Jhpiego is an international NGO that did some work in Mozambique since ten years ago supporting the Ministry of Health in implementing programmes around maternal and child health.

Now, in a low resource setting there are things you can do and things you can’t do with cervical cancer. What are your priorities, have you discovered?

Of course, exactly. Now we sit down with the Minister of Health and we prioritise the prevention. What we are doing right now is to do a low cost procedure to screen the cancer in the women which is VIA, visual inspection with acetic acid, which is vinegar. Now, Mozambique started this programme in 2009 and right now we have more than 7,000 people screened.

How successful has the vinegar test been as compared with, say, the Pap smears in America and other countries?

If you are using Pap smear you can’t use it in a large scale. With vinegar you just need to train the health workers and we are training mid-level and even basic staff to be able to identify what are the lesions which can lead to cervical cancer. So here, for me, it’s the cost benefit. With vinegar you can have a large scale with low resources needed to involve.

And you can train health workers to do this quite easily.

Exactly, because you need just to standardise what they should see. And, of course, on top of these people you have more trained staff who can supervise their work so that they’re not alone.

However, the experience from India with the vinegar test shows that when you detect cervical cancer you then need to be able to offer treatment.

Exactly.

Is that going well in Mozambique?

Exactly, because what we are doing is you have a number of centres where you can screen the people and then you need to have a referral centre where those people can go to see; if their lesions are more than 75% then they need to have another kind of treatment. So you do, it’s like a network, you don’t just go there and start screening but you have a network of health facilities.

However, screening for cervical cancer, it’s a very personal thing. You have to approach families and women very discretely. How difficult is it to succeed with this on the psychological level?

In Mozambique we are facing the problem that because we are not in all districts in the country but when someone goes, like the first lady of the country goes in the other district and meets with the people, the people are asking why do you let us out of the business? We need to have this kind of service as well. So the people are demanding so we don’t have… Now, the problem in Mozambique is that the system is not able to respond to the demand of the people. We need to skill up.

That’s brilliant. That’s very encouraging because it means you’ve succeeded psychologically.

Exactly. Exactly.

But what age group are you targeting and how much saturation are you getting? Are you getting to 90% for instance?

Yes, when we started the policy was to test from 35 on but due to HIV we have almost 11% of the people with HIV in Mozambique and you see that cervical cancer starts to appear even in the age of 18, 17 years old if they have HIV. So now we have some, let’s say, like 10% of the people screened are under 25 years.

Can you combine this screening with HPV vaccination as a programme?

Of course.

Are you doing that and how do you recommend that to the girls?

Exactly. Mozambique has applied to receive Gavi support on that and the Ministry of Health is doing all the work on the application. I do believe that in one year we’ll introduce HPV vaccination in Mozambique. Of course it’s important to have HPV vaccination because this helps to cover a huge number of the population to prevent the transmission of HPV.

So finally, from your experience in Mozambique, what messages would you pass on for this overall programme to contain cervical cancer? What messages would you pass on to other doctors elsewhere?

The message is that prevention is possible for some of the cancer and specifically for cervical cancer and a combination of intervention is needed, as you mentioned. If we could access HPV vaccination for all the girls in the country and then combining that with the screening using a low resource, a low cost intervention like VIA, that will be the main intervention which we need to carry on, to improve the likelihood that these people will survive cancer.

Leonardo, thank you very much for joining us.

Thank you. Thank you very much.