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Fight for cervical cancer prevention, diagnostics and treatment in Africa !

By Agnès Binagwaho, MD, M(Ped) | 21 Feb, 2011 Last edited by Robert Szypko on 28 Jul 2011

Today, I have been reflecting on the progress the world has made in the fight against infectious diseases. Even though there is a long road ahead, there are many achievements we can be proud of. In my country, Rwanda, we have decreased the rate of deaths due to malaria by more than 65% since 2005. We are now providing universal access to anti-retroviral therapy (ART) for all those diagnosed to be in need of treatment, a total of over 83,000 people. Rwanda currently has multiple hygiene campaigns; and has provided 60,000 Community Health Workers with antibiotics (Ampiciline), oral rehydration solution, and training on how to treat digestive and pulmonary diseases at home. Through these interventions, we are sure to continue to make progress in tackling communicable diseases.

In Rwanda, now that morbidity and mortality due to infectious diseases have both decreased, we are looking to take a step forward and tackle the other serious causes of death. According to the WHO, non-communicable diseases (NCDs) are responsible for 25% of mortality in our region of the world. For the past two years, the Ministry of Health of Rwanda has been considering various initiatives specific to NCDs. Cancer is one of the top killers among this category of disease. It is a leading cause of death worldwide accounting for an estimated 7.9 million deaths in 2007 alone. Knowing that over 70% of these deaths occur in low- and middle-income countries, where resources available for prevention, diagnosis and treatment of cancer are limited or nonexistent, I argue that it is time for us to focus on a strategy to reduce the burden of NCDs. The challenge will be to do so without reducing our energy currently put into fighting communicable diseases.

Among women, cancers of the breast, uterus, cervix and ovaries represent the most common cancers diagnosed. Until recently, there was no certain way to prevent these cancers. Yet now one of the most common causes of cancer among women in our region, cervical cancer, is preventable with a simple vaccination. As such, here in Rwanda in 2009, under the leadership of President Paul Kagame, we began to work on a plan to provide universal access for primary prevention of cervical cancer by vaccinating our girls with the HPV vaccine before any sexual intercourse. Now we have finished our strategy for national cervical cancer prevention, screening and treatment, and we are strongly pushing global leaders to help make our plan a reality.

Our program is very simple: One full package for girls (primary prevention = 3 doses of HPV vaccine before any sexual intercourse) and One full package for women (screening technology = HPV/DNA technology and access to treatment at ages 35 and 45). The best place to implement the vaccinations will be where our girls and women are living. Because we are experienced in offering our population a very high vaccine coverage, we are confident in the plan to provide universal coverage for cervical cancer prevention by vaccination. In the case of malaria and HIV, Rwanda has effectively implemented diagnostic and treatment capacities from communities to referral systems. Rwanda has introduced new vaccines and effectively achieved high coverage of these vaccines; we were the first country to introduce pneumococcal vaccine in Africa. Now we have built on our existing capacity to implement preventive, diagnostics and treatment measures at all levels of care, and have used lessons learned to ensure the same for the management of cancer. Therefore, we need the world to believe that such a medical intervention and such technologies should be accessible to Rwandan women; and to believe that we can do this just as we have successfully implemented myriad other public health programs.

Unfortunately, some influential partners contradict their mandate by trying roll us back. This situation reminds me of the late 1980s when activists proposed to make ART accessible to African people living with AIDS. Many argued against this – particularly deliberating about whether African health professionals would be able to manage such complicated treatment instead of working with them on how best to implement such an intervention in resource-poor settings. In the fight against cancer, we will build on the lessons learned from the successful HIV and malaria programs already firmly established in Rwanda. So let’s all push together to make it happen today.

What are your thoughts?



Ingrid Katz Replied at 2:52 PM, 21 Feb 2011

Thank you for bringing this important issue forward. This is so critical and can become a roll model for your neighbors throughout Africa. It is champions like you that make this possible. We can only hope there are others who are willing to do the same. Thank you!

