Clinical Practice Standards: Cervical Cancer Prevention — Cervical Cancer Prevention Practice Guideline Participants' Handbook

Objectives

Enable health workers, service providers and programme managers to deliver accessible, quality cervical cancer prevention services through early detection and treatment of precancerous lesions, principally using visual inspection with acetic acid (VIA) and cryotherapy.[1][2]The clinical guidance seeks to standardise care in resource-constrained settings and strengthen providers’ competence in screening, counselling, treatment, referral, follow-up, documentation, infection prevention and equipment management.[3][4][2]

• Increase access to cervical cancer prevention by promoting primary prevention, including delayed sexual debut, consistent condom use, monogamy and human papillomavirus vaccination, preferably for girls aged 9–13 years before sexual debut.[5]
• Provide secondary prevention through screening and treatment of precancerous lesions before invasive cervical cancer develops.[6][5]
• Prioritise screening for women aged 25–49 years, maximise population coverage rather than repeated testing of the same women, and screen women living with HIV as soon as possible irrespective of age.[7][8]
• Equip health workers to perform VIA and cryotherapy competently, identify cervical abnormalities, determine eligibility for treatment, refer women requiring further assessment, and arrange follow-up retesting.[9][10][11]
• Provide women with understandable information on screening, treatment, possible side effects and follow-up, while maintaining confidentiality, supporting informed consent and enabling questions or family consultation.[12][8]

The prevention model centres on a single-visit approach: screen with VIA using 3–5% acetic acid, offer immediate cryotherapy for eligible acetowhite lesions, and refer lesions that are unsuitable for cryotherapy or suspicious for cancer.[2][5][10]A negative VIA result requires no treatment and ordinarily prompts retesting after three years, while women living with HIV with a negative first screen should be rescreened within three years.[10][8]

Implementation

Implement the guidance as a clinical practice handbook adapted from World Health Organization standards for comprehensive cervical cancer control and Pathfinder International clinical standards and counselling guidance.[1]Deliver services through trained medical officers, nurses, midwives and clinical officers, under Ministry of Health leadership with World Health Organization technical, financial and logistical collaboration in developing and printing the materials.[1][10][11]

• Deliver VIA through respectful preparation, privacy, informed consent, speculum examination, application of 3–5% acetic acid, observation after at least one minute, assessment of acetowhite changes and discussion of results with the woman.[5][12][9]
• Offer cryotherapy only where acetowhite lesions meet eligibility criteria, including involvement of less than 75% of the cervix and no extension onto the vaginal wall or endocervix; refer larger, extending or cancer-suspicious lesions for further evaluation and management.[10]
• Perform eligible treatment using a centred cryotip and a double-freeze technique of three-minute freeze, five-minute thaw and second three-minute freeze, while avoiding contact between the cryotip and vaginal walls.[13][7]
• Provide post-treatment observation for at least 15 minutes, record treatment and follow-up plans, advise on warning signs, and recommend avoiding vaginal tampons and douching and abstaining from intercourse, or using condoms where abstinence is not possible, for four weeks.[11][7]
• Review women treated after a positive result at one year, treat eligible residual lesions immediately, refer ineligible lesions, and return women with a normal cervix to routine screening under the applicable protocol.[8]

Support service readiness through examination furniture, VIA and cryotherapy equipment, refrigerant gas, instruments, infection-prevention materials and, where available, HIV testing and family-planning commodities.[8][14]Prepare equipment and supplies before treatment, including functional cryotherapy equipment, carbon dioxide gas, sterilised or high-level disinfected cryotips and personal protective equipment.[13][15]

Apply rigorous infection prevention and equipment handling throughout delivery. Decontaminate reusable instruments in 0.5% chlorine for 10 minutes, then clean, rinse and dry them; sterilise cryotips by autoclave or use high-level disinfection by boiling for 20 minutes after boiling begins.[16][17]Store carbon dioxide cylinders securely in dry, ventilated locations away from heat and ignition sources, transport them upright and secured, check for leaks and pressure, and close the gas valve and release residual gas after use.[17][18]

