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Despite COVID-19 Challenges, I-TECH Supports Progress Toward Cervical Cancer Elimination

The World Health Organization (WHO) Global Strategy to Accelerate the Elimination of Cervical Cancer, launched in November 2020, calls for a world where cervical cancer—which kills more than 300,000 women per year—is eliminated. To achieve this, the strategy proposes ambitious 90-70-90 targets over the next decade.

However, the COVID-19 pandemic has severely hindered critical work on cervical cancer interventions, including reduced clinic flow, training opportunities, and outreach.

Due to agile programs and dedicated staff, several teams within the International Training and Education Center for Health (I-TECH) network, despite the challenges presented by COVID-19, have continued to make strides toward the WHO cervical cancer elimination goal.

Record-breaking cervical cancer screening in Namibia

The I-TECH Namibia program focuses on cervical cancer screening services for women living with HIV (WLHIV). Namibia’s national antiretroviral therapy (ART) program has rapidly adjusted to COVID-19 and the need to decongest public health facilities through multi-month dispensing (MMD) of ART. While this has helped with ART access, it has significantly reduced opportunities for performing facility-based services, since the frequency of health facility visits by women on ART has declined rapidly.

In close collaboration with the Namibia Ministry of Health and Social Services (MoHSS), I-TECH is implementing enhanced facility-based screening campaigns to increase access and rapidly reach more women. For these enhanced screenings, clients within a district are mobilized and given paced appointment times at several facilities in-line with COVID-19 restrictions. Service providers are then assigned to the specific sites where they provide screening services.

From 8-12 February, 805 women were screened through visual inspection with acetic acid (VIA) or Pap smear, 95% of whom were women living with HIV (WLHIV). Of the 137 women screened VIA positive, 98% received treatment. This campaign broke national records by achieving the highest recorded number of women screened in a 5-day campaign, as well as the highest number of women screened in a single day (210).

“As the COVID 19 pandemic rages on, and preventative restrictions limit client screening, the downtime should be used in planning for catch-up screening activities,” says Dr. Laura Muzingwani, I-TECH’s Cervical Cancer Lead Physician in Namibia. “Resource and client mobilization are both key to prepare for any window of opportunity when COVID restrictions are relaxed to enable rapid mass screening.”

Mentoring and training continues in Mozambique via videoconferencing technology

In close collaboration with the Ministry of Health (MOH) and the University of Texas MD Anderson Cancer Center—a Project ECHO® “superhub” for oncology—I-TECH has continued its monthly cervical cancer ECHO sessions in Mozambique, with an additional focus on COVID-19 safety and risk reduction. An average of 40 participants attend each session, and topics have included cervical changes in older women; relevance of normal and abnormal colposcopic findings; and hygiene, disinfection, and asepsis of materials.

“Although the emergence of the COVID-19 pandemic was sudden, it was possible to adapt quickly using remote information and communication technologies,” says Dr. Ernestina David, Program Manager for the I-TECH Cervical Cancer Prevention Program. “The ECHO videoconference sessions made it possible to bring together providers across the country to address uterine cancer and diagnose and treat pre-cancerous lesions, using local cases and looking for ways to approach and treat them.”

In addition, the Mozambique team has continued its regional cervical cancer trainings in a blended format (both virtual and in-person components). I-TECH has implemented three trainings using a model spearheaded by MD Anderson, wherein a two-day LEEP and colposcopy training was adjusted so that trainers could join via Zoom in lieu of traveling to Mozambique.

While some participants join only the Zoom sessions, others are able to watch the sessions from a classroom setting and then work through skills-building demo stations, followed by practice on patients at a provincial hospital.

Access to services increase through health communication in Malawi

Despite the Malawi government indicating cervical cancer screening, care, and treatment as priority services, after the COVID-19 pandemic hit the country, most facilities did not include cervical cancer services on their priority lists. Facilities either completely suspended or heavily reduced screening and treatment. This, coupled with fears among targeted women about contracting COVID-19, marginalized access to services.

To combat these challenges, I-TECH delivered health talks within communities on how women can protect themselves as they access services (social distancing, hand washing, use of face masks, etc.). Those reached were encouraged to pass on information to others.

I-TECH also engaged district health officers and those in charge of affected facilities on the need to continue providing cervical cancer services, in line with MOH COVID-19 prevention guidelines. Presenters emphasized the burden of cervical cancer and how it would worsen should services be interrupted for the entirety of the pandemic. Discussion also touched on including cervical cancer providers on the rotation roster and ensuring that commodities were available.

