Bringing Care Into The Hands Of The Users: Closing Cervical Cancer Screening Coverage Gap Through HPV DNA Self-Sample Collection

Population Solutions for Health Counsellor demonstrating to a client how to self-collect the specimen
Population Solutions for Health Counsellor demonstrating to a client how to self-collect the specimen

According to the World Health Organization (WHO), Cervical cancer is the fourth most common cancer among women globally, with an estimated 604 000 new cases and 342 000 deaths in 2020. Every year cervical cancer kills nearly 350 000 women globally, 90% of whom live in low- and middle-income countries (LMICs).  

Despite being preventable and curable, Cervical cancer is the most common cancer among women in Zimbabwe and accounts for most cancer deaths among females in the country. More than 95% of cervical cancer cases are caused by oncogenic types of human papillomavirus (HPV) which is transmitted through skin-to-skin contact, including sexual activity. Women living with Human Immuno-deficiency Virus (HIV) are 4 to 10 times more likely to develop cervical cancer and more likely to develop it at a younger age 

Population Solutions for Health (PSH) currently provides integrated sexual and reproductive health (SRH) and HIV prevention and treatment services (including cervical cancer screening and treatment of pre-cancerous lesions) in Zimbabwe using a one-stop shop model through both static and outreach service delivery. Cervical cancer screening (secondary prevention) is targeted at preventing invasive cervical cancer by detecting and treating precancerous lesions of the cervix before they progress to cancer.  

In Zimbabwe, the recommended cervical cancer screening methods include HPV DNA test, Visual Inspection with Acetic acid and Cervicography (VIAC) and cervical cytology-based screening (Pap smear). Among these, HPV DNA screening is a more sensitive and specific screening option which provides an opportunity to test women who are above 50 years.  

Funded by the Embassy of Sweden through Population Services International (PSI), Population Solutions for Health (PSH) in collaboration with the Ministry of Health and Child Care carried out the HPV DNA acceptability and feasibility study in 3 districts between November 2019 and June 2020. The goal of this study was to assess the acceptability and feasibility of HPV cervical self-sampling as a cervical cancer screening method and HPV DNA testing as an effective approach for the early detection of cervical cancer among women in Zimbabwe. 

HPV DNA sample collection kit

 Study findings revealed that HPV self-sampling is generally a highly accepted method of cervical cancer screening in Zimbabwe. Over 54% of women in the study chose to privately collect their samples for HPV screening following instructions provided by a healthcare worker. For the women the most appealing features were ease and convenience of use, privacy, less anticipated discomfort and value of their direct participation and involvement in healthcare. At the end of the study 97.6% recommended it, 90.6% will use it again in the future, and 88.8% trust the results. 

HPV DNA sample collection is certainly a game-changer in the prevention and treatment of cervical cancer. Women are often diagnosed with cervical cancer at a more advanced stage, where the opportunity for cure is low.  PSI through implementing partner PSH are offering an alternative screening choice and extending access to underserved communities, a highlight of their dedication to the global policy of the World Health Organization to eradicate cervical cancer and lower the overall mortality rate. To date, more than 33,729 women have screened for cervical cancer using HPV DNA testing through the New Start Centre service delivery network. 

Indeed, PSI and PSH are bringing care into the hands of its users to be in control of their sexual reproductive health. Though lack of self-confidence in collecting a reliable sample was the most cited reason for preferring clinician-collected samples, there was no significant difference in the acceptability and relative ease in self-sample collection between women in rural versus those in urban locations.  

Following this huge success, PSH will support the Ministry of Health and Child Care (MOHCC) to develop communication interventions to address the perceptions and barriers identified to improve uptake of HPV DNA self-sample collection and access to HPV DNA testing countrywide. 

B-OK Bead Bottles: HIV Treatment Simplified

This piece originally ran in the PEPFAR Zimbabwe Newsletter in April 2023

   When John’s health started deteriorating in 2017, he went to get tested for HIV with his wife and received a positive result. Regardless of this knowledge, he refused to initiate HIV treatment. Eventually, John fell ill between 2021 and 2022 and it was during this time he interacted with a community health worker who explained to him how HIV was affecting him. The nurse explained this using bead bottles, developed through the Flip the Script (FtS) treatment literacy campaign to improve HIV treatment adherence. Today, John is on treatment and is looking forward to experiencing the full benefits of HIV treatment in his life.”

