia, India • Range: Country service delivery assessments and trials of safety, efficacy, feasibility, costing studies and acceptability studies • New approaches: Novel screening and treatment methods, single visits, mid-level (female) providers, community mobilization • Acceptability studies – RSA, Thailand, Ghana, India, El Salvador, Peru, Kenya

3. Services to reduce cervical cancer Effective • Good quality screening test • Good quality pre-cancer treatment • High coverage and age targeting • Efficient organization of services • Cost effective • Feasible to implement • Screening • Treatment • Single/multiple visits • Cadre/sex of provider • Abstinence issues Safe Acceptable • Appropriate management • Low complication rate • Mgt of complications • Post treatment abstinence

4. Cost issues • Importance of single visit approaches • Costs associated with number of visits • Benefit accrued through reduced loss to f-up • Single visit approaches using VIA or HPV once a lifetime cost less and reduce CaCx by 26% and 30% compared with no screening

5. ACCP acceptability studies – key elements • Screening by nurses • Variety of screening tests used • Treatment with cryotherapy • Offered immediate treatment after results (RSA SAT study, Thailand); some delayed (India, RSA Pap study) • Women asked about screening and treatment experiences

6. AcceptabilitySome key findings - screening • Most never screened before • Fear of provider, pain (womb removal), bad diagnosis • Fear of challenging partner (RSA) • Embarrassment, shame (RSA) • No discomfort (89% Thailand) • Test better than expected (Thailand 90%)

7. AcceptabilitySome key findings - nurses • Reassured by well-trained female staff • El Salvador study – high satisfaction associated with provider, highest scores for nurses • Clients pleasantly surprised “they touch you, talk to you while doing this examination” (Ghana). • “I can’t think of anything they could have done to make this better for me” (Thailand) • Importance of female staff: “A service for women, by women” (RSA)

8. AcceptabilitySome key findings - treatment • Once screened, treatment decision easy • Type of treatment not relevant to women • Anxious for treatment ASAP • Some cryo fear – in freezer, electrocuted? • Need to be healed, made clean, destroy badness (RSA)

9. AcceptabilitySome key findings – immediate vs. delayed treatment • 97% Thai women, 92% RSA women accepted immediate Tx after screen result • Need for fastest healing, “no worry time” • Feared condition deteriorating • One year later 99% happy with decision • India half treated immediately, and 55% of others lost to follow-up – cultural issues • RSA Pap/colp study – only half treated in 6 months – mgt, tracking issues

10. AcceptabilitySome key findings – cryo procedure • Some minor bleeding • Some mild pain (< 50% Thai, 33% Ghana) • Experience better than expected • General satisfaction (Peru 85%, Kenya 82%) • Vast majority would recommend to friends

11. Cryo sequelae • No serious complications except one • 4% unscheduled visits (Thailand) • RSA – 26% consulted provider within 1 month (2X non-treatment group) • Discharge common but expected – “after putting meat in a freezer, you can expect it to be messy when it thaws” Ghana.

12. Cryo sequelae • Most discharge moderate/heavy, watery and foul smelling • Pain a problem in Kenyan women • Mild pain/cramping reported in 30% RSA women, lasting up to a week • Bleeding variable – median 3 days in Kenya, Peru • 3% in RSA said side effects interfered with daily activities

13. Cryotherapy sequelae

14. Abstinence Issues • Cultural differences but most women reported partner/s supportive • Difficulties-poor, urban, marginalized communities • RSA – many asked friends to “vouch” for them • Small % women “gave in” to pressure, feared partner infidelity, feared violence, or were forced into sex • Some women, however, felt empowered

15. AcceptabilityKey findings – post treatment abstinence • Studies stressed 4 week abstinence, offered counseling for partners, condoms • Concern about inability to negotiate HIV & violence • 23-49% unable to abstain • Waiting days range 7-90 (ave 26) (Kenya) • Overall risk (sex without condom): ranged from 0.4% Ghana, 24% RSA

16. Compliance with abstinence and condom use

17. AcceptabilitySome key findings – overall satisfaction • Some difficulties with abstinence, but no increased HIV (RSA) • Would recommend to friends – Thailand, Peru. RSA, El Salvador & Ghana over 96% • High degree of satisfaction with screening using new technologies, immediate treatment, cryotherapy (despite side effects), use of (female) nurses