An integrated approach to quality improvement of services for the prevention of common cancers and other NCDs in communities growing and aging with HIV in the Uthukela District, KwaZulu Natal

Partnership objectives

The primary goal of our program is to reduce the mortality and morbidity of common cancers, HIV, TB and other NCDs in people aging and growing with HIV by supporting clinics to scale up awareness, screening and treatment services in an integrated chronic care model in the Uthukela District, KwaZulu-Natal, South Africa.   

The estimated number of new cases of cervical cancer in South Africa is over 7,000 with approximately over 4,200 deaths each year. The estimated number of new cases of cervical cancer in South Africa is over 7,000 with approximately over 4,200 deaths each year. Copyright Bristol-Myers Squibb

What are the health needs and challenges?

Sub-Saharan Africa is experiencing a multiple disease burden. Non-communicable diseases (NCDs) are emerging, and their risk factors are becoming more common as lifestyles change due to rapid urbanization, especially in poor communities. Environmental and lifestyle effects of urbanization, targeted marketing for alcohol and cigarettes, gender and   social norms also add to a rise in NCDs, especially in women. Simultaneously, epidemics of infectious diseases such as HIV/AIDS and Tuberculosis persist in the region. According to UNAIDS, one third of persons screened at HIV testing sites are obese and have Hypertension.

Given the declining HIV/AIDS mortality rates and longer life expectancy due to the up-scaling of ART with its concomitant metabolic complications, evidence has shown that HIV-infected adults on ART have a much higher risk of developing other chronic illnesses such as cardiovascular diseases, diabetes,  chronic obstructive lung diseases as well as kidney disease. Other HIV/AIDS comorbid diseases on the increase include common female cancers such as cervical and breast cancer as well mental illness and substance abuse. Two thirds of premature deaths (between 30-70yrs) are linked to exposure to NCD risk factors such as smoking, alcohol, poor diet and physical inactivity and poor healthcare services. Since the advent of ART, HIV-infected women are no longer dying from opportunistic infections, but are living long enough to develop and die from cervical and breast cancer. In South Africa, breast cancer and cervical cancer remain the most common cancers amongst women. According to the HPV Information Centre, the estimated number of new cases of cervical cancer in South Africa is over 7,000 per annum with an age-standardized rate of 31.7/100 000 . The estimated number of deaths among women in South Africa from cervical cancer is approximately over 4200 each year. This higher prevalence of cervical cancer and pre-cancer disease is also due to co-infection of patients with HIV and the human papillomavirus (HPV), which is the causal agent for cervical cancer. 60-80% of HIV-infected women in sub-Saharan Africa are infected with the HPV virus, placing them at substantially increased risk for cervical cancer. The risk of cervical cancer in HIV-infected women has been found to be three times higher than in HIV-uninfected women globally. This calls for a scale up of efforts to reduce the risk of invasive cervical cancer through screening programs targeting HIV positive women with the ultimate goal of expanding the services to HIV uninfected women. 

On the other hand 50% of HIV transmission takes place among those aged 15–24 and 5 000–6000 young people become infected every day because of poor access to health services and commodities, early sexual debut, sexual coercion and violence,  growing up without parents and abuse.. For those on ART, adherence may further be compromised due to partial or non-disclosure by their parents or caregivers, usually a grandparent, as well as lack of psychosocial support.  Awareness and education programs for adolescents and young adults on risk factors for STIs, common cancers and the effects of smoking and alcohol use are not sub optimal in South Africa.

Description of partnership activities and how they address needs and challenges

Project Objectives

  • To create partnerships and collaborations to strengthen the reduction of premature deaths from AIDS related cancers HIV, TB, and other NCDs and increase life expectancy in communities.
  • To educate communities and create awareness on the risk factors for HIV, TB common cancers and NCDs.  
  • To scale up screening services for the early detection of cervical and breast cancers as well as lung cancer.
  • To provide adherence, care and psychosocial support services for Adolescents growing up with HIV and the ageing HIV population.
  • To support an integrated chronic care model which leverages strongly on existing HIV/TB/ Maternal Child Health services to improve access to screening and treatment services for the common cancers and other NCDs.    
  • To capacitate community healthcare workers and primary care givers to provide high quality multidisciplinary support and care to cancer survivors.
  • To strengthen health systems and to ensure sustained delivery of effective and comprehensive patient-centered chronic healthcare programs.
 

Project Approach

The project will have a three-pronged approach. The three significant projects which have been identified for implementation within the three year funding period will run concurrently.

Project 1: Quality Improvement of services through an integrated chronic care model for communities ageing with HIV.

Project 2: Conduct impactful implementation and quality improvement research on cervical cancer screening using VIAC.

Project 3: Awareness creation and prevention of common cancers and NCDs in Adolescents Living with HIV and empowerment of adolescents through behavior modification and life skills training.

