Pandemic, UK aid cuts to further limit cervical cancer screenings

Access to cervical cancer screenings has always been limited in many low-resource settings — and this has only been exacerbated by the COVID-19 pandemic. Severe cuts to the aid budget of the United Kingdom, which has been a global leader in funding reproductive health, are expected to make the situation even bleaker.

Many of the development community’s efforts in low- and middle-income countries focus on outreach to marginalized and hard-to-reach populations. Building up these health offerings — and relationships in communities — has taken years, according to service providers. But now organizations can’t host community screening or fundraising drives because of the pandemic, and women are less likely to want to receive the service due to fears of contracting COVID-19.

“It's not as if the situation was good and it's now deteriorated; we were already in a very poor situation, and now it's absolutely dismal because of the pandemic,” said Raveena Chowdhury, head of integrated service delivery at MSI Reproductive Choices. “The pandemic was unavoidable, but the U.K. aid cuts are really very disappointing.”

Cervical cancer screening rates in MSI’s global programs have dropped by 40% since 2019, and the U.K. funding cuts might lead to a further reduction of 30%, Chowdhury said. Overall, MSI is facing a £45 million ($64 million) funding gap as a result of the aid cuts — an even greater gap than when former U.S. President Donald Trump’s administration reinstated and expanded the Mexico City Policy, also known as the “global gag rule.”

“With a cut in this funding, plus the pandemic, my expectation is that we're going to see a really, really significant decline. We're going to go back five to 10 years in terms of service volumes as a result of this,” Chowdhury said.

During the height of the COVID-19 lockdowns last year, partner groups of TogetHER for Health — which focuses on ending cervical cancer deaths — also saw reductions in screenings ranging from 50% to 90% of pre-pandemic levels, said Heather White, executive director at the organization.

Early screening

Cervical cancer causes an estimated 311,000 deaths globally each year, with over 85% occuring in low- and middle-income countries. Women living with HIV are six times more likely to develop the disease.

Cervical cancer is linked to HPV. Globally, the majority of sexually active women will at some point have an HPV infection. But from the age of 30, recurring HPV infections with lesions can lead to a higher risk of cancer, Chowdhury said.

Because of this, the World Health Organization recommends that every woman be screened for cervical cancer at least once between the ages of 30 and 49.

Two types of prevention therapy can be used after a lesion is discovered, with irregular cells in the cervix frozen or burned through a probe to prevent the development of cancer.

Finding these lesions early is crucial because cancer treatment is inaccessible or prohibitively expensive for many women, who might not even have access to palliative care, Chowdhury said.

“The sheer amounts of pain that women have to suffer is really heartbreaking. What really gets you is that if that woman had one screening — just one screening after the age of 30 — she would likely not be in this position,” she said.

These screenings aren’t accessible in many settings. For example, in MSI-led programs in Kenya, Nigeria, Tanzania, and Uganda, 85% of examined women had never been screened before.

Decreased turnout

Screenings have been deprioritized amid the pandemic. While they are still available in many places, women are only getting their most immediate needs met, service providers said. Health providers also might not encourage these screenings because of their own hesitancy to touch people.

“Women fear that going to hospital could potentially expose them to the COVID-19 infection. Because of that, we've seen a drop in the screening,” said Benda Kithaka, executive director at KILELE Health in Kenya. “Obviously, this is going to have an implication in the long term.”

In Kenya, many civil society organizations rely on public appeals for funding of cervical cancer screenings, Kithaka said. These include charity walks and golf days — which aren’t possible with social distancing. The flow of funds through public appeals has also decreased because of reductions in people’s disposable income during the pandemic.

With those funds, organizations used to host community screening events, working with trusted community leaders who would educate women about the importance of the screenings beforehand, Kithaka said. Restrictions on public gatherings mean that these events are not possible either.

Service providers in Malawi have a similar community-based screening approach, and while women can still currently get screened at health facilities, turnout has decreased, said Maud Mwakasungula, executive director at Women's Coalition Against Cancer.

Her organization’s members are now going from door to door, telling women to travel to health facilities on certain days for screenings. But this is more resource-intensive and harder for those who might be far away from a health facility.

For Kithaka, boosting access to COVID-19 vaccines is key to ensuring that cervical cancer screenings increase.

“It is hard to divorce cancer screening from the COVID-19 vaccine, because the COVID vaccine has the impact of getting us back to normal sooner,” she said.

And concerns remain about whether the previous systems can be easily revitalized when the pandemic is over. Building up services can take many years, Chowdhury said. This includes training health workers, procuring equipment, setting up data systems, and building trust with communities, as well as educating them on the importance of screenings.

“We suddenly get set back a whole decade because those conversations have stopped, and they will need to be restarted, and we will need to, again, start building up,” Chowdhury said, adding that MSI is also now being impacted by a shift in donor funding to short-term contracts instead of multiannual projects.

Eliminating cervical cancer

HPV vaccines, which have been distributed to girls in school, can be a tool for preventing cases of cervical cancer.

Vaccination, screenings, and treatment of precancerous lesions will prevent most cervical cancer cases, according to WHO.

But access to vaccines is limited, and there are shortages.

Additionally, many African countries just began vaccination campaigns before the pandemic hit and might have not distributed second doses because of school closures, said TogetHER for Health’s White, with fears that large numbers of girls won’t ever return to school after the pandemic.

In Kenya, for example, HPV vaccinations began in 2019. Girls vaccinated in October of that year would have needed their second dose in April 2020 — right in “the eye of the storm of COVID,” Kithaka said. The vaccine is still being administered in the country but at a slower pace than planned.

WHO has set the ambitious goal of eliminating cervical cancer, with targets for 2030 including 90% of girls vaccinated against HPV by age 15, 70% of women screened for cervical cancer by 35 and again by 45, and 90% of women who have been diagnosed with the disease receiving treatment.

But some advocates say more is needed to achieve these ambitions, including increased leadership, accountability, and financing, as well as road maps to translate these targets into manageable goals, White said.

Lessons from the pandemic can be used to improve health systems and service delivery, such as pivoting to self-sampling approaches to HPV, she said.

“As much as we've got challenges — and, of course, we all face challenges every day — we do have opportunities to build back better within our communities and within our programs,” White said.

Visit the Building Back Health series for more coverage on how we can build back health systems that are more effective, equitable, and preventive. You can join the conversation using the hashtag #BuildingBackBetter.