Saving lives of women living with HIV and cervical cancer

“This is too much for one person - having cancer and HIV in one body is overwhelming. I am constantly thinking it over and searching for a way to clear the thoughts and concentrate on my treatment,” Nereah Akinyi tells Healthy Nation.

She goes back in time to about four decades ago, laying bare memories of the harrowing experiences that punched her life when she learnt that she was living with HIV.  

Her heart crushed anytime she heard that someone had died of HIV/Aids. When the disease took the life of her aunt, Nereah registered that she would be next. 

She recalls when her doctor held a small half poster detailing the stages of Aids, explaining the likely course of the rest of her life. The last line of the poster showed a path that led to either "death", marked in red or what seemed like an errant "?" marked in blue.

“This was unexpected, to say the least. It was like a death sentence. Death carried more weight back then when you were confirmed HIV positive,” she says.

Nereah was immediately placed on a cocktail of drugs that kept the virus in check. 

She was born with the virus, and thanks to the little-known intervention then, she contracted the disease from her mother during delivery. 

For 38 years, she has lived with the disease, and it was not a death sentence as she thought, after all.

A year ago, however, she spotted a tinge vaginal discharge that contained blood. She ignored it and assumed it was a result of the drugs she was taking. She only shared this with one of the nurses who included the symptoms in her file.

One day in July 2021 when she had gone for her usual ARVs refill, the nurse in charge requested if she could be screened for cervical cancer given the symptoms she had reported earlier. She consented and after screening, a pap smear test was conducted.

A few weeks later, Nereah had a new diagnosis –cervical cancer. 

“This was like being handed another death sentence. A sentence that seemed more severe than HIV. This time I knew I was going to die,” says Nereah who hails from Kasipul Kabondo in Homa Bay County.

Luckily, she was enrolled in the treatment protocol almost immediately. The response was quick and definite, this kept her cancer from progressing. She is still under treatment.

Nereah is among the 26,851 women living with HIV from Homa Bay and Kisii counties who were screened for cervical cancer through a five-year study introduced by Elizabeth Glaser Paediatric AIDS Foundation (EGPAF) in October 2021.

Of those screened, 229 were diagnosed with cervical cancer and about 79 received treatment, with the remaining failing to turn up at the treatment sites.

Nereah is still undergoing chemotherapy and she is lucky since her cancer was found in the first stage. 

Enrolled in the same study two years ago, Caroline Adhiambo Dede, a 36-year-old resident of Mariwa village in Homa Bay County, also found out that she had cervical cancer after consenting to be screened. 

“As usual, I went to pick up my medication and also had a cervical cancer screening. The test turned out to be positive and the doctor recommended that I start treatment immediately,” explains Caroline.

She began her treatment, which included three brachytherapy sessions that she got from a private hospital within her locality. She would later seek additional treatment at the Homa Bay Referral Hospital after it became apparent that there was not much improvement.

“I was admitted for two weeks and here more samples were extracted and taken to Nairobi for further analysis. In the meantime, I was discharged while I continued to receive outpatient treatment from home,” says Caroline

“When I got the results, the diagnosis was confirmed again and luckily enough, the cervical cancer was at stage one. For that, the doctor prescribed drugs plus a monthly outpatient visit to the hospital, which I have been doing ever since,” she adds.

Last August, Caroline was declared cancer-free though she continues to receive treatment for opportunistic infections.

Caroline and Nereah represent women living with HIV who may miss out on cancer screening services because it is not a mandatory requirement in most health facilities in the country. Occasionally, the cases are picked when the cancer has progressed to a late stage. 

Late diagnosis means that treatment and cancer management is likely to be delayed making the whole experience expensive.

According to the World Health Organization (WHO), cervical cancer in women living with HIV is known as one of the Aids-defining malignancies. When one is diagnosed with cancer, then it means that the person’s HIV infection has progressed to a full-blown infection. In most cases, people don’t die from the disease itself, but from infections that trump the already weakened immune system.

Kenya's cervical cancer incidence is estimated to be at 200 per 100 000 women annually, with a higher risk among women living with HIV.

Cancer cases

WHO ranks cervical cancer as the fourth-commonest cancer among women. In 2020 alone, there were 604, 000 new cases and 342, 000 deaths worldwide. About 90 per cent of these occurred in low- and middle-income countries.

In Kenya, cervical cancer is ranked as the leading cause of cancer deaths among women.  Despite the disease being treatable upon early diagnosis, 50 per cent of the cases are diagnosed late due to a lack of awareness and access to early screening.

 “Integrating cervical cancer screening with HIV is critical as women living with HIV are six times prone to cervical cancer than women who are HIV negative,” says Dr Jacob Khaoya, a HIV specialist, adding that early detection is crucial. 

The risk of the patient developing cervical cancer increases by day, it is for this reason that EGPAF introduced the Vukisha 95 project.

“We chose to start the trials in the Homa Bay County since it is one of the regions in the country heavily burdened with HIV,” explains Ms Irene Walaska Wattoyi, senior technical officer, Care and Treatment, EGPAF, Kenya and lead principal investigator in the study.

The project that supports 164 facilities distributed in the nine sub-counties in Homa Bay integrates cervical cancer screening and management in the HIV care project, targeting women living with the virus in the area.

