Cervical cancer is one of the commonest cancers in women, comprising 12% of cancers on a global basis. However, it is the commonest cancer in women from developing countries. An estimated 490 000 new cases of cervical cancer occur annually among women worldwide and nearly 80% of these are in developing countries, where screening programmes are poorly established and poorly organised.

HIV seropositive women are at much higher risk of developing changes in the cervix that can lead to cervical cancer. We are seeing these changes in 50% of our women at our cervical cancer clinic at the Themba Lethu Clinic, with many having severe changes of early cancer limited to the cervix. In some areas of South Africa the incidence is even higher.

Screening programmes, involving a Pap smear, in the Australia, Europe and USA, have greatly reduced the incidence of cervical cancer in these countries. A Pap smear is merely a screening tool that obtains a few cells off the cervix. An abnormal Pap smear needs to be verified by a biopsy. This is done using a colposcopy microscope. The procedure involves painting the cervix with acetic acid, which turns disease areas white. White areas are then visualised more specifically with the aid of this microscope.

Once the biopsy is taken in the disease area of the cervix and the Pap smear abnormal cells are verified, the patient returns for the removal of disease areas. This is called a Loop Electro-Excision Procedure (LEEP). Local anaesthesia is placed around the cervix and then an electrically charge wire loop cuts out the pre-cancerous or early cancer areas, preventing the spread of cancer.

In October 2008, we started expanding the cervical cancer screening and treatment programme based on the Pap smear screening programme described above, that we developed at Themba Lethu Clinic. Our model is to screen for and treat any pre-cancerous lesion on-site in the HIV clinic. This avoids the patient having to go to another clinic, additional transport costs, days off work, and reduces loss to follow up. From October 2008 to September 2009, this programme expanded to eight locations in Gauteng and other provinces.

At Right to Care we have developed a training programme. This training takes several months and significant practice under mentoring, which was done by the team’s obstetrical and gynaecological specialists Prof Simon Levin and Dr Mark Faesen. Thirteen professional and primary healthcare nurses were trained in doing Pap smears.

In addition, equipment was procured for each site, which included colposcopy and LEEP machines. Information forms and databases were created to store the results of the Pap smears, colposcopy, and LEEP procedures. From May 2009 until September 2009, as sites began coming on-stream, 2095 Pap smears, 218 colposcopy, and 77 LEEPs were done.In addition, several nurses were trained in an innovative form of screening: Visual Inspection of the Cervix with Acetic Acid (VIA), with treatment using cryotherapy, the ‘see-and-treat’ method. It involves the nurse spreading acetic acid on the cervix, turning the disease areas white. The white areas, if small enough, can be treated with cryotherapy. This method is highly efficient in a resource-limited setting, since it is nurse driven. Screening and treatment can be done in one visit and no pathologist is needed.

However, a drawback of the procedure is that white areas may not always represent disease. Five nurses were trained in this see-and-treat method. This type of screening and treatment is being set up in the Northern Cape, for which specialist doctors are difficult to recruit. Digital pictures of the cervix that are screened and treated by the nurse are taken and reviewed electronically by one of our specialist physicians. If necessary, the nurse is called and an adjustment in the treatment plan made.