 I'm delighted to now welcome Anne, and Anne is also working for MSF, and I think she qualified fairly recently and straight away went to work for MSF, so that must be a good thing to do. And Anne is going to talk about cervical cancer screening in Zimbabwe. I look forward to your talk. Thank you very much. Good morning everyone. So, the aim of this presentation is to approximate the rates of precancers and cancerous lesions that are found among our HIV positive women, and also to determine the effectiveness of our program. We did a retrospective review of all our routine data collected data, and because of this we didn't have to go for an ethical review. So, MSF started in Epworth, which is a suburb to Harare by the 2006 in response to the HIV crisis. And our current focus is HIV treatment failure, its pediatric HIV, and other certain co-infections such as multi-drug resistance TB. The cervical cancer screening program was started in 2013 and handed over to the Ministry of Health in January 2015. So, why did we decide to start a cervical cancer screening program? It's one of the defining diseases, but also it's one of the most common forms of cancer in Zimbabwe and black women, accounted for more than 5,000 new cases per year, out of which 60% are HIV associated. But as most women can't afford to go to a health facility for diagnosis or treatment, it's a gross underestimation. So, because of this, the Zimbabwe Minister of Health decided to start scaling up cervical cancer screening services using visual inspection with acetic acid and cervicography, but so far the access is quite limited. So, here's one of the nurses who are recruiting HIV positive patients in the waiting area, and it was open to all sexually active HIV positive women. They could go for screening on the same day, and the nurses use the camera to take a picture of the cervix and then a monitor for visualisation. Depending on the size of the lesion, the patients were either given cryotherapy on the spot by the nurse or referred for a loop electro-surgical excision procedure at a central hospital, and MSF was paying for the procedure. In cases where the nurses were suspecting cancer, they just offered advice on where to turn next, but MSF weren't covering either investigations or treatment for that. So, in the one-and-a-half years that we did the screening programme, we screened more than 3,000 women for the first time and more than 300 full-up screenings. And considering that the HIV positive cohort of both male and female patients was more than 6,000 patients, we managed to cover the majority of our patients. 16% of them had positive lesions out of the rich 64 required cryotherapy and 46 were referred for a leap. The nurses also found 26 cases where there were suspecting cancers and these ones were referred to hospital for further treatment. So, as you can see, the nurses were seeing more than 150 patients per month, which is approximately 10 patients per day. There's a small peak here in September and October due to that we started referring patients from a neighbouring clinic, but that stopped in November and December and that's where it goes down. I want you to remember this because I'm coming back to it on the latest slide. As to the positivity rate, it was initially quite low towards 10%. And from the start we had a communication with Newlands Clinic, which is a Swiss aid supported HIV clinic, which was one of the first to introduce cervical cancer screening in Zimbabwe. And their positivity rate was 30%. So, they were advising us to send our nurses for retraining at their centre, which we did in July 2014. And after that, you can see that our positivity rate went up to 30% as well. As for the treatment, the green line here stands for all the patients who were with positive lesions. And as you can see, there's a peak in September and October, both as we start finding more patients and also screening more patients, which goes down in November-December due to that we started screening less, but the positivity rate was the same. The light blue staple are the women that were referred for LEAP, not treated, just referred. And the blue staple are the ones who underwent cryotherapy and that gap in between are the women who did not receive cryotherapy. So, out of the 342 that we referred for cryotherapy, only 60% received treatment. And initially that number was even lower towards 30%. And this was due to that the women were booked for cryotherapy at a later date, because after doing a procedure, you have to abstain from sexual intercourse for four weeks. And it was considered prudent that they were allowed to go home and discuss with their partners before undergoing the procedure. However, in August 2014, we introduced a see-and-treat approach where the women were signing a former consent for cryotherapy before doing the screening. And with that, we had a much better treatment rate and the screening rates were the same. But as you see, there was still 20% who did not receive treatment and that was because the cryotherapy broke down for one month during the autumn. Out of the 265 patients referred for LEAP, only 76 were seen at the hospital for a first visit. And out of these, only 52 received an initial biopsy result. When they saw them, they decided that 30% actually needed LEAP, but out of them, only 25 received LEAP. Now, as I said, the Zimbabwe and Minister of Health have been scaling up their cervical cancer screening services, but the access to LEAP has not been scaling up to the same extent. There was a huge queue initially and then the LEAP machine broke down in September 2014 and it's still broken down. So in addition to this, they also had a system to do a biopsy before doing the treatment and that's to make sure that people don't get unnecessary procedures. But as you see, they also lost patients on the way. At Newlands Clinic, they do LEAP at the clinic and they do LEAP for all patients that the nurses send and that gives them better treatment rates. As to the histology results, 3 fourths had abnormal cytology and 55.8% had high-grade lesions and 16.3% said low-grade lesions and 3.8% showed up with cervical carcinoma and these patients have been referred to hospital for further treatment. Sadly, we did not do a biopsy for all our patients with positive screening results, but if we consider that the 26 patients where the nurses