title: Population-level scale-up of cervical cancer prevention services in a low-resource setting: development, implementation, and evaluation of the cervical cancer prevention program in Zambia.
abstract: BACKGROUND
  Very few efforts have been undertaken to scale-up low-cost approaches to cervical cancer prevention in low-resource countries.
  
  
  METHODS
  In a public sector cervical cancer prevention program in Zambia, nurses provided visual-inspection with acetic acid (VIA) and cryotherapy in clinics co-housed with HIV/AIDS programs, and referred women with complex lesions for histopathologic evaluation. Low-cost technological adaptations were deployed for improving VIA detection, facilitating expert physician opinion, and ensuring quality assurance. Key process and outcome indicators were derived by analyzing electronic medical records to evaluate program expansion efforts.
  
  
  RESULTS
  Between 2006-2013, screening services were expanded from 2 to 12 clinics in Lusaka, the most-populous province in Zambia, through which 102,942 women were screened. The majority (71.7%) were in the target age-range of 25-49 years; 28% were HIV-positive. Out of 101,867 with evaluable data, 20,419 (20%) were VIA positive, of whom 11,508 (56.4%) were treated with cryotherapy, and 8,911 (43.6%) were referred for histopathologic evaluation. Most women (87%, 86,301 of 98,961 evaluable) received same-day services (including 5% undergoing same-visit cryotherapy and 82% screening VIA-negative). The proportion of women with cervical intraepithelial neoplasia grade 2 and worse (CIN2+) among those referred for histopathologic evaluation was 44.1% (1,735/3,938 with histopathology results). Detection rates for CIN2+ and invasive cervical cancer were 17 and 7 per 1,000 women screened, respectively. Women with HIV were more likely to screen positive, to be referred for histopathologic evaluation, and to have cervical precancer and cancer than HIV-negative women.
  
  
  CONCLUSIONS
  We creatively disrupted the 'no screening' status quo prevailing in Zambia and addressed the heavy burden of cervical disease among previously unscreened women by establishing and scaling-up public-sector screening and treatment services at a population level. Key determinants for successful expansion included leveraging HIV/AIDS program investments, and context-specific information technology applications for quality assurance and filling human resource gaps.
authors.affiliation: Center for Infectious Disease Research in Zambia, Lusaka, Zambia; University of Zambia, Lusaka, Zambia; University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America; International Agency for Research on Cancer, Lyon, France.
authors.forename: Groesbeck P
authors.initials: GP
authors.lastname: Parham
authors.affiliation: Center for Infectious Disease Research in Zambia, Lusaka, Zambia; University of Zambia, Lusaka, Zambia.
authors.forename: Mulindi H
authors.initials: MH
authors.lastname: Mwanahamuntu
authors.affiliation: Center for Infectious Disease Research in Zambia, Lusaka, Zambia; University of Zambia, Lusaka, Zambia.
authors.forename: Sharon
authors.initials: S
authors.lastname: Kapambwe
authors.affiliation: International Agency for Research on Cancer, Lyon, France.
authors.forename: Richard
authors.initials: R
authors.lastname: Muwonge
authors.affiliation: Center for Infectious Disease Research in Zambia, Lusaka, Zambia; University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.
authors.forename: Allen C
authors.initials: AC
authors.lastname: Bateman
authors.affiliation: Vanderbilt University, Nashville, Tennessee, United States of America.
authors.forename: Meridith
authors.initials: M
authors.lastname: Blevins
authors.affiliation: Center for Infectious Disease Research in Zambia, Lusaka, Zambia; University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.
authors.forename: Carla J
authors.initials: CJ
authors.lastname: Chibwesha
authors.affiliation: Center for Infectious Disease Research in Zambia, Lusaka, Zambia; University of California, Irvine, Irvine, California, United States of America.
authors.forename: Krista S
authors.initials: KS
authors.lastname: Pfaendler
authors.affiliation: University of Zambia, Lusaka, Zambia.
authors.forename: Victor
authors.initials: V
authors.lastname: Mudenda
authors.affiliation: University of Zambia, Lusaka, Zambia.
authors.forename: Aaron L
authors.initials: AL
authors.lastname: Shibemba
authors.affiliation: University of Zambia, Lusaka, Zambia.
authors.forename: Samson
authors.initials: S
authors.lastname: Chisele
authors.affiliation: University of Zambia, Lusaka, Zambia.
authors.forename: Gracilia
authors.initials: G
authors.lastname: Mkumba
authors.affiliation: University of Zambia, Lusaka, Zambia.
authors.forename: Bellington
authors.initials: B
authors.lastname: Vwalika
authors.affiliation: Michigan Cancer Institute, Pontiac, Michigan, United States of America.
authors.forename: Michael L
authors.initials: ML
authors.lastname: Hicks
authors.affiliation: Vanderbilt University, Nashville, Tennessee, United States of America.
authors.forename: Sten H
authors.initials: SH
authors.lastname: Vermund
authors.affiliation: Center for Infectious Disease Research in Zambia, Lusaka, Zambia; University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.
authors.forename: Benjamin H
authors.initials: BH
authors.lastname: Chi
authors.affiliation: Center for Infectious Disease Research in Zambia, Lusaka, Zambia; University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.
authors.forename: Jeffrey S A
authors.initials: JS
authors.lastname: Stringer
authors.affiliation: International Agency for Research on Cancer, Lyon, France.
authors.forename: Rengaswamy
authors.initials: R
authors.lastname: Sankaranarayanan
authors.affiliation: Vanderbilt University, Nashville, Tennessee, United States of America; National Cancer Institute, Bethesda, Maryland, United States of America.
authors.forename: Vikrant V
authors.initials: VV
authors.lastname: Sahasrabuddhe
mesh_terms: D019342:Acetic Acid; D000328:Adult; D017679:Cryotherapy; D003695:Delivery of Health Care; D003710:Demography; D055088:Early Detection of Cancer; D005260:Female; D015658:HIV Infections / Q000150:complications; D006801:Humans; D008403:Mass Screening; D008875:Middle Aged; D016730:Program Development; D015397:Program Evaluation; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis* / Q000453:epidemiology / Q000517:prevention & control; D015024:Zambia / Q000453:epidemiology; D002578:Uterine Cervical Dysplasia / Q000175:diagnosis / Q000473:pathology
chemical_list: D019342:Acetic Acid