By Samkelo Mahlalela | 2019-10-10
Cancer is a class of diseases in which a group of cells display uncontrollable growth, with intrusion on and destruction of adjacent tissues and sometimes spread to other locations in the body via lymph or blood.
Most cancers form a tumour (growth) but some, like leukaemia, do not. Cancer is now recognized globally as one of the leading non-communicable diseases (NCDs). Second to cardiovascular diseases, cancers contribute to over 7.9 million deaths (13% of total global mortality) each year and this figure is projected to rise to nearly 10 million, unless the problem is addressed urgently.
As means of cervical cancer screening, Pap smear was introduced in national cervical cancer prevention programme in 1983. Further, in 2009, the government of the Kingdom of Eswatini incorporated the “See and Treat” approach to quicken the early detection of cervical lesions and facilitate the extension of cervical cancer prevention services across four regions.
Despite such efforts, in 2017, the Director of Health Services in the Ministry of Health, Dr Vusi Magagula announced that ever-increasing new cancer cases in Eswatini had seen cancer rise to become the third deadly disease after HIV and Tuberculosis (TB). Subsequently the country began to intensify the fight against cancer. Presently, the National Cancer Prevention and Control Unit, which coordinates the implementation of interventions aimed at reducing cancer morbidity and mortality, had developed the National Cancer Prevention and Control Strategy 2019, to facilitate the implementation of prioritized interventions.
Since most of cancer determinants are outside the scope of the health sector, the strategy proposes to extend cancer prevention and control interventions to all government sectors and other relevant sectors with active participation of civil society, local associations and the community. It is unsurprising therefore, that the Government of the Kingdom of Eswatini and development partners on Friday, 4th October launched the International Breast and Cervical Cancer Awareness Month. The launch was fittingly held at Fashion International in Matsapha (a company with 2068 workers, 1900 of which are women), was officiated by the Minister of Health Lizzy Nkosi and US Ambassador to Eswatini Lisa Peterson.
The campaign aims to increase attention and support for the awareness, early detection and treatment, as well as palliative care of the disease. There are over 100 types of cancers but for Eswatini the campaign will focus on the top five cancers threatening the country - breast, cervical (now the leading cancer in the Kingdom), prostate, Kaposi Sarcoma and Lymphoma cancers. In 2018, the number of new cases in both sexes and all ages were: cervical cancer 380 (35.4%); Kaposi sarcoma 104 (9.7%); prostate cancer 82 (7.6%); breast cancer 75 (7%); Non-Hodgkin lymphoma 48 (4.5%); and other cases 385 (35.8%).
The Eswatini Cancer Registry reveals that cervical cancer was not just the leading cause of death among women but was also had the highest new cases (53.5%) followed by breast cancer (10.6%); while prostate and Kaposi Sarcoma were the leading cause of death among men. For people living with HIV, the risk for developing cancers such as Kaposi Sarcoma, non-Hodgkin lymphoma, and cervical cancer (in women) and penile cancer (in men) are very high.
Cervical Cancer and HIV
The HIV response has made great gains in the antiretroviral treatment programme, with thousands of people living with HIV (PLHIV) now living longer with an improved quality of life.
The rising cancer incidence therefore challenges and threatens to reverse the gains that have been so painstakingly been achieved.
Cervical cancer develops in the cervix, the neck of the uterus.
The main cause of cervical cancer (almost 80%) is the human papilloma virus (HPV) which is transmitted through sexual intercourse and intimate skin-to-skin contact. Infection rarely shows symptoms and the risk factors include: starting sexual activity at a young age (early sexual debut); high number of sexual partners of women and of their partners (leading to multiple diseases); having a sexually transmitted disease, multiple pregnancies; smoking; being overweight (obesity); and a weak immune system.
The relationship between HIV and some cancers is attributed to HIV which attacks the immune system, reducing the body’s natural protections from infections and diseases. A weaker immune system is less able to fight off diseases, like cancer. People living with HIV, especially those not on treatment, often have a weakened immune system thus have a greater chance of getting cancer. The concern in the HIV response is that infection by one of the viruses (HIV or HPV) may accelerate transmission of the other.
