BHEKISISA | Can South Africa stop cervical cancer in the next 40 years?

08 February 2024 - 10:43 By Mohale Moloi and BHEKISISA CENTRE FOR HEALTH JOURNALISM
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Women who use public hospitals can get a Pap smear every 10 years, unless they also have HIV, in which case they get tested every one to three years depending on their doctor’s advice.
Women who use public hospitals can get a Pap smear every 10 years, unless they also have HIV, in which case they get tested every one to three years depending on their doctor’s advice.
Image: 123rf

In 40 years, South African women want to be where Australians are now: cervical cancer free.

Almost 11,000 women in South Africa get cervical cancer every year and about half of them die. 

But this is unnecessary because a vaccine can protect you. 

Most cervical cancers are caused by the human papillomavirus (HPV). 

The infection spreads through skin to skin contact during sex, but there are hardly any symptoms so it's hard to know if you have the virus. 

In many cases, someone’s immune system is able to clear up the infection.

However, some types of HPV infection could lead to cervical cancer if the virus stays in your body for a long time.

Anti-HPV vaccines are more than 90% effective at protecting you against infection by the virus types that cause cancer most often.

Australia is on track to wipe out cervical cancer by 2030 because they’ve been vaccinating teens (before becoming sexually active, when the vaccine works best) since 2007. In contrast, South Africa only started giving girls the anti-HPV jab in 2014.

By 2028, the health department plans to have given 95% of girls at least one dose (of two) of the vaccine by the age of nine. They also want to help older women, who weren’t part of the school vaccination drive, to find out if they have the virus. 

Image: Picture: 123RF/Jarun011

The state does this by giving women one free Pap smear every 10 years, from the age of 30 until they’re 60. During a Pap smear, a nurse or doctor collects cells from your cervix (the lower part of the womb and just above the vagina) and tests them for the virus.

But many women whose test results show they need a follow-up visit don’t return, says Lynette Denny, head of the department of obstetrics and gynaecology at the University of Cape Town. Coming back to a hospital for treatment can be expensive if, for example, a patient lives far away. Not returning for follow-up appointments is a problem because if the cells in your cervix are found to be abnormal they should be checked and possibly removed by a doctor before they turn cancerous.

Manala Makua, head of reproductive health at the health department, wants to get more women treated for cervical cancer early by allowing them to screen themselves at home.

What is self-screening for HPV?

Denny says HPV self-screening is not the same as a woman having a Pap smear because “no-one looks inside her genital tract”. She runs a community research project in Khayelitsha that looks for ways to speed up testing and treatment for cervical cancer.

At this clinic they gave self-screening kits to about 3,000 women between 30 and 65 years old. A nurse showed them how to use the swab, which looks like a long ear bud. The swab is pushed up through the vagina to take a sample from the cervix and then placed in a small liquid-filled jar to keep the cells alive while the sample is sent to be analysed. 

Results from these tests are usually ready later the same day.

Why should people screen themselves?

The first benefit of self-screening for HPV is you can test more often and find potential problems sooner.

Women who use public hospitals can get a Pap smear every 10 years, unless they also have HIV, in which case they get tested every one to three years depending on their doctor’s advice.

Because it's fairly easy, self-sampling can help find problems earlier, which improves your odds of beating cervical cancer.

Self-sampling also saves time. It can take up to three weeks to get Pap smear results because a microscope slide has to be prepared from the sample in the lab and then analysed manually. In comparison, an HPV test uses a machine to check for signs of the virus, using the same technique the rapid TB test does. The quicker turnaround time from self-sampling tests also means you can get further tests on the same day, and treatment if necessary, meaning you don’t have to come back to the hospital another time. 

Having an HPV infection doesn’t mean someone definitely has cancer. The virus causes cells of the cervix to change, which can lead to cancer developing laterBefore cervical cancer is full-blown, the tissue of the cervix may have sores (called precancerous lesions). If these sores are found early enough, they can be treated with a small procedure to kill dangerous cells. Since this treatment happens before cancer develops, once you are treated “you should be cured”, says Denny.

Is HPV self-testing easy?

Sampling the cervix isn’t easy for everyone. “When we were supervising women, many put [the swab] in the wrong place,” Denny says. To make sure sampling was done right the researchers first helped women use the swab at the clinic, practising on themselves before letting them do it from home.

Another drawback is some women believed screening themselves from home wasn’t as good as having a doctor’s assurance that everything was OK.

Why teach people about HPV before they do the self-test?

To avoid shame and stigma. If people don’t understand how easily HPV spreads, they could assume a positive result was because of infidelity. This may pressure women to hide their results so they avoid being treated badly.

Added to this, patriarchal views influence how women in some communities view their reproductive health. For example, when Denny asked patients to do a writing exercise to help them express their feelings about their vaginas, some wrote “it's not mine, it's owned by my husband”.

She says mass education must be a part of any self-sampling drive so attitudes can change. Her clinic did this by having trusted traditional healers join reproductive health talks with women involved in the study.

Getting an HPV-positive result doesn’t automatically mean you have cancer, says Makua. “You’re not going to know whether you've got abnormal cells or not.”

When will HPV self-testing be available in South Africa?

It will only come to the public sector when the health department figures out if people want to screen themselves for HPV from home and how the logistics will work. This is called an implementation trial. The researcher first used HPV self-sampling kits, rather than pap smears, for 100,000 women in clinics in KwaZulu-Natal, Gauteng and the Eastern Cape in 2023.

The next phase of their implementation trial starts in March 2024. For this part, they’ll aim to get 100,000 women in the same provinces on self-sampling kits they can take home to do the test.

“If we can reach 100,000 [women] within a month, we’ll know people are happy with it. But if it's going to take us three years, we’ll know demand is low or we didn’t market it properly,” says Makua.

They also need to figure out how many women will collect samples correctly and send them in for testing and how they’ll deliver the results. The idea is to avoid repeat clinic visits that could end up costing some a day’s salary, says Makua.

If it all works out, HPV self-sampling could be available within a few years.

In these provinces, the health department first wants to reach women living with HIV because they are more likely to get cervical cancer.

This is because HIV attacks the body's defence system, making fighting off HPV infections more difficult and increasing the chance of their developing cervical cancer.

They also want to reach more young women who test positive for the dangerous type of HPV, which could turn into cancer, before it gets to that stage. Sex workers will also be an important group to test because their jobs expose them to the dangerous types of HPV more often.

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

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