Document each screening, treatment and referral procedure in approved clinical records, including attendance registers, client screening and treatment forms and referral forms where applicable.[8]Maintain client records of VIA findings, maps of cervical lesions where acetowhite change is present, treatment results and follow-up schedules.[9][7][19]Quality assurance relies on clinical skills checklists and assessment tools completed by participants and supervisors, rating performance as Needs Improvement, Competently Performed or Proficiently Performed according to correctness, sequence, efficiency and precision.[20][21][15]The guidance does not specify programme-level indicators, surveillance systems, reporting schedules or a wider accountability framework beyond these records and clinical assessments.[22][21]

Monitoring & Evaluation

Monitoring centres on client-level documentation, scheduled follow-up and competency-based clinical assessment rather than a defined programme-level monitoring and evaluation system.[3][8][20][15]

• Record visual inspection with acetic acid findings, pelvic examination results, treatment outcomes and follow-up plans in client records, charts, registers and, where applicable, referral forms.[9][7][8][19][23]
• Complete client registers throughout service delivery and use Ministry of Health registers, referral log books or forms, and client cards as monitoring and evaluation documentation.[8][14]
• Review women treated after a positive screening result at one year, manage persistent lesions according to cryotherapy eligibility, and return women with a normal cervix to routine screening under the applicable protocol.[8]
• Repeat screening within three years for women living with HIV who have a negative first screening result.[8]
• Advise women with negative VIA results to retest after three years.[10]
• Refer women whose lesions are unsuitable for cryotherapy, including lesions involving more than 75% of the cervix or extending into the vaginal wall or endocervix, for further evaluation and management.[10]
• Refer women with cauliflower-like growths, ulcers or fungating masses suspicious for cancer as soon as possible.[10]
• Instruct women receiving cryotherapy to return for fever lasting more than two days, severe lower abdominal pain especially with fever, heavy bleeding lasting more than two days, or foul-smelling vaginal discharge.[11]
• Observe women for at least 15 minutes after cryotherapy and assess their condition before discharge.[7][23]
• Assess counselling, VIA and cryotherapy skills through structured checklists completed by the participant and supervisor, rating performance as Needs Improvement, Competently Performed or Proficiently Performed.[20][21][24][15]
• Assess whether clinical tasks are completed correctly, in sequence, efficiently and precisely.[20][15]
• Use checklists for clinical skills and for required furniture, supplies and equipment to support service readiness and standardisation.[4]

The material does not specify programme-level indicators, indicator targets, reporting frequencies, data aggregation processes, surveillance arrangements, evaluation schedules or a wider accountability framework beyond clinical records, follow-up procedures and competency assessment tools.[2][5][7][22][19]

Costing & Financing

Resource requirements are described for cervical screening, cryotherapy, infection prevention and equipment management, but the material provides no quantified budget or costing framework.[3][13][8][14]

• Receive financial and logistical assistance from the World Health Organization for development and printing of the guidance.[1]
• Provide furniture, screening and cryotherapy equipment, supplies, cryotherapy gas, infection-prevention materials, and, where available, human immunodeficiency virus testing and family-planning commodities.[3][4][8][14]
• Prepare functional cryotherapy equipment, refrigerant gas, sterilised or high-level disinfected cryotips, instruments and infection-prevention supplies before treatment.[13]
• Maintain carbon dioxide supplies through secure storage, short-term purchasing and stock rotation so that cylinders received first are used first.[17]
• Use the single-visit approach based on visual inspection with acetic acid and cryotherapy, which is characterised as cost effective for developing countries.[2]

No costs, unit prices, budget allocations, financing sources for service delivery, funding gaps, resource-mobilisation plan, quantified economic assumptions or cost-effectiveness estimates are specified.[9][16][18][15]