were suspecting that they had cancer, that they actually had cancer and add that to the two patients with confirmed cancers to make the prevalence of cancer among the patients who did biopsy, who were waiting for LEAP and put that on all the patients who never received LEAP, then we could project and further eight cases among our LEAP patients. If we then add these numbers together, we would get a prevalence of 1.1% and this should be compared to the national prevalence which is 0.035%. HIV causes chronic sinusitis and this leads to more infection with the human papillomavirus with multiple forms, with more oncogenic forms, less self-healing and higher progression rates to cancer and lesions that are more difficult to treat. Because of this, it is recommended that they come for yearly screening but only 25% came back after a year. It is also recommended that they come back six months after going through a procedure, but only 13% came. This is the figures after we handed over to the Minister of Health and as you can see, the patients are still coming for screening, although not to the same amount as before. The positivity rate is high still and all the patients who require cryotherapy receive it. But the nurses are flagging that the ones that they are referring for LEAP can't afford to go for LEAP. Our future plan is to open up a VAIC in one of the neighboring clinics in Donbu and that started in April 2015. In conclusion, we can say that we had a high prevalence both of pre-cancers and cancer lesions among our HIV positive women and that the staff training was very important for us to identify those lesions. However, one of our continuing challenges is that such a low percentage of patients that come for re-screening after one year come after procedures and also to show up before procedures. So, in order to actually see an effect on morbidity and mortality we would have to make a follow-up much later on. But it's important to remember that the patients we treated might actually have self-healed and also some of the patients that we treated can still develop cancer as many of the HIV positive patients need several treatments and there was quite a low percentage who came for re-screening after six months. So, what I would find really interesting for MSF to consider for the future is to look more into human papillom and virus vaccination especially for similar settings such as Zimbabwe. Thank you very much. Thank you very much for that very nice presentation about a very actually important problem in developing countries of viral cancer and particularly so among HIV positive women. So, I'm sure there will be a number of questions from the floor. Would you care to raise your hand and also maybe introduce yourself and let us know where you are working? Yes, sir, in the blue shirt. Thank you. I'm Isaac, Deputy Program Manager for MSF in Tokyo and I also happen to be Zimbabwean. So, maybe I can say hi, ma'am. Ma'am, we are actually considering starting a project similar to this in one of our missions and my question is actually one of your questions so maybe you could give us your opinion on whether you think HPV vaccination could have a role because we are actually considering it as part of our project. What is your opinion? You have asked the question already. Well, I completely agree. I think it's very important and I know that I was reading yesterday about Gaby that they want also to give more access to vaccination in third world countries and according to them the price was $4.5 so it's not very expensive either to do it and that would be a short-term intervention that could give a long-term effect and I think especially for HIV positive adolescents which in our project they have about 1,000 and it's very important to give them HPV vaccination for the women. Yes, we have a question from the online forum. Firstly, I have MSF Zimbabwe who say yay on Twitter and then I have a question from the Lancet ID who asks regarding your research if the false positive rate was estimated? As I said, we didn't do biopsy for all our patients who had positive results. We only have the biopsy result for the mountain leap and as you can see there, there were three fourths who were positive but these are the big lesions. The other ones are small lesions. We haven't assessed that. For interest, the other positivity like we found one TB serviceitis, one sister somiasis so there were other pathologies but not necessarily cancer. Thank you. I would like to add maybe that that is something to consider in future work because this is very clearly a very topical area of work and could do with more evidence as suggested so that might be nice to consider in your various programmes. Yes. Could you speak up a little bit? Sorry, Nellie Staderini. I'm the SRH referend for OCG working on cervical cancer as well in Mozambic. I have two questions. The first one is you said that you take some pictures and I would like to know what do you do with those pictures. Do you send to people who also can compare the diagnosis? And the other thing is how many providers did you have and did you have any difference regarding the different providers? For the result. Thank you very much. The pictures were saved in a computer system so we had a computer filing system and that's where they were saved. So whenever you enter a new picture every year then you can follow the development of those pictures. At the new clinic we don't have a computer system so then we just file them on a computer and then you can search for that picture the next time the patient comes. As for the providers there were mainly three nurses who were providing the screening and only two of them went for the retraining so the other one has still not gone for the retraining and as you saw there was a significant difference between the patient and the patient so we had to give it away before and after the retraining. We also did quality control every month. Over weeks I went through the pictures with the nurses and they were both, you know, we went through them together and when there were pictures that were not good or pictures that were a bit doubtful then we called back the patients for re-screening. Right. Given the time, although you did stick to your time I'm going to ask you to keep the rest of your questions still the panel discussion. Thank you very much again for the next presentation.