Cervical cancer in sub-Saharan Africa: an urgent call for improving accessibility and use of preventive services
International journal for gynecological cancer - Cervical cancer is the most common cause of death among women in 21 of the 48 countries in sub-Saharan Africa. Close to 100% of all cases of cervical cancer are attributable to Human papillomavirus (HPV). HPV types 16 and 18 cause at least 70% of all cervical cancers globally, while types 31, 33, 45, 52, and 58 cause a further 20% of the cases. Women living with HIV are six times more likely to develop cervical cancer than those without HIV. Considering that sub-Saharan Africa carries the greatest burden of cervical cancer, ways to increase accessibility and use of preventive services are urgently required.
Sub-Saharan Africa has the highest rates of cervical cancer in the whole world, which are made worse by the high prevalence of HIV in the region, early sexual intercourse, a high rate of unprotected sex and sexually transmitted infections, and insufficient sexual and reproductive health education among young girls and women.
The age-standardized incidence rate of cervical cancer in sub-Saharan Africa in 2020 was 131.1 per 100 000 women. Countries like Malawi, Zambia, Eswatini, Tanzania, Zimbabwe, and Lesotho have incidence rates that exceed 40 per 100 000.
Cervical cancer is the most common cause of cancer death among women in 21 of the 48 sub-Saharan Africa countries.
Several countries in sub-Saharan Africa have implemented national cervical cancer prevention programs, often with the support of development partners. However, the uptake of these preventive programs remains low in most countries. COVID-19 control strategies are also widely reported to have disrupted cervical cancer prevention programs in some settings.
Hence, measures to increase the accessibility and use of these preventive services are urgently required, including in some instances reversing the disruptions imposed by the COVID-19 pandemic.
PREVENTATIVE MEASURES
The World Health Organization (WHO) in 2020 adopted a global strategy towards eliminating cervical cancer as a public health problem by the end of the century. For a country to be considered to have eliminated cervical cancer, it should have fewer than four cases of cervical cancer per 100 000 women per year. To attain this goal by the end of the 21st century, WHO set up 90-70-90 targets to be reached by 2030 and to be maintained.
The 90-70-90 targets mean that 90% of girls are fully vaccinated with an effective HPV vaccine by the age of 15 years, 70% of women are screened with a high-performance test by the age of 35 years, and again by the age of 45 years, and 90% of women identified with cervical cancer receive treatment.
About 74% of cervical cancer cases can be prevented through HPV vaccination in Africa. Low-to-middle-income countries, including South Africa, Botswana, Rwanda, and Zimbabwe, have also implemented national HPV vaccination programs for school-going adolescent girls aged 10–14 years. Rwanda was the first country in sub-Saharan Africa to implement an HPV vaccination program in 2011, achieving about 98% coverage for the eligible population between 2011 and 2018. Countries such as Scotland which started their HPV vaccination programs much earlier and have much wider coverage have begun to demonstrate that herd immunity is a possibility with HPV vaccination.
CHALLENGES
By the end of 2021, only 45% of countries in sub-Saharan Africa, including South Africa, Zimbabwe, Botswana, Malawi, Kenya, and Liberia, had introduced HPV vaccination in their vaccination programs. In Africa, only 43% of all girls aged 9–14 years live in countries with HPV vaccination in their national vaccination schedules. However, only 19% of the girls had received the full course of HPV vaccination by the end of 2020.22 Several challenges are being faced by African countries that are already providing HPV vaccination, like South Africa, Kenya, and Rwanda, which may be faced by other countries in sub-Saharan Africa that are in the process of implementing and expanding their HPV vaccination programs. One of the challenges is identifying the target population because the young adolescents aged 9–14 years typically do not have routine vaccination follow-ups or screening programs and are therefore not captured in health system data. Using education ministries' data may underestimate the target population since some of the girls may be out of school, especially in marginalized communities.
Another challenge that might be faced is obtaining political support because the vaccine is still quite expensive, and most African governments have limited health budgets that must cover multiple competing priorities. Even though most countries in sub-Saharan Africa are eligible to receive HPV vaccination program funding from the Global Alliance for Vaccines and Immunization (GAVI), an organization that subsidizes vaccines for low-to-middle-income countries, some of them may not be able to meet the gradual increase in co-financing over 5 years required by GAVI. This is because the co-financing requirements may exceed the projected growth in health budgets. Furthermore, changes in gross national income per capita may push some countries over the eligibility criteria.
Considering that most countries in sub-Saharan Africa have not even started providing HPV vaccination to girls aged 9–14 years, it will be more challenging to convince governments to offer the vaccine to women aged 27–45 years, as suggested by the Advisory Committee on Immunization Practices.
Only 20% of African countries, which included Botswana, Cameroon, Ethiopia, Kenya, Malawi, South Africa, Rwanda, and Zimbabwe, reported having a national cervical cancer screening program in 2019.7 However, most of the countries had a screening coverage of less than 10%. Source: www.international-journal-of-gynecological-cancer.com
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Urban
The few available cervical cancer screening services are usually found in secondary and tertiary healthcare facilities located in urban areas.
