LETTERS
Integrating cervical cancer prevention in HIV/AIDS treatment and care programmes
Mulindi H MwanahamuntuI; Vikrant V SahasrabuddheII, 1; Jeffrey SA StringerIII; Groesbeck P ParhamIII
IUniversity Teaching Hospital, Lusaka, Zambia
IIInstitute for Global Health, Vanderbilt University, Nashville, TN, United States of America
IIIUniversity of Alabama at Birmingham, Birmingham, AL, USA
Peckham and Hann's call for integrating cervical cancer prevention as part of broader sexual and reproductive health prevention services1 is especially relevant to sub-Saharan Africa where both cervical cancer and sexually transmitted infections, especially HIV/ AIDS, are widely prevalent.
Over the past decade, successful HIV/AIDS care and treatment programmes have been instituted in over a dozen hardest-hit sub-Saharan African countries, largely through bilateral and multilateral programmes like the United States President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria.2 HIV-infected women are at heightened risk for pre-invasive and invasive neoplasia of the cervix.3,4 HIV/AIDS care and treatment programmes thus provide an ideal platform to integrate cervical cancer prevention activities in countries which face a dual burden of both AIDS and cervical cancer, an AIDS-defning disease. With steady donor support over the past 5 years, these programmes are slowly but steadily contributing to the development of health-care service delivery capacity in emerging nations by establishing infrastructures, training the health-care work force, and tackling complex and challenging problems in implementation and scale-up.5
Limited access to cervical cancer prevention services, the usual circum-stance for women in low-resource environments, serves as a counterforce to the life-prolonging potential of increased access to afordable antiretro-viral therapy. Cervical cancer prevention strategies that use visual inspection with acetic acid (VIA) and same-visit cryotherapy ("see-and-treat") are cost-efective alternatives to cytology-based screening programmes. Tese procedures can be performed by nurses and other non-physician health-care workers and allow screening and treatment to be linked to the same clinic visit. Our experience in Zambia has shown that VIA-based prevention services that are nested within the context of antiretro-viral therapy programmes allow early detection of cervical cancer in high-risk HIV-infected women in a cost-efective way.6,7 It also allows opportunities for the provision of broader gynaecologic and other health care for women. Eventual integration of low-cost, rapid screening tests for detecting human papillomavirus within VIA-based screening services will additionally increase programmatic efciency. When cervical cancer prevention services are ofered to HIV-infected women in a venue attended by non-HIV-infected women, a scalable intervention is established that can reach out to all women regardless of HIV status.
Horizontal and diagonal collaborations between agencies and individuals focusing on HIV/AIDS care and cancer prevention could open new vistas for expanding availability of care for women at risk of one or both of these conditions, thereby ensuring wider programme impact. Te conjoint contributions of such collaborations may be larger than the sum of their parts. 
References
1. Peckham S, Hann A. A sexual health prevention priority. Bull World Health Organ 2008;86:490-1. PMID:18568280 doi:10.2471/BLT.08.053876
2. PEPFAR and the fght against HIV/AIDS. Lancet 2007;369:1141. PMID:17416238 doi:10.1016/ S0140-6736(07)60536-4
3. Franceschi S, Jaffe H. Cervical cancer screening of women living with HIV infection: a must in the era of antiretroviral therapy. Clin Infect Dis 2007;45:510-3. PMID:17638204 doi:10.1086/520022
4. Parham G P, Sahasrabuddhe VV, Mwanahamuntu MH, Shepherd BE, Hicks ML, Stringer EM, et al. Prevalence and predictors of squamous intraepithelial lesions of the cervix in HIV-infected women in Lusaka, Zambia. Gynecol Oncol 2006;103:1017-22. PMID:16875716 doi:10.1016/j.ygyno.2006.06.015
5. Stringer JS, Zulu I, Levy J, Stringer EM, Mwango A, Chi BH, et al. Rapid scale-up of antiretroviral therapy at primary care sites in Zambia: feasibility and early outcomes. JAMA 2006;296:782-93. PMID:16905784 doi:10.1001/jama.296.7.782
6. Parham G P, Mwanahamuntu MH, Pfaendler KS, Mkumba G, Sahasrabuddhe VV, Hicks ML, et al. Building a cervical cancer prevention program into an HIV care and treatment infrastructure. In: Marlink R, Teitelman S et al., eds. From the ground up: a guide to building comprehensive HIV/AIDS care programs in resource-limited settings. Washington, DC: Elizabeth Glaser Pediatric AIDS Foundation; 2008.
7. Pfaendler KS, Mwanahamuntu MH, Sahasrabuddhe VV, Mudenda V, Stringer JS, Parham G P. Management of cryotherapy-ineligible women in a "screen-and-treat" cervical cancer prevention program targeting HIV-infected women in Zambia: Lessons from the feld. Gynecol Oncol 2008;e-pub 13 June.
1 Correspondence to Vikrant Sahasrabuddhe (e-mail:vikrant.sahasrabuddhe@vanderbilt.edu).