Screening for cervical cancer has been in place for years via Pap smear. Previously Pap smears were conducted on those who knew to ask for them and there was no national policy.
In the early 1990s one of the policies developed focused on women's access to equitable healthcare. To ensure that all women had access to a Pap smear that would be provided at a time when it was likely that cervical changes could be picked up, the 'three in a lifetime over 30' policy was developed. This made sense in terms of health economics and health systems. Cervical cancer is believed to be a slow growing cancer and a Pap smear at the ages of 30, 40 and 50 was regarded as a smart way to manage this epidemic. Women who died of cervical cancer were generally in their 60s.
Pap smears are qUite difficult to manage in the health system and this has been proven with a low rate of provision of smears. Currently we are reaching between 20 and 30 percent of the population, and aiming for a target of 70 per cent.
Nurses need clean, cared for and available equipment. The Pap smear procedure is also invasive and can be alienating for many women. The slides also need to be transported carefully and results managed and delivered back to clients. Although the policy is good on paper, there have been health system challenges in delivery. Visual inspection of the cervix with acetic acid (VIA) with on-site treatment is another strategy but also needs increased health systems and in particular trained human resources -- usually nurses. Given our context, these techniques might not work for us.
In the last month we have seen the introduction of two vaccines developed to address cervical cancer: Cervarix, developed by GSK, was launched first and addressed HPV types 16,18, 45 and 31, which make up 80 per cent of the cervical cancers associated with HPV. In those vaccinated fm HPV 16 and 18 there is a suggestion that it is 100 per cent antibody responsive. The other vaccine by Merck and Company/MSD, Gardasil is also effective against genital warts (caused by HPV 6 and 11), and vulval and vaginal cancerS, but also includes effectiveness against HPV 16 and 18. The burden of genital warts and the resultant distress it causes women would be important to consider in addressing women's rights and access to care.
The price tag is the huge factor in implementing this vaccine. As a health system we have in place good systems to manage vaccines. Girls need to be provided with the vaccine fmm age 10 onwards and this can be managed in schools. The cost of the Cervarix vaccine (three shots administered over six months) costs R2 100. This is without any mark-up from the pharmacy or administrators. This is a key area to watch as lobby groups and governments balance drug companies' prerogatives to recoup costs versus a public health imperative of granting access to lifesaving medication.
We also need to address the gender implications of the vaccine, while cervical cancer affects women, HPV affects both men and women. Women and girls bear the brunt of having to deal with health-seeking behaviour related to sexual, reproductive and fertility intentions. There is no data on vaccinating boys, but this might be an option if there were less constraints costs and availalble data.
The challenge that confronts us at the moment is that young women are contracting cervical cancer possibly due to increased HIV prevalence and that our screening policy is not getting to those who are HIV-positive- and have HPV. These women have a very fast-developing cervical cancer. We also do not know how these vaccines will work in those affected with HIV. Led by Professor Lyn Denny at the University of Cape Town, research is currently underway to explore the impact of the vaccine in HIV-positive women.
This is a space to watch. Can we let this oppoliunity go? Should we not be calling for costs of the vaccine to be reduced in trade agreements by government as with HAART medicines? Is this an HIV treatment issue for women? How do you feel as nurses? Would you be happy to do another vaccine as part of your scope of practice? Despite these new vaccines it is argued that screening should be continued 'as it is important to also monitor other possible HPV types, and our goal should still be to provide women with three Paps in a lifetime. |
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