title: Implementation of cervical cancer prevention services for HIV-infected women in Zambia: measuring program effectiveness.
abstract: BACKGROUND
  Cervical cancer kills more women in low-income nations than any other malignancy. A variety of research and demonstration efforts have proven the efficacy and effectiveness of low-cost cervical cancer prevention methods but none in routine program implementation settings of the developing world, particularly in HIV-infected women.
  
  
  METHODS
  In our public sector cervical cancer prevention program in Zambia, nurses conduct screening using visual inspection with acetic acid aided by digital cervicography. Women with visible lesions are offered same-visit cryotherapy or referred for histologic evaluation and clinical management. We analyzed clinical outcomes and modeled program effectiveness among HIV-infected women by estimating the total number of cervical cancer deaths prevented through screening and treatment.
  
  
  RESULTS
  Between 2006 and 2008, 6572 HIV-infected women were screened, 53.6% (3523) had visible lesions, 58.5% (2062) were eligible for cryotherapy and 41.5% (1461) were referred for histologic evaluation. A total of 75% (1095 out of 1462) of patients who were referred for evaluation complied. Pathology results from 65% (715 out of 1095) of women revealed benign abnormalities in 21% (151), cervical intraepithelial neoplasia (CIN) I in 30% (214), CIN 2/3 in 33% (235) and invasive cervical cancer in 16.1% (115, of which 69% were early stage). Using a conditional probability model, we estimated that our program prevented 142 cervical cancer deaths (high/low range: 238-96) among the 6572 HIV-infected women screened, or one cervical cancer death prevented per 46 (corresponding range: 28-68) HIV-infected women screened.
  
  
  CONCLUSIONS
  Our prevention efforts using setting-appropriate human resources and technology have reduced morbidity and mortality from cervical cancer among HIV-infected women in Zambia. Financial support for implementing cervical cancer prevention programs integrated within HIV/AIDS care programs is warranted. Our prevention model can serve as the implementation platform for future low-cost HPV-based screening methods, and our results may provide the basis for comparison of programmatic effectiveness of future prevention efforts.
authors.affiliation: University of Alabama at Birmingham, AL, USA ; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia ; University Teaching Hospital, Lusaka, Zambia.
authors.forename: Groesbeck P
authors.initials: GP
authors.lastname: Parham
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia ; University Teaching Hospital, Lusaka, Zambia.
authors.forename: Mulindi H
authors.initials: MH
authors.lastname: Mwanahamuntu
authors.affiliation: Vanderbilt University, TN, USA ; National Cancer Institute, MD, USA.
authors.forename: Vikrant V
authors.initials: VV
authors.lastname: Sahasrabuddhe
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
authors.forename: Andrew O
authors.initials: AO
authors.lastname: Westfall
authors.affiliation: University of Michigan, MI, USA.
authors.forename: Kristin E
authors.initials: KE
authors.lastname: King
authors.affiliation: University of Alabama at Birmingham, AL, USA ; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
authors.forename: Carla
authors.initials: C
authors.lastname: Chibwesha
authors.affiliation: University of Cincinnati, OH, USA.
authors.forename: Krista S
authors.initials: KS
authors.lastname: Pfaendler
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia ; University Teaching Hospital, Lusaka, Zambia.
authors.forename: Gracilia
authors.initials: G
authors.lastname: Mkumba
authors.affiliation: University Teaching Hospital, Lusaka, Zambia.
authors.forename: Victor
authors.initials: V
authors.lastname: Mudenda
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia ; University Teaching Hospital, Lusaka, Zambia.
authors.forename: Sharon
authors.initials: S
authors.lastname: Kapambwe
authors.affiliation: Vanderbilt University, TN, USA.
authors.forename: Sten H
authors.initials: SH
authors.lastname: Vermund
authors.affiliation: Michigan Cancer Institute, MI, USA.
authors.forename: Michael L
authors.initials: ML
authors.lastname: Hicks
authors.affiliation: University of Alabama at Birmingham, AL, USA ; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
authors.forename: Jeffrey Sa
authors.initials: JS
authors.lastname: Stringer
authors.affiliation: University of Alabama at Birmingham, AL, USA ; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
authors.forename: Benjamin H
authors.initials: BH
authors.lastname: Chi
keywords: HIV/AIDS; Zambia; cervical cancer; program effectiveness; screening