In Malawi, 391 health facilities are currently providing cervical cancer screening services, and 80% of those health facilities are also providing treatment services. More than a quarter of a million women were screened between January 2020 and June 2021, 57% of whom were WLHIV.

Zimbabwe consortium takes measures to blunt the impact of COVID-19

I-TECH and its network partner the Zimbabwe Training, Technical Assistance and Education Center for Health (Zim-TTECH) implement cervical cancer screening and treatment via the local Zimbabwean consortium ZimPAAC.

By March 2021, ZimPAAC had achieved 53% of the annual target for the number of women on ART screened for cervical cancer. ZimPAAC implemented several measures to mitigate the impact of COVID-19 on continuity of cervical cancer screening services, including:

  • Training of all health care workers on COVID-19 safety and security, transmission, and prevention;
  • Support to ensure infection prevention and control (IPC) and triage at health facilities through training, procurement and distribution of personal protective equipment (PPE), hand washing stations/commodities, face masks for both staff and clients in need; and
  • Procurement and distribution adequate PPE for use by health care workers at facilities.

National COVID-19 Emergency Response in Malawi

In collaboration with the Malawi Ministry of Health (MOH) and Centers for the Disease Control and Prevention (CDC), I-TECH has supported the national COVID-19 response in Malawi since March 2020. Technical assistance has focused on laboratory capacity, supporting quality COVID-19 surveillance and data management, and implementing a COVID-19 population-based survey with oversight from the Public Health Institute of Malawi (PHIM), under MOH.

In June 2020, I-TECH seconded a Technical Advisor (TA) to PHIM to support COVID-19 activities. The I-TECH TA acts as secretariat for the national Public Health Emergency Operations Center (PHEOC), supporting the coordination of the multi-sectoral COVID-19 response, developing and revising strategies and procedures, facilitating communication, and ensuring access to and sharing of COVID-19 data and information between partners.

I-TECH has also assisted with data management and reporting at the district level, as well as with contact tracing and adherence to infection prevention and control measures.

I-TECH has been able to leverage use of its platform for HIV laboratory activities to provide critical lab support for COVID-19 activities and provide key support to the National Health Reference Laboratory, focusing on building or increasing laboratory capacity including with genomic sequencing, maintaining quality assurance, and improving communication and coordination among laboratory stakeholders.

The I-TECH Team also coordinated a population-based survey to evaluate the extent of spread of COVID-19 in five high-burden districts in Malawi.

I-TECH Team Contributes to New WHO Recommendations for Cervical Cancer Screening and Treatment

After two years of collaborative work, the World Health Organization (WHO) today launched a critical publication to aid health care workers in the march toward cervical cancer elimination: The WHO Guidelines for Screening and Treatment of Cervical Pre-Cancer Lesions for Cervical Cancer Prevention.

The guidelines contain evidence-based recommendations for cervical cancer screening and were created in the context of the WHO global strategy to accelerate the elimination of cervical cancer, as well as the need to provide screening and prevention services to all women around the globe.

Dr. Linda Eckert–University of Washington (UW) Professor of Obstetrics & Gynecology, Adjunct Professor of Global Health, and technical advisor to I-TECH’s cervical cancer programs in Namibia, Malawi, and Botswana–served as one of the lead consultants coordinating the WHO guidelines.

“It has been a true privilege to join with WHO colleagues to collect and synthesize data and work with cost effectiveness modelers and our 60-member multinational Guideline Development Group, who shared their immense experience and knowledge to create these evidence-based guidelines,” said Dr. Eckert. “It is so hopeful for women around the globe, and I feel inspired thinking about how many women can be spared the suffering of cervical cancer through implementation of these guidelines.”

Dr. Laura Muzingwani, the lead physician for I-TECH’s Cervical Cancer Prevention Program in Namibia, was also an active member of the Guideline Development Group. Her experience and expertise in cervical cancer screening and treatment in Namibia enabled her to offer valuable guidance in the crafting of these recommendations.

In addition to the UW, contributing partners in the project included McMaster University, the London School of Hygiene and Tropical Medicine, the Clinton Health Access Initiative, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the United States Agency for International Development (USAID), and Unitaid, among others.

HIV Recency Surveillance in Malawi

The International Training and Education Center for Health (I-TECH), in collaboration with the Malawian Ministry of Health (MOH) and the Centers for Disease Control and Prevention, began implementing recent HIV infection surveillance in April 2019. The project aims to establish a surveillance system among persons newly diagnosed with HIV infection by integrating point-of-care testing for recent infection into routine HIV testing services (HTS). A rapid test for recent infection is given to consenting clients 13-years-and-older who screen HIV positive within routine HTS across participating health facilities. Between April 2019-2020, I-TECH and MOH activated 485 testing points at 155 facilities in Malawi. All 155 facilities implemented recent HIV infection surveillance and reported data. The project has reached 11 of 28 districts to date.

