Continuing Activity

Cervical cancer is a major public health problem for women in Guyana, where the incidence and mortality

rates are 60% higher than the average rates for the Latin American and Caribbean (LAC) region. While

cervical cancer prevention initiatives exist in Guyana, the country currently 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. 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 70-90%.

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

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

infected women are at greater risk of developing precancerous lesions of the cervix, and have more rapid

progression to cancer than women who are not HIV-infected. It is within this context that cervical cancer

can be considered an opportunistic disease. In addition, women receiving appropriate antiretroviral therapy

(ART) are living longer, increasing the risk that precancerous lesions of the cervix progress to cancer. HIV-

infected women should therefore receive cervical cancer prevention services as part of their comprehensive

HIV care and treatment.

In response to these issues, 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. SVA is a recognized alternative for low

resource settings to the cytology-based model of cervical cancer prevention services. In contrast to the

cytology-based program where results are available a few weeks later and the client is referred to a central

site for confirmatory tests and therapy, the SVA model links testing with the offer of treatment or other

management options during 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 approach, defined as

fewest dollars spent per life-year saved or cancers avoided. In addition, Omni Med's collaborative efforts in

Guyana over the past four years have recently led to 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 also committed its own resources to pay the in-country

costs of implementing a national cervical cancer prevention program.

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

the HPV vaccine, when, and if, these activities become feasible and appropriate in this setting. The SVA

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. While 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.

Progress on FY 08 Activities & Targets

Working in partnership with the GoG, Jhpiego and Omni Med are collaborating to provide the needed

technical assistance for this program. During FY08, the project will have conducted the following activities

upon which the FY09 activities will be built:

?conduct a needs assessment to provide specific recommendations to refine program implementation,

policy development and service delivery guidelines;

?conduct an information system (IS) assessment to determine existing IS needs for data collection and

monitoring, pilot data collection system (electronic or paper-based) and conduct follow up

?establish a technical advisory group for cervical cancer;

?conduct stakeholder meetings to ensure broad-based support for cervical cancer prevention;

?support development of cervical cancer service delivery and training guidelines;

?conduct training of supervisors and health care providers from selected care and treatment (C&T) sites;

?conduct follow up and supervisory visits of trained supervisors and health care providers at C&T sites;

?provide limited cervical cancer screening and treatment equipment and supplies needed to start up

services at selected C&T sites; and

?conduct an end-of-project year assessment to determine progress of project and inform Project Year 2

implementation

During FY 09, the project will support expansion from 4 HIV C&T sites providing cervical cancer prevention

services to 6 additional sites. Activities will include:

?In collaboration with the MOH, support development of a national policy for cervical cancer treatment as

part of the overall policy on cervical cancer, as well as treatment guidelines for cervical cancer.

?Support coordination and facilitation (as needed) of the technical advisory group for cervical cancer

prevention.

?Conduct a training of trainers (TOT) workshop with supervisors and health care providers previously

trained in VIA and cryotherapy during Project Year 1.

?Conduct two training workshops for a new group of supervisors and health care providers to support

program expansion. These participants will be trained by the new trainers (mentioned in previous bullet) as

part of their practicum to become certified trainers.

?Conduct a workshop on supportive supervision for selected trainers, supervisors and proficient health care

providers to ensure supervisors provide effective supervision and providers receive adequate support and

guidance.

?Provide a refresher workshop to providers at the referral site, Georgetown Public Hospital, to manage

patients referred from C&T sites for advanced pre-cancerous lesions.

Activity Narrative: ?Support community education and awareness of cervical cancer and available services in collaboration

with mechanisms that are already in place to reach women in the targeted group, including

developing/adapting educational materials.

?Support ongoing data collection and analysis of data, including streamlining data capture and reporting to

include advanced cervical pre-cancer and cancer lesions and treatment received.

In addition, currently the Georgetown Public Hospital sees all patients referred from the C&T sites for

treatment of advanced pre-cancerous lesions using the loop electrosurgical excision procedure (LEEP).

LEEP is a commonly used approach to treat high grade cervical dysplasia and has many advantages,

including relative low cost, high success rate, and a relatively short learning time for specific physicians.

During FY 09, the project will support 1-2 C&T sites that already provide VIA to provide LEEP onsite,

including training providers on LEEP and provision of LEEP machines.

New/Continuing Activity: Continuing Activity

Continuing Activity: 15464

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

15464 15464.08 U.S. Agency for JHPIEGO 7145 7145.08 JHPIEGO $315,000

International OmniMed

Development

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $160,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.08: