Cervical cancer, which is caused by certain strains of the human papillomavirus (HPV), presents a significant public health threat to women on the African continent – all but one of the top 20 countries worldwide with the highest burden of cervical cancer in 2018 were in Africa.

Cervical cancer progresses slowly from the precancer stage to invasive cancer and it is entirely curable if diagnosed and treated early. The tragedy is that while this type of cancer is one of the most preventable, poor access to prevention, screening and treatment contributes to 90% of deaths.

The situation is further complicated by the fact that this cancer is also one of the most common in women living with HIV, with patterns of cervical cancer and HIV typifying the experience of young women in Africa who face multiple barriers to good health.

Everyone who is sexually active will become infected with HPV at some point in their lives. While most strains are harmless and will not harm people with a healthy immune system, two types – 16 and 18 – cause 70% of cervical cancers and precancerous cervical lesions.

There are cost effective screening tests that are available to detect precancer lesions as well as effective, safe and simple treatment for precancer, thus preventing the development of cancer in these women.

WHO recommends a life-course approach to prevention and control of cervical cancer with age appropriate, cost-effective interventions that target the disease along the life course. These range from interventions that prevent infection with cancer causing HPV strains, to screening for precancer and early cancer to diagnosis, prompt treatment of cancer and palliative care.

Unlike other cancers, cervical cancer is almost 100% preventable by ensuring that young girls are vaccinated with HPV vaccines and women receive quality screening and treatment of precancerous lesions.

Primary prevention:  vaccinations that protect against HPV-16 and HPV-18.

WHO recommends that adolescents, principally girls aged between nine and 14 get two doses of HPV vaccine to prevent infection with HPV, the second dose about six to 12 months after the first one. Studies have also shown adequate immune response in HIV-positive children to allow them to receive the HPV vaccine. Other preventive measures include culture and age appropriate adolescent sexual reproductive health education as well as male circumcision. It is also recommended to raise awareness and educate people about cervical cancer.

Secondary prevention: screening and treatment of precancerous lesions.

Today, especially in resource-poor settings such as most of Africa, cervical cancer is mostly diagnosed when the disease has progressed to advanced stages. WHO recommends screening for women aged 30 to 49 years. Recommended screening methods should be able to detect precancer and include HPV DNA testing, visual inspection with acetic acid (VIA) as well as Pap smear. These tests are simple to conduct in low-resource settings and the results can be available almost immediately, thus ensuring that women who test positive can be treated almost immediately. Although a woman need not be screened again for at least five years if she has screened negative for HPV, she must be rescreened within the next 10 years. However, in order to have the maximum impact in terms of reducing cervical cancer suffering and death, priority should be given to maximizing coverage and treatment rather than maximizing the number of screening tests in a woman’s lifetime. This is true for all women regardless of HIV status. It is important to ensure that every woman is screened at least once in her lifetime.

Cervical lesions, once confirmed, can be treated using a process that involves the removal of the abnormal cells in the cervix to prevent them from progressing to cancer.

Tertiary prevention: diagnosis and treatment of invasive cervical cancer.

Effective pathology services are required to be able to diagnose and stage cervical cancer. Depending on the type and stage of cervical cancer, patients may need more than one type of treatment. Treatment modalities include surgery or radiation combined with chemotherapy.

As rates of cervical cancer and deaths rise at an alarming rate in the Region and countries grapple with the challenge of managing the disease in poorly-resourced settings, WHO warns that without an effective intervention, global cervical cancer deaths will increase to 460 000 by 2040 –and low- and middle-income countries (LMICs) will have the greatest relative increase.

We have developed guidance on how to prevent and control the disease across the various stages of the life course, through vaccination, screening and management of invasive cervical cancer as well as palliative care. We also work with countries and partners to develop and implement comprehensive programmes.

On World Cancer Day in 2019, WHO launched a new toolkit to guide countries on how to collect and use standardized cervical cancer data to help them fight the disease. Recognizing that the burden and prevention strategies vary between countries, we focused attention on the common questions, including how to measure screening and secondary prevention coverage, how to implement and strengthen systems to monitor patients and programmes, and how to estimate costs of screening and treatment programmes.

Having this high-quality data will help countries inform, plan, scale up and improve their cervical cancer programmes. For example, data on screening coverage and update will inform interventions that ensure no woman is left behind.

Elimination of cervical cancer as a public health problem is one of our flagship projects. In May 2018 we issued a global call to action towards achieving this goal, followed by a request from the Executive Board in January 2019 that the Director-General consult with Member States and other relevant stakeholders on the development of a global strategy specifying clear targets for 2020–2030. This effort to mobilize new political will to tackle this fast-growing challenge saw a zero Draft of the Global Strategy towards the Elimination of Cervical Cancer become a reality in July 2019. Further development is expected, with a view to the final version being ready for consideration by the Seventy-third World Health Assembly, through the Executive Board at its 146th Session in January 2020.

The global strategy sets the following targets for countries to achieve by 2030:

• 90% of girls must be fully vaccinated with the HPV vaccine by the time they turn 15
• 70% of women must be screened with a high-precision test 1 at 35 years of age, and then again at the age of 45 years
• 90% of women identified with cervical disease must receive treatment and care.

The document emphasizes that vaccination against HPV virus, screening and treatment of precancers, early detection and prompt treatment of invasive cancers and palliative care, are all proven, cost-effective strategies that, together, address cervical cancer across the care continuum.

Other key elements for ensuring the success of eliminating cervical cancer as a public health problem include the following:

• Member States and partners increase investment in this goal so as to secure sustainable financing for cervical cancer programmes, and jointly mobilize resources
• a framework that can track improvement processes by monitoring implementation and validating elimination is made available
• partners to expedite research outcomes with respect to innovations that will secure faster and more efficient elimination, and facilitate access to such innovations. Examples are cheaper HPV vaccine delivery mechanisms, and screening and treatment technologies that would promote access.

Status of the Cervical Cancer Elimination Initiative in WHO African Region