The programme has trained 123 community health workers on screening and identification of early signs of cancer in women living with HIV.

Ms Wattoyi tells tHealthy Nation that screening is done by the community health workers at the hospital when the patients come for their ARVs refill. Further analysis of the screening results is done, and for those in need of a test, it is immediately conducted and those proceeding for treatment are referred to the nearest treatment site.

Through the programme, 56 per cent of women living with HIV in the area were screened yearly for cervical cancer within that period, compared to only 14 per cent for those who are free from HIV. 

“This translates to over 26,000 women who have been tested for the disease,” explains Irene.

The programme was also introduced in Lesotho given it has the highest cervical cancer rates in the world. According to WHO, Lesotho had a cervical cancer rate of 49.9 per every 100,000 women in 2021.

Between October 2019 and March 2022, over 100,000 women living with HIV were screened for cervical cancer; with many initiated on treatment.

Justifying why it is important to integrate cervical cancer screening and management with HIV, Dr Catherine Nyongesa, a clinical oncologist in Nairobi, says cervical cancer rarely presents with signs at the initial stages.

“By the time one begins to see signs, it will have already advanced to a late stage,” she notes.

She says the cost of treatment can only be estimated once the stage has been established. 

“Primary prevention- Human Papillomavirus vaccination - is by far the cheapest method of reducing the cost of cervical cancer treatment,” she says.

She insists that screening tests offer the best chance to have cervical cancer found early when treatment can be most successful. 

“Screening can also actually prevent most cervical cancers by finding abnormal cervical cell changes (pre-cancers) so that they can be treated before they have a chance to turn into cervical cancer.”

This is supported by a study published in the Lancet Global Health journal, which shows that women living with HIV have a six-fold increase in the risk of cervical cancer compared to those without the virus. 

They also found that globally, six per cent of all cases of cervical cancer are found in women with HIV. Only that there were huge regional disparities, with 63 per cent of cervical cancer cases in southern Africa and a fifth of cases in East Africa involving women with HIV compared to well below a percentage in some other regions. 

The researchers estimated that five per cent of new cervical cancer cases in 2020 were attributable to HIV.

“Women living with HIV have a substantially increased risk for cervical cancer when compared to women without HIV infection. In countries with a high burden of both cervical cancer and HIV, it is vital to integrate HIV and cervical cancer care and vaccinate girls against human papillomavirus to secure long-term declines in the future burden of disease,” suggests the study.

The Lancet meta-analysis study led by Dr Dominik Stelzle of the Technical University of Munich and Dr Shona Dalal of WHO involved women in Africa, Asia, Europe and North America. 

The study was conducted between 1981 and 2014 and took place in 17 countries (eight in Africa; three in Asia; four in Western Europe; two in North America) and Kenya was one of the countries.

From the findings, there were 2,138 cases of cervical cancer.

Particularly affected was the African region - 64 per cent of all cases of cervical cancer in southern Africa were in women with HIV as were 27 per cent of cases in eastern Africa, 12 per cent in central Africa and 10 per cent in western Africa. 

“Increased risk of cervical cancer in women with HIV is likely due to the risk of disease progression caused by HIV-related immune suppression, the burden of cervical cancer is especially high among women with a low CD4 cell count and not taking antiretroviral therapy,” says the study

The researchers recommended that integrating cervical screening into a routine, six-monthly HIV care could mean that pre-cancerous cell changes are spotted early, therefore allowing for prompt treatment.

According to WHO, cervical cancer screening followed by adequate management and HPV vaccination are the two prevention tools that are highly effective hence the need for expansion of HPV vaccination to areas with HIV high prevalence to achieve long-term reductions in the overall cervical cancer burden. 

HIV and Cancer: What is the Link?

HIV itself plays a role in how cancer grows in people living with HIV.

The virus attacks the immune system, which protects the body from infections and diseases. A weaker immune system is less able to fight off diseases, like cancer. People with HIV often have weakened immune systems, which means they will have a greater chance of getting cancer.

Most cancers begin when healthy cells change and grow out of control, forming a mass called a tumour. A tumour can be cancerous or benign. A cancerous tumour is malignant, meaning it can grow and spread to other parts of the body. A benign tumour means the tumour can grow but will not spread. 

People living with HIV are often infected with three types of cancers - Kaposi sarcoma, cervical cancer and non-Hodgkin lymphoma because they occur more often in people whose immune systems have been weakened by HIV/Aids. 

The three are also known as “AIDS-defining conditions.” This means that if a person living with HIV has one of these cancers, it can mean that Aids, the most advanced stage of HIV, has developed. 

Cervical cancer affects the cervix, the entrance from the vagina to the uterus. Almost all women who get cervical cancer also have HPV. Having HIV and HPV makes cervical cancer grow faster.

Kaposi's Sarcoma is caused by the herpes virus, it can be deadly if it gets in your throat or lungs. It grows into reddish-purple patches on your skin 

Non-Hodgkin's Lymphoma starts in the lymph glands, which are part of your immune system and help fight off disease. Lymph glands are mainly in the neck, under the arms, in the groin, and inside the belly. 

 
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