Worldwide, cervical cancer is the fourth- most frequent cancer in women, with an estimated 604 000 new cases in 2022. Of the estimated 342 000 deaths from cervical cancer in 2022, about 90% occurred in low- and middle-income countries, including Namibia. About 5% of all cervical cancer cases are attributable to HIV infections, and women living with HIV are six times more likely to develop cervical cancer, compared to women without HIV. The cervix is the lower narrowing of the uterus which connects the vagina (the birth canal) to the upper part of the uterus.
The uterus (or womb) is where a baby grows when a woman is pregnant. Women must thus be well-informed about the prevention and early detection methods for cervical cancer. About 95% of cervical cancer is due to the human papillomavirus (HPV).
HPV is the most common viral infection of the reproductive tract, and most sexually active women and men will be infected at some point in their lives. There are more than 200 subtypes of HPV reported in the literature that are further classified into two groups: low-risk and high-risk. The high-risk HPV types are the ones associated with cervical cancer. There are about 14 high-risk HPV types, including HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68. Two of these, HPV16 and HPV18, are responsible for 70% of the HPV-associated cervical cancers. More than 90% of the HPV-infected populations eventually clear the infection without any treatment or medical intervention. But there is a risk for all women that HPV infection may become chronic, and form a pre-cancerous lesion which can progress to invasive cervical cancer. In women with normal immune systems, it takes 15 to 20 years after primary HPV infection for cervical cancer to develop, whereas it can take only five to 10 years in women with weakened immune systems, such as those with untreated HIV infection. Hence, screening is very crucial in that population group. Due to the high prevalence of HPV and its well-reported association with cervical cancer, the WHO and other health organisations have recommended the HPV vaccine rollout to teenagers, ideally before their first sexual encounter. There are currently several vaccines which have been prequalified by the WHO, all protecting against HPV types 16 and 18 which are known to cause at least 70% of cervical cancers. Two of the vaccines also protect against HPV types 6 and 11, which cause anogenital warts. HPV vaccines are safe and effective in preventing HPV infections. The HPV vaccine is recommended for all people, ideally before they become sexually active. WHO recommends vaccinating girls aged nine to 14.
Children who start the vaccine series before age 15 need two doses to be protected. For young people who weren’t vaccinated within the age recommendations, HPV vaccination is recommended up to age 26. Those who receive their first dose at age 15 or older need three doses to be protected. HPV vaccination does not replace cervical cancer screening. Cervical cancer screening involves Cytology (Pap-Smear) to detect pre-cancerous lesions and HPV screening.
Pap-smears look for pre-cancers, cell changes on the cervix that might progress to cervical cancer if they are not treated appropriately, whereas the HPV test looks for the virus (human papillomavirus) which can cause these cell changes. Screening is done among women who have no symptoms and may feel perfectly healthy. The WHO now encourages countries to include HPV tests for cervical screening.
Women aged 25 to 29 who ever had sexual experience should have screening by cytology (Pap-smear) every three years after two consecutive normal annual screenings. Women aged 21 to 24 who ever had sexual experience and with risk factors for HPV infection or cervical cancer are considered at increased risk, and therefore should receive screening based on the doctor’s assessment and recommendations. Pap-smear based screening should be done annually for women living with HIV or are immunocompromised. HPV screening should start from 30 years, with regular screening using a validated HPV test every five to 10 years. Women living with HIV need to be screened more frequently, every three to five years. Additional actions people can take to help prevent cervical cancer include delaying their first sexual intercourse until the late teens or older, limiting the number of sexual partners, practising safer sex by using condoms, avoiding sexual intercourse with people who have had many partners, avoiding sexual intercourse with people who are infected with genital warts or who show other symptoms, and quitting smoking.
In 2020, the World Health Assembly adopted the global strategy to accelerate the elimination of cervical cancer as a public health problem, and target that by 2030, 90% of girls get fully vaccinated with the HPV vaccine by age 15; 70% of women be screened with a high-performance test by age 35; and 90% of women identified with cervical disease receive treatment.
The WHO calls for all women to ensure they get regular cervical cancer screening tests, in line with the recommendations of their local healthcare providers.
*Dr Simon Emvula is a specialist obstetrician and gynaecologist at
Lady Pohamba Private Hospital.