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A Partnership Takes All of Us: Stories from Botswana
Go Further is made possible by the individuals working daily to ensure women are receiving the services they need to live healthy and full lives, and the brave women living positively with HIV and taking control of their health. We spoke with four women who are all contributing to our collective efforts to go further for women in Botswana.
In Botswana, one in four women aged 15 to 49 are living with HIV. Because women living with HIV are six times more likely to develop cervical cancer, it is important they have access to quality screening and treatment services. PEPFAR and the Bush Institute have been partnering with the Government of Botswana since 2012, and in 2018, strengthened their collaboration through Go Further, a public-private partnership between PEPFAR, the Bush Institute, UNAIDS, and Merck. The partnership aims to reduce new cervical cancer cases by 95 percent among women living with HIV in twelve African countries, including Botswana.
Go Further is made possible by the individuals working daily to ensure women are receiving the services they need to live healthy and full lives, and the brave women living positively with HIV and taking control of their health.
We spoke with four women who are all contributing to our collective efforts to go further for women in Botswana. From the clients who choose to lead in their communities and be screened, to the nurses who care for them, the community healthcare workers who make sure women know about their risks for cervical cancer and opportunities for screening, and the government representatives who guide the policy and implementation of nation-wide programs, it takes all of us to ensure the partnership’s success.
JOYCE MOSEMELA, Go Further Client and Cervical Cancer Survivor
Joyce is 54 years old and lives in Botswana’s capital city, Gaborone, with her three children. She could not attend school because the tuition fees were too expensive for her family, and today she works multiple jobs to make a living.
After listening to a radio jingle about cervical cancer prevention, Joyce was inspired to go for screening even though she was not feeling sick or having any symptoms. During her visit, she was diagnosed with suspected cancer and was referred to Princess Marina Hospital, the country’s only tertiary cancer care facility, for further care. The clinical provider carefully explained the procedure and investigation process. Unfortunately, the results showed early stages of cervical cancer, so she was immediately scheduled for a surgical operation to remove the cancerous region. The surgery was successful, and Joyce made a full recovery.
Joyce says the staff at the clinic were amazing. She received information on cervical cancer and ways of managing the condition. Nurse Alexander and her doctor helped her throughout her cancer journey. Joyce has regular check-ups, and she has stayed healthy and free from cervical cancer.
Her dream is to see every woman free from cervical cancer. She encourages women to adhere to their check-up visits at the clinics. She wants every woman to stand up for their right to get checked for cancer so that they are not diagnosed too late. Joyce encourages women go for cervical cancer screening because it is very easy to do, but most importantly, it saved her life.
ALEXANDER GABO SEIPHETLHENG, See & Treat Nurse at Princess Marina Hospital
Alexander is a nurse at Princess Marina Hospital in Gaborone, the same nurse who helped Joyce through her cervical cancer fight and works daily to ensure women receive screening and treatment for cervical cancer. The past year has been challenging for the cervical cancer program in Botswana due to the COVID-19 pandemic, but Alexander has focused on caring for the women who need her most.
On March 30, 2020, the first three COVID-19 cases were reported in Botswana and four days later a State of Emergency was declared, quickly followed by a series of COVID-19 mitigation measures such as extreme social distancing. Since the intimate nature of the cervical cancer screening procedures does not permit extreme social distancing, all cervical cancer prevention services were abruptly halted to protect the safety of both health care workers and patients.
Following the lifting of Botswana’s first lockdown, the clinic continued to experience effects of COVID-19. For example, most of the clinical staff were temporarily deployed for the COVID-19 emergency response. As a result, all LEEP appointments (a procedure to remove invasive precancerous cervical lesions) were postponed to future dates. Many women with suspected cancer were delayed for further management and most of these women had their cancer progress while waiting for treatment.
Although screening has resumed, it is on a limited scale. After a second lockdown in July, Alexander reports the clinic was able to take advantage of patients’ routine hospital visits to collect their HIV medication to ensure they were screened for cervical cancer and followed-up with patients who had been previously screened. The University of Botswana School of Medicine also generously had its multi-disciplinary team of a gynaecologic and medical oncologist working in the clinic which enabled timely diagnosis of patients and helped the clinic keep in close touch with patients by telephone.
Despite the clinic’s efforts, the COVID-19 pandemic has had severe impacts on women’s health. Alexander says the clinic continues to face challenges in ramping up cervical cancer screening while COVID-19 cases continue to rise. Many clients understandably prefer to avoid the health facilities where they might be exposed to COVID-19. Furthermore, travel restrictions have created barriers for some who wish to visit the clinic. As a result, fewer women than expected are being screened.
Compared to the same period in 2019, Alexander reports an increase in the number of women presenting with advanced cervical disease. Likewise, more women lost their lives due to progressed disease compared to the same time last year, and sadly some died while awaiting treatment. More women also became pregnant post-LEEP procedures while awaiting pathology results. If advanced disease was found, women had to make difficult decisions about their pregnancies. These cases had profound emotional and psychological repercussions on both patients and staff. Moreover, the fear of being exposed to COVID-19 at work causes significant stress and anxiety among the facility staff, which affects both their own wellbeing as well as the quality of care they provide.
