title: Cervical cancer screening uptake and challenges in Malawi from 2011 to 2015: retrospective cohort study.
abstract: Malawi has the highest cervical cancer incidence and mortality in the world with age-standardized rate (ASR) of 75.9 and 49.8 per 100,000 population respectively. In response, Ministry of Health established a cervical cancer screening programme using visual inspection with acetic acid (VIA) and treatment of precancerous lesions with cryotherapy. This paper highlights the roll out, integration with family planning services and HIV ART Programme, uptake and challenges of VIA and Cryotherapy programme.
  
  
  
  We analyzed program data, supportive supervision, quarterly and annual reports from the National Cervical Cancer Control Program. We evaluated the uptake and challenges of screening services by age, HIV serostatus and trends over a five year period (2011-2015).
  
  
  
  Between 2011 and 2015, number of cervical cancer screening sites, number of women screened and coverage per annum increased from 75 to 130, 15,331 to 49,301 and 9.3 % to 26.5 % respectively. In this five year period, a total of 145,015 women were screened. Of these, 7,349 (5.1 %) and 6,289 (4.3 %) were VIA positive and suspect cancer respectively. Overall 13,638 (9.4 %) were detected to be VIA positive or had suspect cancer. Of the 48,588 women with known age screened in 2015; 13,642 (28.1 %), 27,275 (56.1 %) and 7,671 (15.8 %) were aged 29 or less, 30-45, 46 years or more. Among 39,101 women with data on HIV serostatus; 21,546 (55.1 %) were HIV negative, 6,209 (15.9 %) were HIV positive and 11, 346 (29.0 %) status was unknown. VIA positivity rate and prevalence of suspect cancer were significantly higher in HIV positive than HIV negative women (8.8 % vs 5.0 %, 6.4 % vs 3.0 %); in women aged 30-45 years than women aged 29 years or less (5.6 % vs 2.3 %, 2.6 % vs 1.2 %) respectively, all p <0.05). The main challenge of the programme was failure to treat VIA positive women eligible for cryotherapy. Over the five year period, the programme only treated 1,001 (43.3 %) out of 2,311 eligible women and only 266 (31.8 %) of the 836 women with large lesion or suspect cancer who were referred, received the health care at the referral centre. The reasons for failure to provide cryotherapy treatment were stock out of gas, faulty/broken cryotherapy machine (usually connectors or probes) or no cryotherapy machine at all in the whole district. For women with large lesion or suspect cancer; lack of loop electrosurgical excision procedure (LEEP) machine or inadequate gynaecologists at the referral centre, were the major reasons. Cancer radiotherapy services were not available in Malawi.
  
  
  
  This study provided data on VIA positivity rate, prevalence of suspect cancer, failure rate of cryotherapy and challenges in the provision of cryotherapy and LEEP treatment in Malawi. These data could be used as baseline for monitoring and evaluation of Human Papillomavirus (HPV) vaccination programme which the country introduced in 2013, the linkage of cervical cancer screening and women on HIV ART and the long term effect of ART, voluntary male medical circumcision on the prevalence and incidence of cervical cancer.
authors.affiliation: World Health Organization, Malawi Country Office, Lilongwe, Malawi. msyambozak@who.int.|WHO Malawi, ADL House, City Centre, P.O. Box 30390, Lilongwe, Malawi. msyambozak@who.int.
authors.forename: Kelias Phiri
authors.initials: KP
authors.lastname: Msyamboza
authors.affiliation: Ministry of Health, Reproductive Health Directorate, Lilongwe, Malawi.
authors.forename: Twambilire
authors.initials: T
authors.lastname: Phiri
authors.affiliation: Ministry of Health, Mzimba North District Hospital Office, Mzuzu, Malawi.
authors.forename: Wesley
authors.initials: W
authors.lastname: Sichali
authors.affiliation: Ministry of Health, Balaka District Hospital Office, Balaka, Malawi.
authors.forename: Willy
authors.initials: W
authors.lastname: Kwenda
authors.affiliation: Ministry of Health, Reproductive Health Directorate, Lilongwe, Malawi.
authors.forename: Fanny
authors.initials: F
authors.lastname: Kachale
mesh_terms: D000328:Adult; D015331:Cohort Studies; D055088:Early Detection of Cancer / Q000379:methods / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008295:Malawi; D008403:Mass Screening / Q000379:methods / Q000706:statistics & numerical data*; D008875:Middle Aged; D012189:Retrospective Studies; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis* / Q000517:prevention & control / Q000628:therapy*
keywords: Cervical cancer; Cryotherapy; Malawi; Sub-Saharan Africa; Visual inspection with acetic acid