Repositioning Prevention and
Control of Cancers of
Reproductive Organs in
Kenya
Dr. Gathari Ndirangu
Ob/Gyn
RH Technical Advisor
Cervix, Breast and Prostate
•Equipment for screening and Rx
•Capacity building
•Advocacy
– Resources and support
•Resource mobilization including PPP
•Developments in routine HPV vaccination
•National Cancer Prevention and Control Bill,
2011
• M&E
– Data reporting tools
– Incorporate indicators into HMIS
• Integrated prevention, screening and Rx
services
• Male involvement
• Community mobilization and community
health strategy
– Prevention, screening, early diagnosis and Rx
• Palliative care
Cervical Cancer Prevention
and Control in Women with
HIV in Kenya
HPV-HIV Co-infection
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Higher prevalence of persistent HR HPV infection
Higher prevalence multiple HR HPV types
Faster progression to CIN3 and ICC
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10y earlier
More advanced disease
Poorer histological types
Poorer prognosis
Effect of cART on ICC
De Vuyst H, Lillo F, Broutet N, Smith JS (2008). HIV, HPV, and cervical neoplasia and cancer in the era of HAART. Eur J
Cancer Prev 2008;17:545–54
Gichangi PB, Bwayo J, Estambale B, et al (2003). Impact of HIV infection on invasive cervical cancer in Kenyan women. AIDS
2003;17:1963–8.
HPV Vaccines in HIV-infected
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HPV type distribution in HIV+ women similar to HIVwomen*
HPV2 and HPV4 vaccines in WHIV
Similar immunogenicity between HIV- and HIV+
* De Vuyst H, Ndirangu G, Moodley M et al. (2011) Prevalence of HPV in women with ICC by HIV status in
Kenya and South Africa. Int. J. Cancer. DOI: 10.1002/ijc.26470
Higher Risk of Infection with Multiple HR HPV Types
OR for multiple HPV infection in HIV+ versus HIV- women with cervical SCC, and by CD4 count and cART
De Vuyst H, Ndirangu G, Moodley M et al., (2011) Prevalence of HPV in women with ICC by HIV status in
Kenya and South Africa. Int. J. Cancer. DOI: 10.1002/ijc.26470
Screening in WHIV
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Higher prevalence of benign cervical lesions e.g.
ectopy, cervicitis
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Lower VIA specificity (higher false-positive rates)
Over-treatment using the ‘screen and treat’ approach
Unnecessary exposure to side effects of CryoRx
Possible increased HIV shedding
Screen all WHIV in reproductive age
 At HIV diagnosis
 6 months after diagnosis
 Annually thereafter if the screening test normal
Management of CIN1 in WHIV
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CIN 1 in WHIV has
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High recurrence rates
Higher prevalence of HPV
More rapid progression to CIN 2/3
Increased incidence of ICC
Rx of CIN1 does not reduce risk of progression
<50% clearance rates post treatment
No difference between LEEP and CryoRx
Close follow up is mandatory
Progression of cervical carcinogenesis
Mild cytological abnormalities
and/or CIN1
Normal
cervix
Infection
HPVinfected
cervix
Persistent
infection
Cervical
cancer
CIN1: 57%
CIN2: 43%
CIN3: 32%
Clearance: (approximate likelihood)
Progression
Precancer
Months
Years
> 20 years
CIN = cervical intraepithelial neoplasia.
Precancer is equivalent to CIN2/3.
10
Adapted from Schiffman M & Kruger Kjaer S. J Natl Cancer Inst Monogr 2003; 31:14–19.
Management of CIN 2/3
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Less successful than in HIV- women
High recurrence rates after Rx
Rx reduces risk of progression to ICC
Closer follow up
Post treatment
Encourage
 Adherence to cART
 Prevention of re-infection
 Male circumcision
 Cessation of smoking
 Expand integrated HTC and cervical cancer
screening services
HPV Vaccines: In the Horizon
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Second generation HPV vaccines
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Therapeutic vaccines
Thermostable vaccines
Mucosal surface vaccines?
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Additional HPV types
HPV9 (studies ongoing)
Incorporation of additional vaccine preventable diseases e.g. HSV?
Injection-free
Fewer doses?
Childhood administration?
Lifetime protection?
More affordable vaccines?
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GAVI
Possible production in India?
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Call for Action
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Appreciate and recognize efforts by GOK
Continued advocacy
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Leaders
Community
HRH and equipment
Conduct, share and disseminate research
on cancer for policy formulation
Agents to reduce stigma
Palliative care
Thank You