Story and photos by Margaret High
NKHOMA, MALAWI – As the sun rises over Nkhoma, Malawi, and the smell of firewood grows stronger, women begin to walk to the cervical cancer clinic at Nkhoma Hospital.
By mid-morning, concrete benches under a thatched roof are packed with women wearing colorful prints waiting their turn. A nurse named Harriet walks to the front of the crowd, standing out in her crisp white shirt and royal blue skirt.
She begins to sing and the women join in. They sing songs about family planning.
Nkhoma Hospital is about an hour outside of Lilongwe, the capital of Malawi, and serves as one of the main cervical cancer clinics in the country. It’s one of eight clinical sites implementing a new treatment program developed by Dr. Lameck Chinula and Dr. Jennifer Tang, both of UNC-Chapel Hill.
This new program targets rural communities and women with little access to health care working toward providing better cervical cancer treatment. Some components of the program, like self-screening, allow quicker and more efficient results and don’t require women to be at the clinic.
Already, Chinula and Tang’s research has filtered to North Carolina where women’s health clinics are mailing self-screening kits to rural communities.
UNC Project Malawi has been instrumental in cancer care in recent years. Since its establishment in 1990, the research center based in Lilongwe has evolved from studying infectious diseases like HIV, to studying and treating HIV-associated cancers, like cervical, Kaposi sarcoma and lymphoma.
Drawing attention to cervical cancer in Malawi wasn’t difficult for the two doctors as Malawi has the second highest cervical cancer rate in the world. This is attributed to high HIV and HPV rates in the country.
The new treatment is thermo coagulation, a highly efficient and effective tool that looks like a ray gun and burns off cervical cysts and cancerous cells.
Traditional cervical cancer care involves cryotherapy, a method of freezing precancerous cervical lesions. Cryotherapy is resource intensive, requiring carbon dioxide gas, and significantly more energy, time and money. It is also a more invasive procedure.
“There are two challenges with the old screening policy,” Tang says. “One is that (visual inspection of the cervix with acetic acid) is very observer dependent, so what some people think is a lesion others might not think it is, or vice versa. And then cryotherapy is also a difficult treatment modality because to freeze the cervix you have to have carbon dioxide gas, and carbon dioxide gas is not something that is easy to get in Malawi.”
Chinula noticed this inefficiency in treating Malawi women with cervical cancer and wanted to blend together different practices in order to provide better care to larger populations of women.
He knew the Malawian healthcare system was on a first-come first-serve basis, meaning long wait times for women. He knew cryotherapy was resource intensive and not culturally sensitive. He knew cancer care was highly centralized in Malawi, leaving out large groups of rural women.
He and Tang concocted a plan.
Studies show a certain strain of HPV is more effective in determining cervical cancer than pap smears, meaning women don’t have to wait in long lines to be screened. They can just swab while waiting for a different clinic or at home, then decide if they need to visit the hospital. HPV test results can be determined within hours.
If they test positive for HPV or are HIV-positive, they would come in for a formal screening and treated with thermo coagulation instead of cryotherapy. Thermo coagulators are battery powered and can treat about 30 women before needing to be recharged.
This same day testing and treatment allows significantly more women to be treated and allows healthcare providers to go into rural communities instead of placing the burden on the women.
Chinula and Tang are implementing this new strategy because of a $5.1 million grant from the U.S. Agency for International Development and the U.S. National Academies of Science, Engineering and Medicine.
“As HIV populations get access to effective HIV treatment, one of the main things that people start to suffer from is HIV associated cancers,” says Dr. Satish Gopal, cancer program director for UNC Project Malawi. “HIV itself doesn’t cause cancer, but other viruses can cause cancer, and they tend to be both more common in people with HIV and less well controlled by the immune system by people with HIV.”
One of those viruses that causes cancer in Malawi is HPV, which causes a majority, if not all, of cervical cancer cases.
The replacement of pap smears with HPV testing has increased testing population size in Malawi and is starting to do the same in North Carolina. Counties such as Robeson and Cumberland have particularly low access to cervical cancer care and the self-sampling strategy is allowing women to know if they need to travel to the closest clinic or wait another five years to test again.
“This has been really helpful because some women are very uncomfortable with pap smears anyway,” says Andrea Des Marais, project manager for the Gillings School of Public Health department of epidemiology. “By being at home, women are more comfortable with testing and we’re able to reach larger populations and different demographics.”
Currently, North Carolina is in the third phase of home-based HPV self-collecting, meaning they’re able to focus specifically on low income and under-served populations to study efficacy.
“(Researchers) don’t look at the planet as divided geographically,” says Dr. Myron Cohen, an infectious disease physician at UNC-CH. “So for people who work globally, the main reason is because of high density of infected populations. HIV is an example of working (in Malawi) because the incidence and prevalence is so high. Answering questions there would take decades in the U.S. When the prevalence is so high, you can address questions much more quickly.”
The same holds true for cervical cancer in Malawi, allowing quicker research results to inform North Carolina’s health care strategy.
As the lines at Nkhoma Hospital begin to dwindle and the music stops, health care providers plug in the thermo coagulators to recharge over the night. Today they treated 30 HPV-positive women, burning off cysts and preventing them from developing cervical cancer.
“We think the proposed strategy that Lameck and Jennifer Tang are leading will hopefully be a demonstration of the strategy that has the highest population coverage in a Sub-Saharan country,” Gopal says. “It takes advantage of HPV testing, which is the most current and cutting edge method for cervical cancer screening.”
