The Wolrd Health Organisation (WHO) recommended screen and treat strategies for low-income countries to overcome some of the challenges of cytology-based multiple visit screening strategies. Currently, molecular HPV tests are the recommended screening tests in a SAT setting, and where this is not available, visual inspection with acetic acid (VIA) can be used. With advancing technologies, point of care (POC) molecular HPV testing methods are becoming available. Visual Inspection with Acetic acid (VIA), while truly a point of care test, is fraught with logistical and quality assurance issues. Cryotherapy is the most common treatment modality used in SAT settings in LMIC. In recent years, the use of thermocoagulation has gained popularity due to the logistical issues surrounding the use of cryotherapy. In the very near future, many screening technological advances are expected. In our recent study, we improved the specificity of Xpert HPV test in HIV positive women by restricting the test to certain HPV types and changing the cycle threshold cutoffs to reduce overtreatment. Many HPV oncogenic biomarker tests are also currently in development to improve the diagnostic accuracy of traditional HPV tests Self-sampling for HPV testing is a strategy that seeks to address some cultural and logistical barriers to screening in LMIC. This method has been found to be acceptable by women and comparable to clinician collected samples. Many self-sampling devices currently being investigated. Enhanced digital analysis is truly POC devices that enhance the accuracy of detection of visual methods and allow real-time remote assistance by expert colposcopists. Many of these devices are at various stages of development. Artificial intelligence algorithms are being developed to detect premalignant and malignant diseases of the cervix from a single cervical image within seconds with over 90% accuracy. These algorithms are being incorporated into enhanced digital imaging devices. These technological advances are crucial to achieving the WHO target of screening 70% of women with a high-precision test, towards the elimination of cervical cancer.

Cervical cancer control requires primary prevention through education and high HPV vaccine coverage of girls, supplemented by national organised screening programmes. Cervical screening programmes are equally important, but to be effective require quality assured provision from well trained providers. Although HPV testing is increasingly the method of choice, screening by cytology or visual inspection with acetic acid (VIA) or lugol’s iodine (VILI) can deliver, with VIA the cheapest way to provide high coverage. Screening, no matter how accurate, is unethical if adequate treatment and clinical pathways for those with disease is not readily available or accessible. Cryotherapy is recommended by WHO for ablative treatment of low-grade squamous lesions in resource-constrained settings. However, in many countries access to suitable gas and working delivery guns is limited. Thermal ablation (TA; originally thermal coagulation) is an alternative treatment to cryotherapy which can reach larger cohorts, especially in rural settings. Since 2013, the Nkhoma Cervical Cancer Screening Programme has implemented a ‘screen and treat’ approach using VIA and thermal ablation in a rural district general hospital and associated health centers. Over 26,000 women have been screened with around 6% being diagnosed as VIA positive and a further 2% having suspicious or frank cancer. At 1 year follow-up of 580 treated women, over 90% were VIA negative (91% of HIV+ and 94.3% of HIV-), in line with international literature. Thermal ablation was shown to be an effective treatment modality, acceptable to clients and patients and is now being expanded to all regions of Malawi. The Malawian Government accepted the benefits of thermal ablation in the absence of WHO guidance. This guidance has now been updated (April 2019) to include thermal ablation as an acceptable alternative to cryotherapy. While focusing on TA, this talk will also describe the feasibility of excision treatment for larger lesions.

INTRODUCTION In women, cervical cancer ranks as the fourth most common cancer and the fourth most common cause of cancer deaths. In 2018, 570 000 new cases were diagnosed and 311 000 women succumbed to the disease. Cervical cancer is the leading cause of cancer deaths in many african and South-East asian countries, where the incidence and mortality rates are about 10 times higher than in North America, Australia, New Zealand and Western Asia. The elimination of cervical cancer is now considered a priority under the thirteenth world health organisation general programme of work. Wide-scale hpv vaccination with adequate population coverage, improved primary screening with hr-hpv and early treatment of cervical cancer make the elimination of cervical cancer a possibility in the foreseeable future.
REDUCING MORTALITY THROUGH SCREENING In countries with organised cervical cancer screening, mortality has fallen by about 50-80%. Organised screening, especially cytology-based, require a relatively sophisticated laboratory set-up with appropriate equipment and technical support, built-in quality control, trained staff and a health system underpinned by good referral pathways. Appropriate and clear referral pathways are important for timely treatment of women with screen detected early cervical cancer.
TREATMENT OF SCREEN DETECTED CERVICAL CANCER Treatment is usually surgical and prognosis is good with cure rates of about 80% for stage 1.
AFRICAN CHALLENGES In Africa, huge challenges exist for women with early cervical cancer to receive appropriate treatment.
PRE-SURGERY CHALLENGES
a. Pathology services. There is a huge shortage of pathologists to assess excisonal biopsy specimens prior to surgery
b. Radiological and laboratory services. Very few countries in africa offer women with cervical cancer advanced imaging. even basic imaging like chest-x-rays and abdominal and pelvic ultrasound scans are not readily available in the public sector. Getting basic haematological, biochemical and serological investigations remain a challenge. unavailability of safe blood for transfusion is another big issue
c. Cost of surgery. In most african countries, medical treatment is not free, hence unaffordable
d. Shortage of radiologists, gynaecological, radiation and medical oncologists. There is always a risk of suboptimal treatment due to unavailability of highly specialised doctors
POST-SURGERY CHALLENGES
a. Shortage of drugs- antibiotics, analgesics, anticoagulants
b. Pathological services to assess post surgical specimens
c. Unavailability and unaffordability of adjuvant radiation treatment
d. High loss to follow-up
CONCLUSION Huge challenges have to be overcome in africa in order to improve outcomes in women with early cervical cancer