Abstracts

Introduction

Every year cervical cancer kills an average of 275 000 women and five sixths of these deaths occur in low- and middle-income countries. In sub-Saharan Africa, for example, the incidence of cervical cancer and breast cancer is no higher than in other parts of the world, but the risk of death among women with either disease is much higher than in high-income countries ­– eight times higher in the case of cervical cancer – because African women face enormous barriers to treatment.¹1 Arbyn M, Castellsagué X, de Sanjosé S, Bruni L, Saraiya M, Bray F et al. Worldwide burden of cervical cancer in 2008. Ann Oncol 2011;22:2675–86. doi: http://dx.doi.org/10.1093/annonc/mdr015 PMID:21471563
https://doi.org/10.1093/annonc/mdr015... ^,22 Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM [Internet]. Globocan 2008: estimated cancer incidence, prevalence, mortality and disability-adjusted life years (DALYs) worldwide in 2008. Lyon: International Agency for Research on Cancer; 2010. Available from: http://globocan.iarc.fr [accessed 23 May 2013].
http://globocan.iarc.fr... If case-fatality is to be reduced, access to primary prevention, screening, treatment and palliative care will need to be facilitated and women's cancers will have to be prioritized in countries' health agendas.

Pink Ribbon Red Ribbon (PRRR), launched in September 2011, is an innovative public–private partnership that supports African and Latin American countries in accelerating the implementation of their national strategies for the control of women's cancers. The partnership consists of four organizing members – the George W Bush Institute, the United States President's Emergency Plan for AIDS Relief (PEPFAR), Susan G Komen for the Cure and the Joint United Nations Programme on HIV/AIDS – as well as Becton, Dickinson and Company, the Bill & Melinda Gates Foundation, the Bristol-Myers Squibb Foundation, the Caris Foundation, GlaxoSmithKline (GSK), IBM, Merck, QIAGEN and other organizations with more limited engagement. It seeks primarily to reduce mortality from cervical cancer by 25% between 2012 and 2016 among the women screened and treated through the programme and to reduce deaths from breast cancer by promoting early detection. Specifically, PRRR focuses on improving access to the human papillomavirus (HPV) vaccine, increasing awareness of breast and cervical cancer prevention, diagnosis and treatment and reducing the stigma that so often surrounds a cancer diagnosis.

PRRR builds primarily on the PEPFAR platform and operates as a country-aligned partnership. Currently engaged in Botswana and Zambia with PEPFAR providing some support to nine additional countries – Cote d'Ivoire, Ethiopia, Kenya, Mozambique, Nigeria, Rwanda, South Africa, Uganda and the United Republic of Tanzania – PRRR aims to create innovative implementation models that can be used and scaled up globally. This paper outlines how PRRR supports countries and the lessons learnt after one year of implementation.

Approach

Diagonal integration

PRRR takes a diagonal approach to cancer control. This consists of leveraging existing – usually vertical – programmes focused on achieving disease-specific results with measures designed to enhance health systems more generally, often by integrating the activities of different disease programmes.³3 Frenk J. Bridging the divide: global lessons from evidence-based health policy in Mexico. Lancet 2006;368:954–61. doi: http://dx.doi.org/10.1016/S0140-6736(06)69376-8 PMID:16962886
https://doi.org/10.1016/S0140-6736(06)69... A diagonal approach requires: (i) entry points for programme integration based on overlapping health services or patient populations; (ii) the identification of those health systems into which certain services can be integrated; and (iii) the development of a strategy for broader health systems strengthening.