The bead bottles have been a game changer in reshaping the attitudes and perceptions of people living with HIV and the broader community towards HIV treatment by amplifying the concept of U=U (undetectable equals untransmittable). This concept conveys that a virally suppressed person with an undetectable viral load cannot transmit HIV to their partner. This challenges the narrative of an HIV-positive diagnosis as a death sentence which has been a huge barrier to HIV testing and consequently starting and/or continuing treatment for many people. The first of three bead bottles represents a body that has been taken over by HIV. The second bottle symbolizes a scenario where HIV treatment is gradually reducing the amount of HIV in the body. The last bottle represents a virally suppressed body which means the person cannot transmit HIV to their partner.

   Interacting with the ART Champions and their b-ok demonstration has changed my attitude towards HIV treatment,” said one client from Marange. “I sometimes skipped it, but now take it every day, at the same time, even when I attend a funeral or church event, I carry my ART medication.”

Through this innovation, people living with HIV have gained the confidence to continue living the lives they desire through taking their HIV medication. It also highlights the importance of a periodic viral load test for all recipients of care to determine adherence to and effectiveness of treatment and the associated achievement of viral suppression.

   … the red beads represent HIV in the body and the black beads represent the body’s immune system. Taking your HIV medication every day at the same time helps you reduce the amount of HIV in the body and gradually, we have less of the red beads and more black ones. In the last bottle, the amount of HIV is so little that we only have that one red bead and so many black ones. At this point, you have a low chance of falling sick due to HIV and you have reduced chances of passing on HIV,” according to FtS Expert Client, Nyabira.

The bead bottles have equipped clinicians and community healthcare workers with the confidence and skills to explain what a viral load test result means using simple language. It has also helped people living with HIV to understand the benefits of consistently taking their HIV treatment leading to viral load suppression and reduced chances of passing on HIV to your partner.

   We have seen these tools work and they simplify our ways of counseling and giving information,” said one healthcare provider in Nyabira.

Community health worker leads a group discussion on viral load suppression.

Population Solutions for Health (PSH) and Population Services International (PSI) are implementing the Flip the Script (FtS) program in partnership with the Ministry of Health and Child Care with support from the  Bill and Melinda Gates Foundation, PEPFAR and Johnson & Johnson.

To assess the impact of the FtS intervention, the program conducted a reflexive study, tracked digital and mass media campaign reach, tracked ART champions’ community level program outputs and compared treatment indicators before and after the campaign at intervention and control sites. More than 1.4 million social media users were reached through digital and mass media campaign, while 1,600 people were reached by 37 ART Champions trained under FtS.

ART Champions supported over 1.400 recipients of care to access HIV testing, ART (re)initiation, and/or viral load testing. The reflexive design showed significant improvement in ART adherence, improved perceived community and household level social support, and improved knowledge on the benefits of ART among PLHIV exposed to the campaign. Viral load tests done increased by 164% comparing periods before and after the FtS campaign in the intervention sites. Qualitative results corroborated these quantitative results.

Giving Adolescent Girls & Young Women urgency, choice & control to protect themselves against HIV infection. Is Dapivirine Vaginal Ring the Game Changer?

PSH’s health care worker demonstrates the use of the Dapivirine Vaginal Ring (DPV-VR) to AGYW (Adolescent Girls and Young Women)

Imagine having to go to a discreet place or looking over your shoulder every time you must take oral pre-exposure prophylaxis (PrEP) for fear of stigmatization, being labelled as promiscuous, or experiencing abuse from your intimate partner. These are some of the challenges AGYW face daily as they try to take oral PrEP for the prevention of HIV infection.  

To mitigate these challenges, Populations Services International (PSI) and Population Solutions for Health (PSH), with support from PEPFAR through USAID, and in collaboration with the Ministry of Health and Child Care (MOHCC) is implementing a demonstration project in 8 districts under the $101M Going the Last Mile for HIV Control (Last Mile) Program in Zimbabwe. The goal is to assess the acceptability and feasibility of introducing the Dapivirine Vaginal Ring (DPV-VR) as an HIV prevention method among AGYW at high risk of HIV infection.  Preliminary findings show high acceptability of the DPV-VR with over 80% of AGYW offered either DPV-VR or oral PrEP opting for the ring. 

