Project 1: A Public Health Approach to Cervical Cancer Prevention in East Africa

Women in sub-Saharan Africa, and particularly East Africa, bear among the greatest burden of cervical cancer in the world, and the reasons are clear: lack of widespread HPV vaccination, lack of screening for pre- cancer, lack of early detection, and high prevalence of one of the most potent accelerants of cervical cancer — HIV infection. It is of note that while great strides have been made in HIV infection control in the last decade in Africa, progress in cervical cancer control has languished. Indeed, continued occurrence of malignant complications of HIV  such as cervical cancer  threaten to undermine the successes. In recognition of the relevance of cervical cancer, the WHO has drafted a global strategy for cervical cancer elimination. It calls for 90% HPV vaccination coverage, 70% screening coverage, and treatment of 90% of those with cervical disease. Lacking in this strategy, however, is a clear path towards implementation. Through funding from U54 CA190153, to address the gap in implementation of effective preventive interventions for cervical cancer, we began to develop, in Uganda, what we call a public health approach to cervical cancer prevention. The approach combined Village Health Team-led community mobilization with community-based self-collected vaginal specimens for HPV testing and a mobile team to provide community- based ablative treatment for those HPV-infected. These community-based campaigns were feasible, well- attended and well-accepted. Given the initial success of this approach, the Ministries of Health in Uganda and Kenya seek to partner with us to add HPV vaccination to this public health approach in a model called the Integrated Cervical Cancer Prevention Program (ICCPP). The Ministries of Health will implement the ICCPP, and the overarching goal of the current proposal is to evaluate it. We propose 3 specific aims: Aim 1: Evaluate the uptake and acceptability of the HPV vaccination and cervical cancer screening components of the ICCPP in East Africa; Aim 2: Determine the factors explaining non-participation in either HPV vaccination among adolescent girls or in cervical cancer screening and treatment among women in East Africa; and Aim 3: Assess the costs and efficiency of the integrated public health approach to HPV vaccination and cervical cancer screening in East Africa. To address our aims, we will evaluate an entirely community-based integrated program implemented by our Ministry of Health partners in Uganda and Kenya in which women undergo cervical cancer screening and treatment and adolescent girls who have not been fully HPV-immunized get vaccinated. Evaluation will include uptake, acceptability, exploration of reasons for non-participation and costs. The project tests a new paradigm in cervical cancer prevention in Africa — a public health approach to reach the greatest number of girls and women at lowest cost. Findings may form a blueprint for the ultimate elimination of cervical cancer.