New Activity

Cervical cancer continues to be a major public health problem for women in Guyana, as it is in many

developing countries and throughout most of Latin America and Caribbean (LAC) region. Cervical cancer is

the leading cause of cancer deaths in women of the LAC region, and Guyana suffers one of the highest

cervical cancer burdens in the world. The age-standardized rate (ASR) in 2002 for cervical cancer incidence

in Guyana is 47.3 cases per 100,000 women, and a mortality rate of 22.2 per 100,000 women (Global

Epidemiology Group), both of which are 50% higher than the LAC region. Yet, when precancerous lesions

are detected and treated, cervical cancer is almost completely preventable. In countries that have

developed and implemented high quality organized cervical cancer prevention programs with high

participation rates, the incidence of cervical cancer has decreased by a remarkable 70-90%. In comparison,

Guyana lacks an organized cervical cancer prevention program. Cervical cancer prevention services in

Guyana are characterized by low coverage rates, poorly targeted services, lack of coordination and linkage

of screening and treatment components, and inadequate tracking of patients for follow-up.

A "Single Visit Approach" (SVA) that is proposed for introduction in Guyana, is a recognized alternative for

low resource setting to the cytology-based model of cervical cancer prevention services. In the cytology

based program a test is taken, read at a laboratory, results become available a few weeks later, the client is

referred to a central site for confirmatory tests and therapy - a process that takes a long while, and is a

significant burden on women. By contrast, the SVA approach links testing with the offer of treatment or

other management options, at the same visit. This linkage is not only clinically important; it is cost-effective,

as reported in two recent studies (New England Journal of Medicine, November 17; Journal of the National

Cancer Institute; 94:1-15). Both studies report that once-in-a lifetime VIA testing, followed by offer of

immediate cryotherapy treatment for eligible lesions, was the most cost-effective, defined as fewest dollars

spent per life-year saved or cancers avoided.

The situation of HIV/AIDS in Guyana, and its influence on the development of cervical cancer, poses very

significant risks for women's health, as well as the well-being of their families and communities. HIV-infected

women are at a much higher risk of developing precancerous lesions of the cervix, and have more rapid

progression to cancer than women who are not HIV-infected. In addition, women receiving appropriate ARV

therapy are living longer, increasing the risk of precancerous lesions of the cervix to progress to cancer. As

a result, HIV-infected women should receive cervical cancer prevention services as part of their routine HIV

care and treatment (Gynecologic Oncology: 103: 1017-1022). Currently, this is not happening in Guyana.

An excellent opportunity exists to integrate cervical cancer prevention and HIV services because Guyana

receives support from the President's Emergency Plan for AIDS Relief (PEPFAR) program, and Omni Med

has previously conducted some cervical cancer prevention training and education at the HIV Center of

Excellence (GUM Clinic).

The Government of Guyana (GoG), through its Ministry of Health (MoH), has prioritized cervical cancer

prevention as a programmatic issue to be addressed using a single-visit approach (SVA) with visual

inspection with acetic acid (VIA) and cryotherapy. Omni Med's collaborative efforts over the past three years

within Guyana has led to the development of a national policy for cervical cancer prevention based on the

VIA and SVA model, and the desire of the MoH to have Omni Med partner with them to provide technical

assistance for the program. The GoG has committed its own resources to pay the in-country costs of

initiating a national cervical cancer prevention program, including funds for training, local travel, supplies,

and equipment. In addition, the local Rotary Club has committed resources to pay for equipment, supplies,

and to help conduct education and mobilization campaigns. However, in order to initiate the program, funds

are needed to support the costs of the international expertise needed to guide the MoH through the initial

three-year start up phase in order to establish local capacity to provide and maintain services. Working in

partnership with the GoG, JHPIEGO and Omni Med are collaborating to provide the needed technical

assistance for this program: development of national policy and service delivery guidelines, conducting

stakeholder meetings to ensure broad-based support, training trainers and providers, adapting learning

materials, installing information and monitoring systems, and supervising initial training and service

provision.

Importantly, through this program, the GoG intends to lay the groundwork for introducing HPV testing and

the HPV vaccine. The single visit approach combined with appropriate use of HPV testing and the HPV

vaccine is an effective national strategy for detection; control; treatment, care and management; and

prevention of an important public health problem that accounts for significant disease and death among

Guyanese women. This will be achieved by using the screening program as a platform to reach young

women with the vaccine when it becomes available and affordable. Although this combined initiative may be

many years before becoming a reality in Guyana, an initial effort to establish the screening program (the

platform for launching HPV vaccine services) is a requisite first step to provide prevention services to

women.

Program Goal and Objectives:

?Establish strategy, policy, and guidelines for cervical cancer prevention services for the general population

and for HIV-infected women in particular.

?Provide cervical cancer prevention services with appropriate follow-up to at least 2000 HIV+ women.

?Establish cervical cancer prevention services with appropriate follow-up as part of routine care for HIV-

infected women at the HIV Center of Excellence (GUM Clinic), with at least 50 percent of these women

receiving cervical cancer prevention services in the first program year.

?Establish cervical cancer prevention services with appropriate follow-up as part of the PMTCT program,

with at least 30 percent of these women receiving cervical cancer prevention services in the first program

year.

?Develop two screening centers in the public sector (Georgetown and either New Amsterdam or Suddie) to

provide regular cervical cancer screening with linkage to appropriate treatment, utilizing a single-visit or

screen-and-treat approach.

Activity Narrative: ?Increase from one to three the number of the ten Regions served by mobile cervical cancer prevention

clinics staffed primarily by Guyanese health care personnel. The remaining Regions would be covered in

subsequent years.