Cervical cancer is an also known as an AIDS defining illness – directly associated with advanced HIV infection, predominantly affecting women of reproductive ages 15-49. Studies have shown that the prevalence of HPV infection rises soon after the onset of sexual activity and peaks in adolescence and early adulthood, after which it declines during the later decades of life. The high prevalence of HPV infection among young women has been found to be due to absence of adaptive immune response and the relatively larger area of cervical epithelium (thin tissue forming the outer layer of a body’s surface and lining the alimentary canal and other hollow structures) undergoing a harmless non-cancerous change (known as squamous metaplasia).
Risk factors for cervical lesions among HIV+ women
Compared with HIV negative women, HIV positive women are more likely (4-5 times) to be infected with HPV and to have persistent HPV leading to pre-cancer, larger and more difficult to treat precancerous lesions, higher recurrence rates of pre-cancer following treatment, and precancerous lesions that progress more rapidly to invasive cancer. Several studies clearly show an increased risk of rapid progression to cancer among HIV positive women.
The “Screening, prevalence, and risk factors for cervical lesions among HIV positive and HIV negative women in Swaziland” study by Joll et al. BMC Public Health (2017), concluded that the presence of cervical lesions was greater among HIV positive (22.9%) than HIV negative women (5.7%).
In the age-adjusted model women who had 2 or more lifetime sexual partners were 3 times more likely to have cervical lesions compared to women with 1 lifetime partner and the odds of cervical lesions among women with a history of STIs were 2.16 greater than among women with no previous STI. In the adjusted model, women who had a previous cervical exam were 2.5 times more likely to have cervical lesions than women who had not.
Fortunately, the US Government, through the PEPFAR/Eswatini programme, in 2018 began supporting the Government of the Kingdom of Eswatini on cervical cancer screening and treatment of precancerous lesions for women living with HIV. The programme accelerated and the number of HIV positive women aged 25-49 who have been screened for cervical cancer increased from 1, 090 to 5, 968 between April and August 2019. The number of health facilities providing screening and pre-cancerous lesion treatment services has also increased from 78 to 130 in the period.
Government committed to ending cervical cancer
In May 2018, the U.S. 2018, launched a global cervical cancer screening and treatment program called “Go Further”, which aims to reduce new cervical cancer cases by 95% among HIV-positive women in Eswatini and other high burden African countries. The innovative public-private partnership includes PEPFAR, the George W. Bush Institute, UNAIDS and the pharmaceutical company, Merck.
Recently, while in New York, His Majesty King Mswati III and other African heads of state, attended a meeting held on the margins of the 2019 United Nations General Assembly, with former US President George W. Bush, Mrs. Laura Bush and U.S. Global AIDS Coordinator Ambassador Deborah Birx, where the Go Further partnership was discussed. The Go Further partnership is critical to ensure that HIV and cervical cancer services are integrated and available to women and girls that need them most. His Majesty’s presence in the meeting shows the highest possible commitment to the partnership.
In the quest to End AIDS as a public health threat, the Government of the Kingdom of Eswatini continues to demonstrate strong political commitment. In outlining priority programmes of the National Multisectoral HIV and AIDS Strategic Framework (NSF) 2018-2023, opportunistic infections and co-morbidities were included as programmes of focus. The aim is to reduce cancer morbidity and mortality through the implementation of evidence based cost-effective prevention and control interventions and providing palliative care to improve the quality of life for people living with cancer and their families.
Currently, the ministry of health is considering providing Human Papilloma vaccination to girls and women before they are exposed to the virus. This requires finance and given the current socio-economic situation, it will put a further strain on government spending. It is heartening to learn therefore, that His Majesty King Mswati III is currently in Lyon, France to attend the Global Fund Replenishment Conference – a gathering of international leaders to mobilize financial resources for 2020 – 2022.
Cervical cancer can be prevented by vaccination against HPV and is curable if detected and treated early. Sexually active women should have regular Pap smear examination – even more important for women living with HIV on ART as without early diagnosis and treatment, 62% would expect to die from cervical cancer.
Eswatini’s future depends on all citizens. Take care of your health, screen for cancer today.
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