Daily Times

The Pakistani population thrives behind a dense curtain of socio-cultural taboos. Sexual organs and everything associated with themare hushed words, often muted completely or trashed in the hardware of our brain’s computers. Yet again, as the dark internet thrives giving rise to unsafe sexual practices, birthing various sexually transmitted infections (STI).One of the most common yet underdiagnosed STI in Pakistan is the human papillomavirus (HPV).

According to the World Health Organization (WHO), HPV is the most common cause of cervical cancer, the fourth most common cancer in women globally, with an estimated 266,000 deaths and 528,000 new casesin 2012. A vast majority (around 85%) of the global burden occurs in the less developed regions, accounting for almost 12% of all female cancers.

Cervical Cancer Global Crisis Cardusing data from WHO, United Nations, World Bank and IARC Globocon selected the top 50 countries to provide a snapshot of cervical cancer statistics.According to these Pakistan lies at number 7 with more than 7331 annual deaths attributed to cervical cancer alone.

Pakistan alone is a heavy carrier of the HPV with over 5,601 new cases diagnosed annually. It is the 3rd leading cause of female cancer and deaths and the second most common cancer affecting women aged between 15-44 years in Pakistan.

Trends show that the prevalence ofcervical cancer has risen in Pakistan, where almost 20women fall victim to cervical cancer daily, making it one ofthe top 10 countries with the highest female mortalityrates.

Cervical Cancer projections reflect that by the year 2030, almost half a million women would die of cervical cancer, with over 98% deaths expected in low and middle-income countries.

HPV is the most common viral infection of the reproductive tract. Most sexually active women and men will be infected at some point in their lives, and some may be repeatedly affected. In most cases, it usually clears up without any intervention, but a small proportion of certain types of HPV infections can persist and progress to cervical cancer. Nearly all cases of cervical cancer are found to be due to HPV infection.

Cervical Cancer projections reflect that by the year 2030, almost half a million women would die of cervical cancer, with over 98% deaths expected in low and middle-income countries

Cervix carcinoma is the second most prevalent condition in women under 50 years of age, third after breast and oral cavity cancers across all age groups.

Even though it takes typically 15 to 20 years for cervical cancer to develop in women with typical immune systems, but 70% of cancer patients report at a very advanced stage in Pakistan, leading to a high mortality rate simply due to the stigma attached to cervical screening, prevention and vaccination.

According to National Health Services UK, HPV infection is spread by skin-to-skin contact and can be usually found on the fingers, hands, mouth and genitals. This means the virus can be spread during any sexual activity, including touching.

The HPV vaccine works best if girls and boys get it before they come into contact with HPV (in other words, before they become sexually active).

Risk factors for contracting an infection are under unprotected and early sex, poor socioeconomic status, early reproductive cycles and multiparity, co-infections, hormonal altered immune system, smoking and lower education levels.

A major challenge in Pakistan is the social ban on all matters relating to reproductive health and seeking screening or treatment forsexually transmitted infections.

Cervix carcinoma prevention can be grouped into primary and secondary interventions. Primary prevention includes vaccination of young girls and boys while secondary level interventions include screening services.

Globally Recombinant Human Papillomavirus Quadrivalent Vaccinehas been recommended to prevent the HPV spread.

Vaccination of younger women before marriage is the most effective preventive measure, as reported by the WHO. Regular Papanicolaou (Pap) smears, safe sex methods, lowering the number of sexual partners, HPV vaccination and termination of smoking are crucial preventive measures.

Developing countries are more severely struck by the epidemic of cervical cancer, reporting 78% of all global cases.

Cervical cancer can be silent where 20% of patients diagnosed by a Pap smear or routine clinical examination with invasive cervical cancer remain asymptomatic.

80-90% of patients with cervical cancer experience some form of abnormal vaginal bleeding such as postmenopausal bleeding, irregular menses, heavy menstrual flow, painless metrorrhagia, or postcoital bleeding.

Pap smear remains an easy and potent method for early detection of precancerous cervical disease.

Even with the best medical facilities, at least 37.5% of the diagnosed patients die from this disease each year. This represents 2% of all cancer deaths and 18% of deaths from gynaecological cancers.

In the USA, it is the fourth most common cancer in women, after carcinoma of the breast, colorectum, and endometrium. The incidence of invasive cervical cancer has visibly declined over the past few decades attributed to mass screening with Pap smears, which helpsto detect 500 000 new cases each year internationally.

Historically, screening for STIs has never been considered necessary in Muslim countries, under the assumption that it is sexual promiscuity, and therefore sexually transmitted disease, in a Muslim population is non-existent.

The gravity of this matter is further aggravated by the socio-cultural taboos that prohibit investigation of all issues on sex and STIs. In certain countries, including Pakistan, where religious and cultural values strictly discourage sexual promiscuity, protection from sexually transmitted infections, such as HPV, is taken for granted. It is for this reason that on a national level, the need to screen for STIs and increase public awareness. Consequently, hospitals and other healthcare facilities in Pakistan do not routinely prescribe HPV screening to female patients. It is not common practice to perform Pap Smears on Pakistani women. As a result, the frequency of HPV occurrence in the female Pakistani population is virtually unknown.

According to Centres for Disease Control and Prevention (CDC) recommendations, HPV vaccines are administered as a 2-dose series (0, 6-12 months) for most persons who initiate vaccination at ages 9 through 14 years, and a 3-dose series (0, 1-2, 6 months) for persons who start at ages 15 through 26 years, and for immunocompromised persons.

HPV vaccine in Pakistan costs approximately 4700 rupees per dose making it highly unaffordable for the majority of our population, most of which are living under $2 a day.

Countries such as Australia, Denmark, United Kingdom, Canada and the US have introduced HPV in their National Immunization Programs providing free vaccines to both females and males as various HPV related cancers such as head, neck genital and anal cancers are prominent in men.

Many states in Canada have extended its free HPV vaccination programs to young schoolboys as well claiming it to be an investment in long-term health and a big win for cancer prevention.

Similarly, Australia sees a massive success after going gender-neutral in HPV vaccination in its national immunization program started ten years ago. Australia now sees a 77% reduction in HPV types responsible for the majority of cervical cancers, along with a 90% reduction in genital warts in people under 21 years of age.

The socio-cultural taboos on sex have become a significant barrier in establishing HPV in Pakistan. Due to their lack of awareness, people do not get screened for STIs. Due to the stigma attached to sexual diseases, people also choose not to have their STI status diagnosed even though in 2018 alone 3,861 women died due to cervical cancer in Pakistan contributing to 2,225,905 years of life lost and 17,655 years lived with a disability.

Even after identification of the gravity of the problem six years ago in 2013 after the launch of the cervical cancer card, no solid steps have been taken to tackle this growing concern.

Understanding that Cervical cancer is deadly, it is high time that Pakistan recognizes and acknowledges this disease by implementing the WHO strategy for primary prevention HPV vaccination and establish planned Pap smear screening operations all over the country.

HPV screening is a life-threating taboo which now itself needs to be silenced. The need of the hour is that this issue should be seen in the context of the ongoing women empowerment campaign in Pakistan.

The writer is Health Services Management from Griffith University Australia, alumina of John Hopkins Bloomberg School of Public Health