Programmes for the control of human immunodeficiency virus (HIV) infection provide an ideal platform for the integration of cervical cancer control services because most are well funded, decentralized and designed to provide longitudinal care. PEPFAR-supported HIV interventions serve as PRRR's primary integration point for cervical cancer screening and treatment. PRRR's initial focus is on settings where the prevalence of HIV infection is high. In sub-Saharan Africa, countries having the highest burdens of HIV infection are those that also have the highest age-adjusted cervical cancer incidence and mortality rates,²2 Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM [Internet]. Globocan 2008: estimated cancer incidence, prevalence, mortality and disability-adjusted life years (DALYs) worldwide in 2008. Lyon: International Agency for Research on Cancer; 2010. Available from: http://globocan.iarc.fr [accessed 23 May 2013].
http://globocan.iarc.fr... partly because HIV-positive women are at higher risk of developing cervical cancer.⁴4 Grulich AE, van Leeuwen MT, Falster MO, Vajdic CM. Incidence of cancers in people with HIV/AIDS compared with immunosuppressed transplant recipients: a meta-analysis. Lancet 2007;370:59–67. doi: http://dx.doi.org/10.1016/S0140-6736(07)61050-2 PMID:17617273
https://doi.org/10.1016/S0140-6736(07)61... ^–66 De Vuyst H, Lillo F, Broutet N, Smith JS. HIV, human papillomavirus, and cervical neoplasia and cancer in the era of highly active antiretroviral therapy. Eur J Cancer Prev 2008;17:545–54. doi: http://dx.doi.org/10.1097/CEJ.0b013e3282f75ea1 PMID:18941376
https://doi.org/10.1097/CEJ.0b013e3282f7... In countries with strong, decentralized HIV service delivery systems, it is sensible and feasible to integrate HIV and cervical cancer services, a process that can be greatly facilitated by the experience these countries have gathered in the area of chronic disease management.⁷7 Yu D, Souteyrand Y, Banda MA, Kaufman J, Perriëns JH. Investment in HIV/AIDS programs: does it help strengthen health systems in developing countries? Global Health 2008;4:8. doi: http://dx.doi.org/10.1186/1744-8603-4-8 PMID:18796148
https://doi.org/10.1186/1744-8603-4-8... ^,88 El-Sadr WM, Holmes CB, Mugyenyi P, Thirumurthy H, Ellerbrock T, Ferris R et al. Scale-up of HIV treatment through PEPFAR: a historic public health achievement. J Acquir Immune Defic Syndr 2012;60(Suppl 3):S96–104. doi: http://dx.doi.org/10.1097/QAI.0b013e31825eb27b PMID:22797746
https://doi.org/10.1097/QAI.0b013e31825e...

The easiest way to integrate cervical cancer services into existing HIV programmes is to add point-of-care screening using cervical visual inspection with acetic acid, followed by cryotherapy during the same visit, if required. Using this “see and treat” approach to screen and treat both women with HIV infection and uninfected women in the same facility broadens access to basic cervical cancer control services. The health system as a whole is strengthened. This approach has been scaled up in sub-Saharan Africa with support from PEPFAR and the results have been positive. In Zambia, for example, the Centre for Infectious Disease Research has reported broad health system improvements since the country implemented this “see and treat” approach.⁹9 Mwanahamuntu MH, Sahasrabuddhe W, Pfaendler KS, Mudenda V, Hicks ML, Vermund SH et al. Implementation of ‘see-and-treat’ cervical cancer prevention services linked to HIV care in Zambia. AIDS 2009;23:N1–5.

While the above method provides an entry point for screening and treatment, far more is needed for comprehensive cancer control. All of the following need to be available and accessible: advanced diagnostic and pathology services; chemotherapy and radiotherapy services; palliative care; educational interventions for both patients and health workers; stigma reduction strategies; trained workers who can deliver services; referral networks; and data systems for tracking patients across different levels of care. Not all of these elements can be easily integrated into HIV services. However, if they are strengthened in the course of improving cervical cancer screening and management, services for the control of other types of cancer, including breast cancer, will be strengthened as well. The same skilled health workers and advanced diagnostics, referral, treatment and data management facilities can be used in the management of other cancers. There are also other possible entry points for cervical cancer control. For example, school-based campaigns for the promotion of vaccination against infection with the human papillomavirus (HPV) can be integrated with other interventions targeting adolescents, such as education about sexually transmitted infections or mass drug administration for trachoma control. The GAVI Alliance requires that the feasibility of integrating one or more adolescent health interventions be assessed in all its HPV demonstration projects.¹⁰10 GAVI Alliance [Internet]. Guidelines for applications 2012: Human Papillomavirus (HPV) Vaccination Demonstration Programme. Available from: http://www.gavialliance.org/library/documents/gavi-documents/guidelines-and-forms/application-guidelines-for-hpv-vaccination-demonstration-programmes/ [accessed 22 May 2013].
http://www.gavialliance.org/library/docu...