These data allow the detection and characterization of recent HIV infection among newly diagnosed individuals and identify geographic areas associated with recent HIV-1 infection to inform geographic prioritization of HIV prevention and treatment strategies. The project has demonstrated high uptake and allowed characterization of recent infections according to socio-demographic and geographic factors. PEPFAR implementers in Malawi will collaborate with MOH to further investigate the reasons for high recent infection prevalence in identified clusters. Based on the findings of these responses, Malawi may focus on interventions such as youth-focused programs that aim to limit HIV acquisition and transmission among young people.

I-TECH Supports Critical TB Prevention, Screening, and Treatment for PLHIV

The global health community recognizes March 24 as World Tuberculosis (TB) Day to raise awareness of this deadly, yet preventable and curable, disease. The 2021 theme, “The Clock Is Ticking,” underlines the importance of acting now to end the global TB epidemic. According to World Health Organization, the probability of developing active TB disease is 18 times higher in people living with HIV (PLHIV), and in 2019 TB killed 1.4 million people worldwide, which includes 208,000 people who were HIV-positive.

Photo Credit: I-TECH

According to the U.S. Centers for Disease Control and Prevention, TB is one of the leading causes of death worldwide for PLHIV. To help treat and combat the spread of TB, particularly among PLHIV, the International Training and Education Center for Health (I-TECH) supports TB prevention, care, treatment, monitoring, and policy activities across the I-TECH global network. Current I-TECH work includes TB interventions in Mozambique, Namibia, and Malawi.

I-TECH supports the National TB Program in Mozambique by using the Warm Line—a telephone consultation line that supports clinicians—to deliver results for suspected drug-resistant TB cases to clinicians located at health facilities throughout the country. This collaboration with the Ministry of Health’s National TB Reference Lab allows for more timely identification and better management of drug-resistant TB cases. During 2019, 9,103 (83%) of results were delivered via the Warm Line. I-TECH’s team also engaged providers and clinicians in 383 interactions via the Warm Line to support mentoring and to monitoring complicated TB cases.

In addition to supporting clinicians with TB care and diagnosis, I-TECH supports TB prevention, diagnosis, and care among clients attending HIV clinics throughout seven regions and across 150 public health facilities in Namibia. The I-TECH team screens for active TB; monitors drug interactions for TB/HIV co-infection; provides TB screening, prevention, and management of TB/HIV co-infection for HIV-positive clients; tests for HIV at TB clinics for clients with unknown HIV status; and assesses eligibility, previous initiation, and completion of TB Preventive Therapy (TPT) to ensure no clients are missed. As of January 2021, approximately 90% of HIV-positive patients on antiretroviral therapy at supported facilities initiated their TPT course and 80% have completed their TPT course. I-TECH also works closely with healthcare workers and facilities to improve recording keeping of TPT course initiation and completion as well as the use of this data to focus day-to-day clinical efforts.

Since 2015, I-TECH has been providing technical assistance support to the Malawi National TB Program to improve the quality of TB services at all health facilities throughout Malawi. I-TECH continues to train program monitors to interpret and act on data collected using the TB Standard of Care Monitoring Tool. The tool, designed by I-TECH, collects data for case detection, treatment outcome monitoring, TB/HIV status ascertainment, and TB infection control and contact investigation. Using the collected data, I-TECH identifies performance gaps and create action plans for health facilities to improve the quality of TB services. Even with a loss of momentum due to the impact of COVID-19 pandemic, by September 2020, 85% of presumptive TB cases—those who were suspected of TB and referred for testing—knew their HIV status.

 

I-TECH’S WORK IN MOZAMBIQUE IS SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA) OF THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS) UNDER U91HA06801, THE INTERNATIONAL AIDS EDUCATION AND TRAINING CENTER (IAETC). THE CONTENT OF THIS POST IS THE AUTHOR’S AND SHOULD NOT BE CONSTRUED AS THE OFFICIAL POSITION OR POLICY OF, NOR SHOULD ANY ENDORSEMENTS BE INFERRED BY HRSA, HHS OR THE U.S. GOVERNMENT.

COVID-19

I-TECH provides technical assistance on the prevention and control of COVID-19 that ranges from training health care workers and facilities in infection prevention and control best practices to supporting the development of national policies and standard operating procedures. During the COVID-19 pandemic, I-TECH continues to work with ministries of health and other key stakeholders to ensure that laboratories, health facilities, and clinics are implementing and being trained in procedures to prevent and control the spread of COVID-19.

