Gaborone, Botswana – Two years ago, Dr. Mmakgomo “Mimi” Raesima was put in charge of cervical cancer prevention at the Ministry of Health with the task of figuring out how to end its reign as the No. 1 cancer killer of women in Botswana.
This was no easy task given that cervical cancer accounts for more than a quarter of all cancer in Batswana women. Worldwide, about half a million women are diagnosed with cervical cancer every year and around 275,000 women die from the disease, 85% of whom live in low- and middle-income countries.
Undeterred by these challenges, Dr. Raesima has taken the reins and set into motion a new prevention and control strategy with some innovative and cost-effective techniques for fighting cervical cancer in Botswana, including two unlikely weapons: vaccines and vinegar.
With support from partners including the U.S. government, Dr. Raesima plans to scale-up “See and Treat” clinics where women are screened for cervical cancer, diagnosed and treated all in one visit. The clinics use a remarkably simple and low-cost acetic test – otherwise known as household vinegar – to screen for cancerous cells in women.
Meanwhile, plans are moving ahead to vaccinate young Batswana women against the human papillomavirus (HPV), the cause of cervical cancer. Last year, more than 2,000 girls between the ages of 9-11 were voluntarily vaccinated in a demonstration project in Molepolole schools. This year starting in March, the HPV vaccine was being offered in Kweneng East, Kweneng West and Selibe-Phikwe districts.
“Botswana is becoming a leader in the response to cervical cancer and that is exciting,” Dr. Raesima said in a recent interview.
Partnerships between the Government of Botswana and the United States through the President’s Emergency Plan for AIDS Relief (PEPFAR) and the Pink Ribbon Red Ribbon Initiative (PRRR) have helped to put the strategy into motion, Raesima said. “The reason that we are moving ahead so quickly is because of this support. It’s what’s driving our strategy.”
HIV poses another test to cervical cancer prevention. Nearly 30% of women between 15-49 years are estimated to be HIV infected. Women living with HIV are more susceptible to HPV infection and cervical cancer is more aggressive in HIV-infected women. Unfortunately, the incidence of cervical cancer has not diminished since the introduction of antiretroviral therapy as it has with Kaposi sarcoma and other cancers.
The five-year comprehensive prevention and control strategy (2012-2016), launched last year by the Ministry of Health, plans to attack these challenges with a robust and sustainable plan that finally puts cervical cancer on the priority disease hit-list for the country.
“Cervical cancer is now one of the priority disease targets for Botswana,” Ms. Shenaaz El-Halabi, Deputy Permanent Secretary in the Ministry of Health, said during the August 2013 launch of the strategy. “Now is the time to scale-up our response in a coordinated and innovative way.”
Screening for Cervical Cancer
For the past 20 years, the Pap smear has been the only available method of screening for cervical cancer in Botswana. The technique was invented in the 1920s by George Papanicolau and involves a doctor taking a scraping from the lining of the cervix and sending it to a lab to be analyzed under a microscope. It is an expensive and time consuming technique, and when clients go home to wait for their results many are lost to follow-up and never seen again.
“Multiple visits and transportation for clients to and from the clinics and hospitals became an issue,” Dr. Raesima said. “Also, we never had a good plan in place for treatment.”
In 2011, the Ministry of Health supported a CDC consultant’s recommendation to endorse the addition of “VIA/cryo” which stands for visualization of the cervix with acetic acid and treatment with cryotherapy. Nurses using the procedure brush vinegar on a woman’s cervix which makes precancerous spots turn white. The tiny, seed-like spots can then be immediately frozen off with a metal probe cooled by a tank of carbon dioxide.
“We show the woman the picture and say, ‘This is your cervix. Here is the abnormality and we can freeze it today, immediately, getting rid of that seed that could cause cancer.’ The women overwhelmingly agree to treatment,” said Dr. Doreen Ramogola-Masire, director of the Botswana UPENN Partnership which first piloted “See and Treat” at a clinic in Gaborone.
Around 6,000 women have so far been screened through “See and Treat,” says Ramogola-Masire. The clinics are sponsored with PEPFAR funding and implemented through the Ministry of Health and the Botswana-UPENN Partnership. In 2012, Former President George W. Bush visited Botswana to announce $3 million for the scale-up of clinics through PRRR beyond Gaborone. The program has since extended services to Francistown, and plans are underway this year to expand to sites in Mahalapye, Selibe-Phikwe, Lobatse and Maun.
Primary prevention of cervical cancer involves prevention of the HPV infection. Dr. Raesima says this is achieved through social mechanisms like education and awareness campaigns to reduce high-risk sexual behavior. Another way is through biological mechanisms, including the HPV vaccination.
Last year, the Ministry of Health officially launched the HPV vaccine demonstration project targeting students from 23 primary schools in Molepolole. The demonstration project came two years early as a result of a funding agreement between Botswana and the World Bank. Other technical support came from the United States and a donation of vaccine doses from corporate partner Merck through PRRR. Dr. Raesima says she hopes to roll out the vaccine to the rest of the country by 2015.
In the second demonstration phase this year, the Ministry is targeting both school-going and out-of-school girls between 9-13 years old. The vaccines are being rolled out in Kweneng East, Kweneng West and the Selibe-Phikwe districts, this time under the National Immunization Program as part of its larger mission of strengthening school health programs.
“It makes sense, for the sustainability of the HPV vaccine,” Dr. Raesima said.
The fight against cervical cancer in Botswana will, of course, take more than vaccines and vinegar. The objectives of the national strategy also feature health-systems strengthening, health promotion, treatment and palliative care. Still, the introduction of the HPV vaccine and scale-up of “See and Treat” clinics are two vital pieces that help form a concerted and bold effort to combat the disease.
Dr. Raesima says the goal is clear: “We are simply trying to save more lives.”