Treat the Human Being, Not the Disease

The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) has earned its reputation as a key player in driving down incidence of HIV in children around the world—starting with the United States in the 1990s and then in sub-Saharan Africa over the past two decades. EGPAF is now also becoming known for its work to prevent and treat cervical cancer and other reproductive health issues. This includes vaccinating adolescent girls for HPV, the virus that causes cervical cancer.

So how does a cervical cancer program fit into the EGPAF’s mission to end AIDS in children? The nation of Lesotho in southern Africa illustrates the issue well.

When EGPAF started working in Lesotho in 2002, its primary program was prevention of mother-to-child HIV transmission (PMTCT). The focus was on the baby—to ensure that it be born HIV-free. However, in 2013, the World Health Organization began to promote a policy known as Option B+, which broadened that focus to more specifically include both mother and baby. Mothers living with HIV were ensured lifelong antiretroviral treatment to ensure that they, too, remain healthy.

Oluwasanmi Akintade, M.D., EGPAF-Lesotho’s director of reproductive health

“The incidence rate of cervical cancer among women living with HIV is about six times higher than among other women,” says Oluwasanmi Akintade, M.D., EGPAF-Lesotho’s director of reproductive health. “So the question is this: Why should you save the baby of this woman and, yet, allow this woman to die from cervical cancer so that this baby will become an orphan?

“You know, in medicine, at times we mistakenly treat a disease—but not the human being. Ideally, we be able to offer help so that at the end of the day we have treated an individual,” continues Dr. Akintade. “In terms of HIV, we know that’s HIV affects the father, it affects the mother, it affects the baby. So it’s a family issue, and it should be giving the family approach. We don’t want to treat only the virus without giving attention to overall family health.”

South-to-South Knowledge-Sharing

Nurse in Lesotho checking patient for cervical cancer. Photo by Justice Kalebe/EGPAF 2022.

Dr. Akintade came to Lesotho in 2007 from his home nation of Nigeria to work as a gynecologist for the Ministry of Health through the family health division. At that time, Lesotho did not have the resources to routinely screen for cervical cancer, and he was shocked by how many of his patients were fighting the disease.

“There were times that one out of every four beds will be occupied by a woman with cervical cancer,” says Akintade. “It is the leading cause of cancer death among women.”

At that time, a cervical cancer diagnosis was a virtual death sentence—because at diagnosis most of the disease had progressed to a late stage.

“We were doing what we would refer to as opportunistic screening,” says Dr. Akintade. “This means that if this woman reports that she is bleeding or having discharge, she will be referred to the gynecology clinic where she will be diagnosed through a biopsy. Then she will be referred to South Africa for treatment.” Traveling across the border for treatment, however, was beyond the means of some women.

Preventing Cancer

Nurse in Lesotho checking patient for cervical cancer. Photo by Justice Kalebe/EGPAF 2022.

“When I saw the magnitude of cervical cancer and the pain and the suffering that those women were going through, I concluded that I was no longer interested in simply treating cancer for women,” says Dr. Akintade. “I actually wanted to become what I refer to as a preventive oncologist. I wanted to become a gynecologist who prevented women from developing cancer.”

Working with the Ministry of Health team, Dr. Akintade developed the first cervical cancer guidelines for Lesotho. He developed tools for cervical cancer screening and looked for a partner organization to launch a program. Eventually, in 2011, Dr. Akintade came to the EGPAF to build a cervical cancer program.

“The truth is that we had to start everything from zero,” says Dr. Akintade. “We had to work on physical structures where the services will be provided. We had to develop registers and forms. Then we had to begin training health workers.”

In February 2013, EGPAF, under Dr. Akintade’s leadership, opened the Senkatana Centre for Excellence in Maseru, the capital city of Lesotho. Senkatana was the first center in the nation to provide organized screening to women for cervical cancer— using simple, innovative methods to identify cervical cancer in its earliest stages and cure the disease before it can progress. These methods included visual inspection with acetic acid and cryotherapy or thermocoagulation or Loop Electrosurgical Excision Procedure (LEEP) to remove precancerous cells and tissue.

Sentakana continues to provide a full range of services, including breast exams, HIV testing and counseling, and screening for sexually transmitted infections (STIs). But those services, along with cervical cancer services, have now been expanded out to all ten districts of Lesotho, under Dr. Akintade’s leadership.

“You know that before a woman develops cancer of the cervix, there is a grace period of five to 10 years,” says Dr. Akintade. “So within this period, if we put treatment in place and there is adequate follow-up, we are able to cure most of these women, even if they are living with HIV. We can cure as high as 95% of precancers if we catch them very early—and actually prevent them from developing into cancer of the cervix.

“In the last 10 years, we’ve been able to screen hundreds of thousands of women. And those who were identified with precancers of cervix have actually been treated—meaning that we are preventing those women from developing cancer. If, through a biopsy, a woman is diagnosed with an invasive cervical cancer, the Ministry of Health will approve funding to treat the cancer, which may include transferring her to a hospital in South Africa.

Dr. Akintade’s pioneering work has expanded across the countries that EGPAF supports, with cervical cancer prevention integrating into HIV programs across sub-Saharan Africa.

Building Local Capacity Through Technical Assistance

Dr. Akintade leads on cervical cancer prevention training for health care providers in Lesotho. Photo by Makopano Letsatsi/EGPAF 2021.

“Through EGPAF, health workers across the nation are being trained, with the goal that every woman will have local access to routine cervical cancer screening,” says Dr. Akintade. “EGPAF is providing technical assistance to health care workers within the Ministry of Health and the Christian Health Association of Lesotho (CHAL). Once training is completed, certain medical doctors designated as district technical advisors to oversee the activities. If there are still technical deficits, we organize what we call supportive supervisions to identify the gap in knowledge or skill at particular centers.”

While EGPAF has pioneered cervical cancer screening in Lesotho, a primary goal of the program is to transition implementation to local partners for a system of women’s health that will survive on its own, without EGPAF. Baylor College of Medicine Children’s Foundation, Lesotho (BCMCFL), an autonomous affiliate of the Baylor International, is now managing HIV services in two of Lesotho’s districts, having benefitted from EGPAF’s technical assistance. These services include reproductive health and cervical cancer screening. EGPAF is also training m2m, another local organization, to mobilize women to come for cervical cancer screenings.

Vaccination to Prevent Cancer

Lesotho staff promoting cervical cancer prevention and treatment. Photo by: Justice Kalebe/EGPAF 2022

Preventative measures now include vaccination for human papillomavirus (HPV), which causes cervical cancer. HPV vaccination is the most proven primary preventive method against HPV infection—and by extension cervical and other HPV-related cancers.

Lesotho’s Ministry of Health started HPV vaccination in 2009, but it was later put on hold in 2015 due to financial constraints. EGPAF continued to advocate for HPV vaccination, which eventually resulted in the integration of HPV vaccination into routine immunization for girls 9-14, starting in April 2022. Two doses are given, the second dose 6-18 months after the first dose. However, those girls who are 15 years and older or those who are living with HIV receive three doses. The goal is to vaccinate at least 90% of girls in Lesotho.