When asked about what is needed to support healthcare workers, Alexander says they need more knowledge and skills to effectively deal with the wider impacts of cervical cancer on families and communities and more specialized education and training in gynaecologic oncology for doctors and nurses to meet the growing demands of this field. She also identifies telemedicine as one key solution to the constraints imposed by the COVID-19 pandemic.
Alexander hopes that more health education will be conducted in native languages for women, and that messages that will empower women to know how to take good care of themselves and prevent cervical cancer. The women who have been through this journey are serving as roles models to everyone, but Alexander also sees them actively support other women who are going through these situations.
MOKGABO RAMARUMO, Community Outreach Nurse
Mokgabo is a registered nurse and has been providing cervical cancer screening and treatment since August 2016. She currently serves as a trainer for the National Cervical Cancer Prevention Program (NCCPP) at Botswana’s Ministry of Health and Wellness, building the skill levels of health providers and improving the reach and quality of cervical cancer services.
“I have been involved in community outreach in order to increase the number of patients who can be seen through the single visit approach,” Mokgabo says. “With this approach, women are screened and treated on the same day, reducing the waiting time for another appointment to be given treatment. The community outreach strategy has been a successful way to encourage women to get screened for cervical cancer. The strategy uses targeted cancer screening and treatment campaigns, community events like health fairs, and public addresses to speak to women about the benefits of getting screened and treated early and where they can get our services. Most importantly, I partner with community-based leaders and stakeholders such as local chiefs, Village District Committee members, and others to inform the community about the advantages of the single visit method.”
Community outreach is not without its challenges. Lack of working equipment and supplies are significant challenges. The equipment used for treatment is inconvenient and not easily transportable for outreach services and can malfunction frequently. Mokgabo has lobbied for thermal ablation equipment, a newer type of treatment equipment, which is more portable and user-friendly especially for doing community outreach services.
Sometimes, a low number of women turn up for screening because of stigma. They do not want to visit the mobile health van because they do not want to be seen as being sick. Outreach services offer an alternate option for screening and treatment, but mobile vans do not always cater to all women, especially for clients with disabilities.
Mokgabo says to address these challenges, direct community involvement and health education on screening methods and treatment have played an important role in motivating women to seek care. Community leaders and stakeholders help mobilize communities, and their collaboration when conducting health promotion and education campaigns is critical.
Due to the COVID-19 regulations, it has become a challenge to have gatherings to spread the message to the community on the importance of early screening and this has affected the number of women coming for cervical cancer prevention program services.
“We’ve adapted messages to motivate patients to maintain healthy habits including keeping up with regular medical check-ups such as cancer screening.” Mokgabo explained, “While we continue to deal with COVID-19, we can organize only a limited number of women in our small communities to ensure they continue to receive services that will save their lives.”
To maintain regular communication with patients, the team has relied on available technology like text messages to remind clients of their due dates for re-screening and other appointments. And building good relationship with the women in the community has been important for encouraging women to continue to seek services.
“My biggest hope for the future is to have a free world without cervical cancer,” Mokgabo says.
TLHOMAMO PHETO, Ministry of Health and Wellness Official
Tlhomamo is a registered nurse midwife with many years of experience in providing health care services. Currently she is the national training coordinator for the National Cervical Cancer Prevention Program (NCCPP) at the Botswana Ministry of Health and Wellness. The NCCPP is implemented by the Sexual and Reproductive Health Division which addresses a wide range of health issues, such as family planning, intimate partner violence, maternal and neonatal care, as well as adolescent sexual and reproductive health.
The NCCPP was established in 2012 with funding from PEPFAR. “This funding came at an opportune time because of the rising morbidity and mortality rates associated with cervical cancer,” Tlhomamo says. “The PEPFAR partnership has also contributed a lot to our health workforce and made an enormous impact on many of our public health programs and services. Most importantly, many lives of Batswana have been saved and restored through this amazing partnership.”
Tlhomamo’s role as the national training coordinator is to empower and provide technical assistance to the Botswana’s district health teams through trainings, mentoring, and support visits to ensure cervical cancer screening and treatment services are available and accessible. She also facilitates community campaigns including developing information, education, and communication materials to be distributed at the clinics across the country. The NCCPP also collaborates with other stakeholders to reach communities with messages about the importance of cervical cancer screening and treatment.
Furthermore, the Government of Botswana has invested in scaling up HPV vaccination for younger girls, which can prevent cervical cancer from developing as they age. More preventive strategies are being emphasized, and are crucial because they decrease overall costs, reduce the burden on families, and improve wellbeing.
Tlhomamo says, “The role of government in public-private partnerships such as Go Further is making sure that what has been established through this partnership does not go to waste and hence the government encourages sustainability.”
“The Botswana Government is grateful for the American Government’s support, which has enabled us to maximize the coverage and quality of life-saving health services today, while also building sustainability that will ensure we reach and maintain a cancer-free future for Botswana.”