With technical assistance from L’Initiative, the Cambodia’s National Center for HIV/AIDS, Dermatology and STDs (NCHADS) developed standard operating procedures to support cervical cancer screening among women living with HIV receiving care at antiretroviral therapy sites. This project includes an action plan for HPV testing and referrals, aiming to integrate cervical cancer screening into HIV care services. Dr Kennarey Seang collaborated with NCHADS to supervise the development and implementation of the plan.
Doctor Kennarey SEANG
University of Health Sciences, Phnom Penh (Cambodia)
Could you assess the current state of HPV diagnosis and cervical cancer care in Cambodia?
Kennarey Seang: Cambodia has made notable progress in cervical cancer screening. A national team is training healthcare providers, in health centers and hospitals nationwide, on screening and treatment. The training focuses especially on minor treatment, primary using visual inspection (VIA), since HPV-DNA testing is not yet widely available. Healthcare providers are also trained to manage small cervical lesions detected during screening, offering a one-stop service.
The national team has already visited and trained about 400 to 500 health centers. Efforts are ongoing to expand these services across the country, which has a total of 1,000 health centers. The Royal Government is committed to providing cervical cancer screening services to all women in the coming years, starting with VIA until progressing toward wider availability of HPV-DNA testing.
For women living with HIV (WLHIV), World Health Organization (WHO) recommends HPV-DNA testing as a primary screening tool due to its high sensitivity at detecting early signs of cervical cancer. Compared to HIV-negative women, WLHIV are at higher risk of developing precancerous lesions and at greater likelihood of rapid progression to cervical cancer when infected with HPV. Smoking or having repeated or past sexually transmitted infections elevate the risks for all women, particularly those with a compromised immune system.
What are the main challenges associated with this situation?
Kennarey Seang: Currently, about 25,000 WLHIV in Cambodia receive care at antiretroviral therapy (ART) sites, the majority of which are co-located with general health services. The aim is to enable these ART sites to offer HPV-DNA testing for WLHIV–as recommended by WHO–to improve cervical cancer screening. If a test is positive, the next step would be referring women for visual inspection at the nearby general health services that offer cervical cancer screening and treatment.
Another significant challenge is the stigma and discrimination surrounding HIV/AIDS. Referring women from ART services to general healthcare facilities could lead to discomfort with unfamiliar providers who may not understand their specific needs. While there is a commitment to provide HPV-DNA tests to WLHIV for starting, the implementation is still in the planning stage. Access to these tests remains very limited. They are currently available only at some private clinics.
Could you summarize the technical assistance of L’Initiative and its main objectives?
Kennarey Seang: A previous study sponsored by the French research agency ANRS MIE demonstrated the high acceptability of self-sampling methods for HPV-DNA test among WLHIV. It forms the basis for this technical assistance funded by L’Initiative. Its aim is to incorporate the findings and insights of this previous study, where applicable, into practical guidelines, such as action plan or SOPs for national programs like NCHADS. These will be designed to fit within the available resources and jurisdictional frameworks, addressing the health needs of vulnerable populations, including WLHIV. The documents will also include details on logistic issues and set annual screening targets.
A key focus is to recommend the implementation of cervical cancer screening services directly within the ART sites, thus allowing WLHIV to receive HPV-DNA tests without needing referrals. Moreover, training and capacity-building–in conducting HPV-DNA tests (in cases where women are not comfortable doing self-sampling) and HPV and cervical cancer related counseling–is crucial for the NCHADS staffs. This ensures they are equipped with the necessary skills for carrying out effective testing and managing referrals. The project focuses on providing clear guidelines to HIV care providers to ensure effective and sustainable access to cervical cancer screening for all WLHIV.
What actions have been taken to support cervical cancer screening among WLHIV?
Kennarey Seang: The primary action undertaken was to develop the main SOP to support the implementation of specific cervical cancer screening services. The training materials developed afterward were for training the HIV care providers on counseling, cervical cancer screening, and referral procedures for women with positive HPV-DNA test result. In this context, the general care providers to whom WLHIV might be referred had also been trained by NCHADS specifically on HIV-related stigma. In addition, the SOP for health information system had also been developed, allowing NCHADS to track cervical cancer screening results and integrate them into their databases. This will help maintain continuity of care, proper monitoring, and effective referral of eligible women.
Furthermore, at NCHADS’ request, an action plan document was produced to provide scalable implementation scenarios for cervical cancer screening services. It includes guidance on test numbers, budget estimates, and expected outcomes over the first few years, enabling informed decision-making for future funding and resource allocation.
What would be the expected impact?
Kennarey Seang: Previous research showed good acceptance of HPV-DNA tests among WLHIV. We expect high uptake once the main SOP is approved by the Ministry of Health, provided the services are made accessible at the ART sites. If these conditions are met, many WLHIV will be able to get screened for cervical cancer. Those with precancerous lesions or high-grade lesions could be referred effectively and timely for appropriate treatment. In the long run, the mortality and morbidity associated with cervical cancer will be reduced.
While NCHADS plans to include the purchase of the HPV-DNA tests in future funding proposals, the immediate concern is to establish a solid referral system for HPV-positive women. Therefore, working with general healthcare providers to come to an understanding in this regard is very important. NCHADS began this process during the first training session, inviting general care providers to the training of trainers on the main SOP.
This holistic approach ensures that all general healthcare providers are equipped to support WLHIV in accessing cervical cancer screening services and care. Although the initial implementation phase might be limited to Phnom Penh, NCHADS is expected to eventually implement these SOPs nationwide, addressing gaps in access to cervical cancer screening among this vulnerable population.
How would you describe the support provided by L‘Initiative?
Kennarey Seang: L’Initiative’s support has been crucial in adapting scientific findings to support the needs of national programs. Their assistance facilitated the quick development of key SOPs and training materials.
Thanks to L’Initiative’s contribution, NCHADS was able to effectively prepare for implementation of cervical cancer screening program with HPV-DNA tests at ART sites. They now have all necessary resources, including developed training materials, completed training of trainers, and the finalized action plan and SOPs. Collaboration with national experts, HPV and HIV specialists, and stakeholders were instrumental in producing high-quality materials and ensuring complete assessment of the services and coordination. L’Initiative’s involvement has significantly accelerated the SOP development and fostered a supportive environment for technical assistance, laying a solid foundation for the future screening program.