Project Components

Project 1: Quality Improvement of services through an integrated chronic care model for communities ageing with HIV

Activities:

  • A small-scale baseline survey will be conducted in the communities and amongst healthcare workers to assess knowledge, attitudes and health-seeking practices of the target populations.
  • A baseline facility assessment will be conducted at targeted facilities and a skills assessment of healthcare providers done to determine their knowledge of cancer and survivorship care and determine their training needs.    
  • Engage all relevant stakeholders for planning and advocacy to introduce a “See and Treat” cervical cancer prevention program in alignment with Department of Health priorities using data for action at provincial, district and facility level.  
 

Project 2: Conduct impactful implementation and quality improvement research on cervical cancer screening using VIAC

Activities:

  • Conduct implementation research to assess the efficacy of implementing a cervical cancer prevention and control program based on a “screen and treat” protocol using VIAC and cryotherapy at primary care level.
  • A protocol will be developed and Ethics clearance sought within the Q1 and Q2 of Year 1 to conduct a retrospective cross-sectional study on the clinical outcomes of patients screened and treated for cervical cancer prevention using the VIAC. 
  • The study will be preceded by a baseline survey to assess knowledge, attitudes and practices of target populations and an end line survey to be conducted in Q4 of Year 3 to establish trends following the program interventions. After training, Enumerators will begin data collection and verification of data collected and reporting will be facilitated by data capturers for the duration of the study.   
  • Data analysis and the publication of the paper at the end of Year 3 (Q3 and Q4) will be supported by the BMSF TAP faculty members.
 

Project 3: Awareness creation of common preventable cancers and NCDs in Adolescents Living with HIV (ALHIV)

Activities:

  • Educate adolescent girls and young women (AGYW) on prevention of cervical and breast cancer.           
  • Conduct a baseline survey in the first quarter of Year 1 to assess the knowledge, attitudes and practices of young people on cervical and breast cancer.
  • Top-up HPV vaccination support for adolescent girls as a support provincial Department of Health during HPV vaccination campaigns for adolescent girls. 
  • Enhancing adolescent and youth friendly services (AYFS) after conducting baseline facility assessment to establish the existence of AYFS and supporting facilities with the creation of AYFS where none exist.
  • Enhancing adolescent adherence to ART by Conduct file audits for viral loads to identify patients not linked to adherence clubs, creating new and strengthen existing adherence clubs for adolescents within facilities, engaging CBOs to assist with patient tracing of defaulters/ patients LTFU, providing counselling on Disclosure and psychosocial support for adolescents and engaging and educate primary caregivers on disclosure and treatment adherence.
  • Screening for cervical and breast cancer for eligible AGYW and offer VIAC and Cryotherapy to HIV and adolescents 18 years and older.   
  • Educate and create awareness on common cancers, HIV, TB, MMC and other NCDs in adolescent boys and young men (ABYM).
 

Summary of impact and forward looking information

Measurement of progress towards objectives:

Estimated overall value of partnership: US$1,210,000 over two and half years

A detailed monitoring and evaluation framework has been developed covering each objective under each goal listing until completion.  Regular meetings will be scheduled with BMSF and formal reports noting progress will be provided.  The programme will also report into the BMSF STF Balance Score Card.

Expected Outcomes

Project 1:

  • Improved multidisciplinary and integrated holistic care for patients aging with HIV and related conditions.
  • Improved capacity of HCWs to offer testing, screening and treatment services for common cancers and NCDs. 
  • Improved support and management of cancer survivors.
 

Project 2:   

  • Policy review on alternative screening and treatment modalities for cervical cancer prevention.
 

Project 3:

  • Improved and integrated care for Adolescents Living with HIV.
  • Improved access to information, care and support for Adolescents Living with HIV.
  • Improved adherence, lifestyle habits and psychosocial support for Adolescents Living with HIV.

 

Partnership information

Company(ies) Bristol-Myers Squibb

Partner(s) Bhekuzulu Self Sustaining Project (BSSP), Bristol-Myers Squibb Foundation, District Health Information System (DHIS), KwaZulu-Natal Department of Health, Mpilonhle Sanctuary Organization (MSO), National Health Laboratory Services (NHLS), Right to Care, Uthukela District Health Office

Type of Partner(s) Academia / Hospitals, Government, NGOs, Other Business

Therapeutic Focus Non-Communicable Diseases, Women and Children's Health

Disease(s) Breast Cancer, Cancer, Cervical Cancer, Children's Health, Women's Health

Program Type(s) Health System Infrastructure - Outreach & Medical Services, Prevention Programs - Awareness & Outreach

Region(s) Sub-Saharan Africa

Number of Countries 1

Country(ies) South Africa

Start Date 2017

Anticipated completion date 2019