Compared with other countries, South Africa has a much higher global cervical cancer rate – between 22.8 and 27 per 100 000 women, with the global average being 15.8 per 100 000 – which is attributed to low screening coverage, late diagnoses, high HIV prevalence, and limited access to treatment and vaccines.
It is the leading cause of cancer deaths among women in South Africa, writes Yoliswa Sobuwa for Health-e News, with more than 10 700 women receiving a cervical cancer diagnosis every year, and with more than 5 800 dying from it.
Women with HIV are six times more likely to develop cervical cancer than those who are HIV-negative. Because HIV weakens the immune system, it becomes more difficult for the body to clear Human Papillomavirus (HPV) infections, which causes cervical cancer, so these infections tend to persist longer and are more likely to progress to precancerous lesions and, ultimately, cervical cancer.
According to Dr Mark Faesen, a gynaecologist and fertility expert from the Clinical HIV Research Unit (CHRU), HPV is the most common sexually transmitted infection: more than half of young people get infected within three years of being sexually active.
“There are nearly 150 HPV types, but not all pose the same level of threat. Close to 80% of all cervical cancer cases are linked to one or a mix of three high-risk types, which include HPV 16, 18, and 45,” he says.
Once it becomes a persistent infection, it stays in the body for life, he adds. The virus cannot be removed, and continued infection with high-risk HPV strains will cause cervical cancer. The damage doesn’t stop at the cervix; areas like the vulva can also develop ongoing infections.
“The biggest risks tied to lasting HPV infection include weak immunity when HIV isn’t well-managed, having multiple sexual partners, repeated exposure to the virus, co-infection with other STIs, and smoking.”
Drive to prevention
But cervical cancer is preventable. Vaccines are highly effective in preventing HPV, and the World Health Organisation recommends vaccination for HPV, especially for girls aged nine to 14, before they become sexually active, and for girls and young women up to the age of 20. For women over 20, two doses administered six months apart are recommended.
Although HPV vaccination was introduced in South African schools in 2014 for girls nine years and older, Faesen says delivering the jabs to every child who needs them remains challenging, due to logistical issues.
Professor Sinead Delany-Moretlwe, who leads research at Wits Reproductive Health & HIV Institute (Wits RHI), says while the HPV vaccination efforts have made strides, key parts of the overall approach still lack strength.
“Getting women screened, tested, and treated remains a big problem. Many steps are involved, and people often don’t return for follow-ups,” Delany-Moretlwe says.
HPV screening involves testing for the presence of high-risk types of HPV that can lead to cervical cancer – usually done using a sample of cells collected from the cervix, either through a Pap smear or a dedicated HPV test. But unlike Pap smears, which look for abnormal cells, HPV tests detect the virus itself, often identifying risk earlier and more accurately
“Many women, especially those with HIV, don’t realise their cervical cancer risk and avoid getting Pap smears. Overworked health workers at many clinics also struggle to focus on cervical screening because they deal with so many other medical problems,” Faesen says.
While urban clinics manage patient referrals, rural healthcare systems face significant obstacles.
“The system to refer women with abnormal Pap smears is under heavy strain in rural regions. Challenges include far distances, poor infrastructure, and not enough resources,” he says.
Salome Meyer, who leads the Cancer Alliance, said a major issue is that the cervical cancer screening system relies on women visiting primary healthcare clinics on their own.
“There are no large-scale screening efforts. Everything depends on whether a woman decides to go to a clinic. With this system too many women get missed,” she says, adding that the current cervical screening programme covers just 57% of eligible women. This falls far below the 70% required to meet the WHO 2030 cervical cancer elimination target.
Urgent steps required
Faesen says there is a need for increased awareness and a strengthened health system – improving referral pathways and the number of referral centres, and expanding their capacity, will enable early detection and treatment in the pre-malignant stage before cancer has a chance to develop.
See more from MedicalBrief archives:
US cuts affect vital cervical cancer screening, research in SA
High rates of cervical cancer found in women living with HIV
Cervical cancer treatment success with heat therapy – Wits study
Cervical cancer self-screening the answer to reduce fatalities