Daniel Halperin Replied at 9:07 PM, 21 Feb 2011


We of course support the need for access to the cervical cancer vaccine in developing regions.

In addition, FYI UNAIDS sent around this recent article (and commentary) yesterday (and note the conclusion that "In settings where the new HPV vaccines are still not available, male
circumcision services should be scaled up – they will contribute to prevention of cervical cancer"):

Effect of circumcision of HIV-negative men on transmission of human papillomavirus to HIV negative
women: a randomised trial in Rakai, Uganda

Wawer MJ, Tobian AA, Kigozi G, Kong X, Gravitt PE, Serwadda D, Nalugoda F, Makumbi F, Ssempiija V,
Sewankambo N, Watya S, Eaton KP, Oliver AE, Chen MZ, Reynolds SJ, Quinn TC, Gray RH. Lancet. 2011 Jan

Randomised trials show that male circumcision reduces the prevalence and incidence of high-risk human
papillomavirus (HPV) infection in men. Wawer and colleagues assessed the efficacy of male circumcision
to reduce prevalence and incidence of high-risk HPV in female partners of circumcised men. In two
parallel but independent randomised controlled trials of male circumcision, they enrolled HIV-negative men
and their female partners between 2003 and 2006, in Rakai, Uganda. With a computer-generated random
number sequence in blocks of 20, men were assigned to undergo circumcision immediately (intervention) or
after 24 months (control). HIV-uninfected female partners (648 of men from the intervention group, and 597
of men in the control group) were simultaneously enrolled and provided interview information and self collected
vaginal swabs at baseline, 12 months, and 24 months. Vaginal swabs were tested for high-risk
HPV by Roche HPV Linear Array. Female HPV infection was a secondary endpoint of the trials,
assessed as the prevalence of high-risk HPV infection 24 months after intervention and the
incidence of new infections during the trial. Analysis was by intention-to-treat. An as-treated analysis
was also done to account for study-group crossovers. During the trial, 18 men in the control group
underwent circumcision elsewhere, and 31 in the intervention group did not undergo circumcision. At 24-
month follow-up, data were available for 544 women in the intervention group and 488 in the control group;
151 (27·8%) women in the intervention group and 189 (38·7%) in the control group had high-risk HPV
infection (prevalence risk ratio=0·72, 95% CI 0·60-0·85, p=0·001). During the trial, incidence of high-risk
HPV infection in women was lower in the intervention group than in the control group (20·7
infections vs 26·9 infections per 100 person-years; incidence rate ratio=0·77, 0·63-0·93, p=0·008). The
findings indicate that male circumcision should now be accepted as an efficacious intervention for
reducing the prevalence and incidence of HPV infections in female partners. However, protection is
only partial; the promotion of safe sex practices is also important.

Abstract :

Editor’s note: Cervical cancer is the third most common cancer in women worldwide and the leading cause
of cancer mortality in women in parts of Africa. Observational studies have shown that women whose
partners are circumcised have less cancer of the cervix. What is the link? Infection with high-risk human
papillomavirus (HPV) is a necessary precondition for cervical cancer. Circumcision is associated with
decreased HPV detection at the urethra, the coronal sulcus, and the shaft of the penis. Trials have
demonstrated that men who undergo circumcision are less at risk for acquiring HPV and clear the infection
more quickly if they do get infected. In this trial, the women had similar HPV prevalence at baseline but
those whose partners became circumcised experienced a significant drop in high-risk HPV infection. These
women were more likely to clear HPV and less likely to acquire new HPV infections after their partners
became circumcised. Male circumcision decreases risk of HIV, genital ulcer disease, herpes simplex virus-
2, and HPV infections in men and decreases trichomoniasis, bacterial vaginosis, genital ulcer disease, and
now HPV in their female partners. In settings where the new HPV vaccines are still not available, male
circumcision services should be scaled up – they will contribute to prevention of cervical cancer.

Daniel Halperin, PhD
Lecturer on Global Health
Harvard University School of Public Health

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