In addition to directly supporting COVID-19 prevention and control efforts, I-TECH has been working with governments and the ministries of health to ensure the continuity of HIV care and treatment by supporting clinicians via telephone consultations, developing messaging campaigns to connect people living with HIV (PLHIV) with pharmacies and clinics stocked with antiretroviral therapy (ART) medications, and helping PLHIV form community ART refill groups.

Program Highlights

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I-TECH Launches Cervical Cancer Awareness Campaign in Namibia

The International Training and Education Center for Health (I-TECH), in collaboration with the Namibian Ministry of Health and Social Services (MOHSS) and with funding from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC), has launched a campaign to raise awareness of the importance of screening for and treatment of cervical pre-cancer in women aged 20–49.

This awareness campaign is the most recent expansion of the Namibian Cervical Cancer Screening and Treatment Program, which was rolled out in 2018 following the adoption of national cervical cancer guidelines by the MOHSS in March 2018.

MoHSS Health extension worker and data clerk capturing data for the National Cervical Cancer Program.

The rollout of this awareness campaign and expansion of the program has been especially important during the COVID-19 pandemic because patients may be less likely to visit their health care provider for preventive care, including cervical cancer screening and treatment.

“This campaign will bring a much-needed awareness to not only screening but also the different treatment options that are available,” says Dr. Laura Muzingwani, I-TECH’s Cervical Cancer Prevention Lead Physician in Namibia. “We want to ensure that all women, particularly HIV-positive women, are empowered to take action and get screened for cervical cancer. We also want to inform women that they can still be safely screened despite the ongoing COVID-19 pandemic.”

Screening and treatment are available to anyone who needs it, but the I-TECH program has focused its efforts on HIV-positive women. Women living with HIV are five to six times more likely to develop cervical cancer than HIV-negative women, even if they are on antiretroviral therapy (ART). Currently, the I-TECH program supports screening and treatment at 31 MOHSS health facilities and 11 outreach sites in seven regions across Namibia. As of August 2020, the program had performed more than 14,000 screenings and 1,700 treatment procedures for HIV-positive women.

“The cervical cancer program has achieved a lot of success within a short period,” says Dr. Laimi Ashipala, MOHSS Chief Medical Officer HIV/AIDS and STI Control subdivision. “With these additional outreach and awareness efforts, we hope to reach 100,000 HIV-positive women in the next two years.”

As part of the campaign’s outreach efforts to reach HIV-positive women, I-TECH is contacting women receiving ART to offer cervical cancer screenings during their routine medication pick-up visits. The team is also reaching out to community-based ART refill groups as a way to bring screening services to HIV-positive women at community meeting points.

Expanding and Adapting the Health Care Provider Training Program

VIA provider providing VIA services.

In addition to awareness and outreach, the program has expanded cervical cancer screening and treatment training for health care providers (e.g., doctors, registered and enrolled nurses).

“Key aspects of the program have been the training and uptake of our health care providers,” explains Dr. Ashipala. “We are scaling up our efforts to train and certify health care providers in using VIA and ablative treatments throughout the country. In addition to VIA and ablative treatments, we have also expanded training and certification to include LLETZ and cervical biopsies, which allows us to treat patients who may not be eligible for ablative treatments.”

The COVID-19 pandemic has led to adjustments in the way trainings are provided for the safety of facilitators and participants and to aid in pandemic control efforts. In response, I-TECH supported a virtual MOHSS VIA (visual inspection with acetic acid or VIA) screening training for nine, newly recruited cervical cancer screening health care providers. Since the program began in 2018, I-TECH and MOHSS have trained 249 health care providers.

Creating a Suite of Informational Materials

This Cervical Cancer Prevention brochure is one of several pieces in a suite of materials created by I-TECH.

I-TECH, in collaboration with stakeholders, has developed a suite of materials—flyers, brochures, and posters—for patients and providers to complement the outreach and training efforts.

The materials highlight the importance of screening, encourage women to make an appointment, explain the method of screening, and provide information about the treatment options that are offered through the program.

The materials will be used by health care providers during health education sessions with patients, distributed to women when they visit their health care facility or ART clinic, and following screening and/or treatment appointments. Some of the materials will also be displayed at health facilities and referral hospitals to advertise screening availability.

“We applaud the Ministry for highlighting the need for cervical cancer prevention, screening, and treatment despite the ongoing COVID-19 pandemic and taking action by collaborating in the development of resources, adopting guidelines for providers, and supporting training for health care providers,” says Dr. Muzingwani.