   The ring gives me privacy because it is inserted and no one can see it, unlike pills,” says a 23-year-old woman from Insiza 

As one component of a comprehensive and integrated HIV prevention, and sexual and reproductive health package, eligible AGYW have been receiving the flexible silicone Dapivirine vaginal ring and wearing it for 28 days before replacing it with a new one. Clients have been given the choice for provider-assisted DPV-VR insertion at the clinic or self-insertion in their safe spaces, in a self-care approach. To date, 1,137 eligible adolescent girls and young women have accessed the life-changing ring to protect themselves from HIV infection. This intervention brings urgency, choice and hope for AGYW who may not be empowered to negotiate safer sex.  

   I am thankful for the ring. Using daily pills was difficult for me as I could forget to take them sometimes. Unlike the oral PrEP, once the ring is inserted in me, I don’t have to worry about taking anything for 28 days. After the 28 days, I will just call the health care worker through the DREAMS (Determined, Resilient, Empowered, AIDS free, Mentored, and Safe) Facilitators for removal and insertion of a new ring. I am so happy about this ring and plead with PSH & MAC (Matabeleland AIDS Council) to continue providing these services beyond the 6 months period of the demonstration project as it really works for me,” said one of the AGYW using DPV-R for PrEP. 

This young female consumer is one of the many young women enjoying good health to this day, thanks to the HIV and SRHR prevention, treatment and care services provided through the Last Mile program. 


Transforming Community-Based Organizations for the Future!

Through Going the Last Mile Program, a USAID funded program, Population Services International (PSI) and Population Solutions for Health (PSH) is supporting community-based organizations (CBO’s) to strengthen their organizational capacity so that they may graduate to receive direct funding from PEPFAR and other funders. This is achieved through a structured and participatory organizational capacity assessment facilitated by skilled PSH staff.  

The assessment focuses on eight (8) key organizational development components: Leadership and Governance; Systems and Structures, Financial Management; Human Resources; Program Planning and Management; Monitoring and Evaluation; Networking and Collaboration; and Knowledge Management. 

In May 2020, Hands of Hope (HoH), Sexual Rights Centre (SRC), TransSmart, and Matebeleland Aids Council (MAC) participated in the first-round participatory organizational capacity assessment guided by skilled facilitators from PSH. Follow-up capacity assessments for the 4 CBOs were done in February 2023; with observed impressive improvements on the scores. Besides improved scores, the participatory assessment approach also changed perceptions of the assessed CBOs towards organizational capacity assessment and instilled ownership of the process.  

“The first words that came to my mind when I got communication on the Organizational Capacity Assessment from PSH were “oh my!! another fault-finding mission, however this time it was different,” says Viola George, Executive Director from MAC. 

The process did not only assess competency but also allowed the 4 CBO’s learning and development discussions for their betterment. Based on the discussions, scoring and recommendations, they shaped and set priorities for actions in boosting their governance, employee performance management, stakeholder engagement, strategic plan, and position for funding.  

Reflections on OCA and capacity building

“Having a current strategic plan coupled with updated organizational policies gave us a comparative advantage. In eight months, we were able to address key issues, create sound structures and systems to function more efficiently, and attract more funding partners,” says Viola George, Executive Director from MAC. 

She added, “MAC submitted a proposal for funding, and we are happy to say we managed to secure additional funding in February 2023, due to the updated organizational systems. All thanks to PSH.” 

In the same light, Hands of Hope benefited tremendously in improving its financial capacity, human capital, governance, and strategic soundness.

HoH is now better positioned resulting in other community-based organizations reaching out for support to strengthen their institutional capacity. HoH has plans to work with the two organizations as part of a funding and technical assistance consortium.” says an HoH representative.

Sexual Rights Centre and PSH team after a successful OCA.

Indeed, organizational success hinges on the role of identifying strengths and gaps and then developing and implementing a strategic plan to address identified gaps. It is the pathway to remaining a healthy organization.  MAC and HoH are reaping the fruits of organizational capacity assessment and are looking forward to a new era.