Epidemics of HIV and HPV are inherently interconnected, and when they meet in the context of weak health systems, their effects serve to amplify each other.
Both HIV and cervical cancer present significant public health threats to women in sub-Saharan Africa. But while the threat of HIV is well documented, and the mass mobilisation of resources to treat HIV, unprecedented, cervical cancer is a relatively new and developing challenge for the region.
Cervical cancer is preventable, but it remains the second most common cause of cancer among women and the leading cause of female cancer deaths in sub-Saharan Africa. It is also one of the most common cancers in women living with HIV. Patterns of cervical cancer and HIV typify the experience of young women in Africa – who face multiple barriers to good health.
Gender inequality, intimate partner violence, inequitable laws and harmful traditional practices reinforce power dynamics between men and women. These dynamics limit women’s choices, opportunities, and access to information, health and social services, education and employment. This sets up a challenging environment for preventing infections and morbidities.
“It makes no sense to save a woman’s life from AIDS, only to let her die from treatable or preventable cancer,”U.S. President George W. Bush in October 2015.
Alarmingly, rates of cervical cancer and deaths are rising in sub-Saharan Africa, where efforts to control communicable diseases, like HIV, are improving and more people are living into older age. The rise of non-communicable diseases (NCDs) across the region gives health systems a new, significant challenge: how to manage cancer in poorly resourced settings?
It makes no sense to save a woman’s life from AIDS, only to let her die from treatable or preventable cancer.
Cervical cancer is caused by the human papillomavirus (HPV), the world’s most common sexually transmitted infection (STI). While the large majority of strains are harmless and the body can fight infection without intervention, some strains, notably HPV-16 and HPV-18, can lead to pre-cancerous lesions which can cause cervical cancer if left untreated.
Women living with HIV are particularly vulnerable, they are four to five times more likely to develop invasive cervical cancer, are more vulnerable to persistent HPV infections, and can develop pre-cancerous lesions faster. HPV is also associated with having a greater risk of acquiring HIV. This is problematic, as it is women in Africa who are most affected by HIV worldwide. Young women in sub-Saharan Africa make up 58% of new HIV infections among young people globally and 67% of new infections in Africa.
Thankfully, mass immunisation programmes for young girls and cervical cancer screening to catch pre-cancerous HPV in women can dramatically cut incidence and mortality – as has already been shown in some high-income countries. If young girls are given the vaccine before the age of sexual debut, it can provide 100% protection against the deadliest HPV strains.
But financial, logistical and cultural barriers have delayed the roll-out of these programmes in low- and middle-income countries.
And the stats don’t lie, southern, eastern and western Africa have some of the highest incidence and mortality rates of cervical cancer in the world. In southern Africa, the cervical cancer incidence rate is 43 cases per 100,000 women annually, compared to just 6.8 per 100,000 in Western Europe. In several countries, including Malawi, Mozambique, Zambia, Zimbabwe and Tanzania, the incident rate is over 50 cases per 100,000 women annually.
The mortality rate is highest in east Africa, at 30 per 100,000 compared to 2.1 per 100,000 in western Europe. The World Health Organization (WHO) estimates that without an effective intervention, global cervical cancer death will double to 440,000 people by 2030, 90% of them being in sub-Saharan Africa.
But controlling HPV is feasible on the continent. Rwanda, the first country to implement a national HPV policy, achieved child HPV vaccination rates in their immunisation programme of over 98%, higher than some high-income countries. Their model can be replicated elsewhere but requires political will and ownership, social mobilisation, school-based delivery, as well as strategies to reach girls who are not in school. Public-private partnerships with drug companies to procure cheap drugs also facilitated their success.
There are also opportunities to combine efforts to prevent both HIV and HPV as overlapping epidemics. “There is a growing awareness of the need to maximise synergies between the AIDS response and efforts to prevent, diagnose and treat cervical cancer through HPV vaccination, education, screening and treatment,” said UNAIDS. “Likewise, existing HIV programmes can play a strategic role in expanding cervical cancer prevention services.”
Women on the African continent continue to bear a disproportionate share of the global disease burden, and while integrating services to increase access to lifesaving care is important – significant social, cultural and economic interventions are also needed to ensure these very women have agency and the ability to keep themselves disease-free.