A final point is that programmes need to be linked across different levels of care, from the community to the referral facility level. PRRR's “see and treat” approach to cervical cancer detection and control can be implemented in primary care facilities. Its clinical integration with HIV services will increase its uptake, but uptake will also depend on community-level activities. Some examples of these are the sensitization activities supported by Susan G Komen for the Cure and Bristol-Myers Squibb, designed to increase knowledge, awareness and understanding of cervical cancer services. Many of the women screened will have lesions too advanced for cryotherapy and will have to undergo the loop electrosurgical excision procedure (LEEP) in a secondary hospital and perhaps radiotherapy, chemotherapy or both in a tertiary hospital. This highlights the need to support the strengthening of referral systems, patient tracking and data management systems, and laboratory and surgical capacity. IBM supports health management information systems; Becton, Dickinson and Company and the MD Anderson Cancer Center support laboratory and surgical capacity, respectively.

Country-owned, country-led

PRRR combines the flexibility of a public–private partnership with a structure that invites country ownership and leadership of national measures for the control of women's cancers (Fig. 1). PRRR focuses on filling those gaps in national cancer control strategies and plans that each government identifies and prioritizes. In most countries, the ministry of health convenes a technical working group composed of various stakeholders from governmental, nongovernmental, private and other types of organizations whose role is to develop the national strategy and plan for the control of women's cancers. The ministry of health takes primary responsibility for operationalizing the strategy and plan and relies on support from its partners, including PRRR, to identify, prioritize and fill gaps in implementation. By operating as a country-led public–private partnership in alignment with countries' goals, PRRR seeks to allay the concern of some advocates, scholars and policy-makers that public–private partnerships may shift country priorities towards commercial interests or “marketable” high-profile conditions.¹¹11 Buse K, Harmer A. Power to the partners? The politics of public–private health partnerships. Development 2004;47:49–56. doi: http://dx.doi.org/10.1057/palgrave.development.1100029
https://doi.org/10.1057/palgrave.develop...

PRRR's member organizations interface with each country's national technical working group through country-specific PRRR teams. These teams are composed of in-country staff members of each PRRR organization and of personnel at headquarters. The former understand national programme needs and the status of women's cancer control, whereas the latter can quickly mobilize resources. The country teams coordinate activities across member organizations and ensure alignment with country goals. Members of the country teams also hold one another accountable for commitments made to support particular countries.

The PRRR's secretariat, led by the partnership's executive director and housed at the George W Bush Institute, is a small body that coordinates the PRRR's activities. It is funded by the Bristol-Myers Squibb Foundation, the Caris Foundation, the Bill & Melinda Gates Foundation, GSK and QIAGEN. As country teams identify gaps and priorities, the secretariat works with existing partners to address them. For example, Zambia identified palliative care as a priority, so the secretariat engaged GSK to provide one million doses of morphine sulfate to Zambia annually for three years. The secretariat also identifies new potential partners to fill additional gaps. To qualify, these must have goals in alignment with those of the PRRR, be seen as valuable in filling specific gaps and agree to be held accountable for commitments.

Finally, the PRRR strategy is led by its steering committee, which operates like a board of directors and sets high-level directions. It is supported by working groups composed of specialized personnel from member organizations that focus on particular domains. For example, in consultation with the countries, the Targets, Indicators and Evaluation Working Group develops standardized indicators in alignment with World Health Organization (WHO) indicators and other types of measures, such as partnership assessment indicators. The Scale-up, Quality and Sustainability Task Group reaches beyond PRRR members to include WHO, the Union for International Cancer Control, the American Cancer Society, the GAVI Alliance and ministries of health in efforts to scale up interventions in a sustainable manner without compromising programme quality.

