Developing a sustainable programme of cervical screening using VIA (visual inspection with acetic acid) and HPV (human papillomavirus) testing in rural Malawi

Overall goals

To reduce cervical cancer morbidity and mortality in the population served by Nkhoma Hospital, and its associated health centres, through the development of sustainable patient pathways for cervical cancer prevention - from primary education through cervical screening to treatment and care - and thus contribute to improving maternal and women’s health in rural Malawi.

Key UK Colleagues and Partners

Dr Christine Campbell, Usher Institute, University of Edinburgh
Dr Graeme Walker and Mrs Hilary Walker, Gynae Oncology and Colposcopy, NHS Lothian but now in Queensland, Australia
Dr Miriam Deeny, recently retired from colposcopy, NHS GG&C; Dr Wendy McMullen, NHS Tayside; Dr Dr Grazyna Stanckzuk, NHS Western Isles
Scotland Malawi Partnership for helpful advice and support

International Partners

Nkhoma CCSP Hospital, Nkhoma, Central Malawi; from May 2013
Malawi Ministry of Health Safe Motherhood sub-committee and national cervical screening co-ordinators
University of Malawi College of Medicine and The Polytechnic
Partners in Hope, Lilongwe

Sustainable development goals

• SDG 3 - Good health and well-being
• SDG 17 - Partnerships for the goals

Funding source

Scottish Government International Development Fund for Malawi 2013-2016 ( MW01)
Voluntary and individual support 2016-2018
Scottish governemtn International Development Fund for Malawi 2018-2023 (MAL-18-03); lead Dr Christine Campbell – see separate entry

Project origin

Malawi had the highest incidence of cervical cancer in the world ( now 2nd highest) and highest mortality with almost no access to screening or treatment. Colleagues in University of Edinburgh already had a link to Nkhoma CCAP Hospital; At the time Church of Scotland also had two partners in Nkhoma (Deputy Medical Director Dr David Mortonand chief Pharmacist, Mr Rob Jones) with whom we linked

Evidence of need

See (a)

Project areas

Education
Service Improvement

Project activities

To 2016, To end of 2016 funding, the Project had:
• Reached 100,000 people through sensitisation
• Trained 37 healthcare staff
• Established daily Cervical Cancer Clinics at Nkhoma Hospital and weekly clinics in 8 Health Centres and screening campaigns in 2 others
• Provided screening to >17,000 women previously unscreened women
• Reassured >91% of women that they were VIA negative and could be rescreened in 5 years’ time as per Malawi guidelines
• Treated 60-70% of VIA+ women on same day as screening
• Encouraged attendance from ART clinics (>6%)
• Confirmed VIA and HPV positivity were each twice as common in HIV+ infected women
• Had positive feedback from Local Chiefs, clinicians, patients
• Shared training with Partners in Hope, Ministry of Health, others
• Provided an additional national trainer for VIA screening and treatment

To 2018, >26,000 women who had never been screened had VIA screening

Changes

Development of a local cadre of trained and competent nursing and clinical officer providers, leading eventually to a national screen and treat programme reaching to a good percentage of eligible women

Next steps

Our next project is funded by Scottish government to 2023. We hope to roll out the Nkhoma ‘hub and spokes’ model to 6 additional hubs in North, Central and Southern Malawi, reaching over 30 health centres and developing a group of highly trained expert providers who will act as mentors for future Malawian service provision, together with a mentoring toolkit which can be shared and disseminated more widely (see Dr Christine Campbell’s entry)

Challenges

Staff turnover/move to different duties - especially in government facilities – has been a challenge;
Provision of basic consumables by government such as gloves, cotton wool and consistent 3-5% vinegar has been variable
Lack of adequate sterilising facilities has been mitigated by purchase of small clinic sterilisers
Lack of access to more advanced treatments is a major problem across Malawi

Mitigating challenges

As we move forward we need to consider more effective clinical pathways for women identified with severe lesions and cancers. There is a lack of capacity for excisional treatment, surgical intervention and access to chemotherapy or radiotherapy. A different level of investment and training is required.

Partnership principles

• strategic
• harmonised
• effective
• respectful
• organised
• responsible
• flexible

Project gains

• leadership
• teamwork
• clinical
• awareness
• academic
• patient
• resilience