I-TECH Presents Posters at AIDS 2020: Virtual

The International AIDS Society (IAS) virtually hosted their 23rd International AIDS conference (AIDS 2020: Virtual) on 6-10 July 2020. The AIDS 2020: Virtual theme was resilience, to celebrate and acknowledge the strength of the HIV community and the significant advances in treatment, while also addressing gaps in treatment, prevention, and care.

Representatives from the International Training and Education Center for Health (I-TECH) virtually presented the following posters with accompanying audio recordings:

In addition to the I-TECH representatives presenting their posters, representatives from the Centers for Disease Control and Prevention (CDC) and Health Alliance International (HAI) also presented data from I-TECH programs in Malawi and Mozambique.

Expanding Two-Way Texting to Reduce Follow-Up Appointments for Male Circumcision Patients

This piece was first posted on the University of Washington Department of Global Health’s (DGH) website.

A new five-year research project will study two-way texting as a means of communication between healthcare providers and male circumcision (MC) patients in South Africa. It will build on previous research conducted in Zimbabwe.

Caryl Feldacker is the Principal Investigator (PI) on this RO1, which will support research through 2025. The multi-stage implementation science study is based out of the International Training and Education Center for Health (I-TECH), and will be implemented with Dr. Geoffrey Setswe, PI for South Africa partner, Aurum Institute, and with technology partner, Medic Mobile.

“Previous research shows that healthcare workers waste a lot of time and money reviewing MC clients without complications,” Feldacker said. “So, in partnership with Medic Mobile, we developed a two-way texting (2wT) system to identify and refer men with potential medical issues to in-person care while allowing the vast majority to opt-out of routine post-operative visits.”

Programs providing voluntary medical male circumcision (MC) in sub-Saharan Africa are struggling to meet the annual goal of 5 million MCs. However, chronic human and financial resource shortages threaten achievement of MC targets, reducing impact of this effective HIV prevention intervention. Although MC is safe with an adverse event (AE) rate of less than 2% , global MC guidelines require one or more in-person, post-operative visits within 14 days of MC for timely AE identification. With low AE rates, overstretched clinic staff likely waste invaluable resources conducting unnecessary routine reviews for MC clients without complications while men healing well needlessly pay for transport, miss work, and wait for reviews, discouraging MC uptake.

With this background, Dr. Feldacker’s prior randomized controlled trial (RCT) in Zimbabwe tested whether 2wT between patients and providers during the critical 13-day post-operative period (instead of routine in-person reviews) could ensure patient safety while reducing provider workload. 2wT safely reduced client visits by 85%, increased AE identification, and cut follow-up costs, suggesting that 2wT could make a dramatic difference in MC programs operating at scale. Plus, providers and patients found the 2wT follow-up approach highly usable and acceptable. “These daily text exchanges really empowered men to be partners in their healing process, creating a win-win for providers and patients.”

Read the entire story on the DGH website.

Pamela Collins

Pamela Collins, MD, MPH, is Professor of Psychiatry and Behavioral Sciences and Professor of Global Health at the University of Washington (UW), where she is Executive Director of I-TECH, Director of the UW Consortium for Global Mental Health–a joint effort of the UW Department of Psychiatry and Behavioral Sciences and the UW Department of Global Health–and Associate Director of the UW Behavioral Research Center for HIV (BIRCH). She is a psychiatrist and mixed methods researcher with 25 years of experience in global public health and global mental health research, education, training and capacity-building, and science policy leadership. Prior to her current role she directed the Office for Research on Disparities & Global Mental Health and the Office of Rural Mental Health Research at the National Institute of Mental Health (NIMH) (USA). Dr. Collins has served the field in diverse leadership roles, most recently as a commissioner for the Lancet Commission on Global Mental Health and Sustainable Development, a leader of the Grand Challenges in Global Mental Health initiative, co-lead of the NIMH-PEPFAR initiative on mental health and HIV, a member of the World Economic Forum’s Agenda Council on Mental Health, and the director of the RISING SUN initiative on suicide prevention in Arctic Indigenous communities.

Dr. Collins’s research has focused on social stigma related to mental illness and its relationship to HIV risk among women of color with severe mental illness; the intersections of mental health with HIV prevention, care, and treatment; and the mental health needs of diverse groups in the US, Latin America and Sub-Saharan Africa. She is currently the Principal Investigator of EQUIP Nairobi: a pilot implementation of Trauma-Focused CBT in Nairobi, Kenya, part of a more comprehensive effort to meet the mental health needs of children and adolescents in Nairobi.