Effect of partnership activities

Although no formal impact evaluation has been conducted yet, service data suggest that PRRR support has strengthened country activities. According to data reported by the African Centre of Excellence for Women's Cancer Control, more than 27 049 women in Zambia were screened for cervical cancer through PRRR-affiliated programmes supported by PEPFAR in the 14-month period from December 2011, when the partnership was launched in Zambia, to January 2013. This is nearly twice the number of women who were screened in 2011 (14 363). Similarly, between July and December 2012 more than 1000 women in Botswana, a country with a much smaller population, were screened through PRRR-affiliated programmes with support from PEPFAR. Nearly all the women who screened positive for cancerous and precancerous lesions – approximately 18% of those screened – received cryotherapy or LEEP or were referred for advanced diagnostics and treatment. In Zambia, more than 40 health workers have been trained in the “see and treat” cervical cancer screening and treatment approach. More than a dozen of these recently trained practitioners also work in other countries in sub-Saharan Africa. During the recently completed first phase of the HPV vaccine demonstration project in Botswana, more than 2000 girls were vaccinated in one week with support from Merck.

Coordination across sectors

PRRR members have pledged over 85 million United States dollars in money and in-kind support for the first five years of PRRR activities. However, public–private partnerships do more than mobilize resources. They capitalize on the particular efficiency and expertise of different organizations while avoiding duplication of effort among them.

Comprehensive cancer control requires that inputs be coordinated along the cancer continuum of care, from “vaccine to morphine”: primary prevention with HPV vaccination, basic screening and treatment, advanced diagnostics, surgery, chemotherapy, radiotherapy and palliative care.¹²12 Comprehensive cervical cancer control: a guide to essential practice. Geneva: World Health Organization; 2006. Available from: http://whqlibdoc.who.int/publications/2006/9241547006_eng.pdf [accessed 20 May 2013].
http://whqlibdoc.who.int/publications/20... Some of these inputs are outside the mandate of particular organizations. For example, PEPFAR cannot provide the HPV vaccine because it is not directly related to HIV prevention, but Merck and GSK can donate it or offer it at appropriately discounted prices. Furthermore, private organizations can often provide expertise that others cannot match and can respond nimbly to certain country needs. They can, for instance, quickly procure necessary commodities. Other organizations, such as the Joint United Nations Programme on HIV/AIDS, enjoy a level of credibility with governments and civil society organizations, such as the Global Network of People Living with HIV, that facilitates support for advocacy, policy and guideline development.

Finally, to ensure that resources, once committed, are disbursed, PRRR uses an innovative accountability mechanism. Instead of creating rigid memoranda of understanding, bylaws or similar instruments to bind members to their pledges, PRRR exercises flexibility to allow them to adapt to changes in countries' strategies and needs. To promote accountability, PRRR requires that pledges be made publicly and every quarter its secretariat determines whether those commitments are on track and reports their status to all PRRR members.

Lessons learnt

In the process of creating a complex partnership, with its attendant challenges, we have learnt valuable lessons that may be helpful to other public–private partnerships (Box 1). Coordinating public–private partnerships is challenging because each partner has both shared and separate organizational goals. Different partners may be ready to move faster than countries can act. Processes are slower at the country level since countries often have to vet strategies with stakeholders. Effective implementation, therefore, requires a well-phased and flexible approach that enables support to be mobilized when high-priority needs are identified. This will often involve starting opportunistically when partners can meet the prioritized needs, such as with basic screening and treatment. However, this approach works only if there is an efficient country coordination mechanism, ideally a national women's cancer technical working group that represents a wide range of stakeholders and can inform government policy and plans. Such an approach also recognizes that implementation models will vary depending on what is most appropriate for particular countries and national preferences. Within public–private partnerships, frequent communication that quickly addresses the problems faced by any partner is critical for proper coordination and continued engagement of partners.

As high-income countries enter periods of fiscal austerity, it will become ever more important to develop models for increasing domestic and international private sector investment while simultaneously improving countries' capacity to implement programmes. The lessons we have learnt at PRRR can help other public–private partnerships avoid pitfalls and meet challenges.

Competing interests:

References

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