Perceptions of integrating cervical cancer screening with HIV and sexual and reproductive health services: results from serial multiple methods studies among health workers and women in Zimbabwe.

BACKGROUND: Cervical cancer screening among Zimbabwean women is suboptimal. Integrating cervical cancer screening with HIV and sexual and reproductive health services can improve uptake. To inform optimisation of integrated models, we explored evolution of women's and health worker views on integration and cervical cancer screening. METHODS: Over three phases between Nov-2013 and Mar-2016, we collected serial multiple methods data from female attendees and health workers at four clinics providing integrated cervical cancer screening and HIV and sexual/reproductive health services. Using program data, we examined trends in uptake of cervical cancer screening. RESULTS: Between 2013 and 2016, 38,342 women were screened for cervical cancer at three clinics. Program data showed increasing trends in uptake, capping at clinic capacity. Qualitative studies showed that clinic attendees and health workers viewed integration positively across phases because: (i) information on cervical cancer screening was easily disseminated, leading to improved uptake; (ii) co-location of services was convenient. As knowledge increased, demand exceeded supply, requiring operation of strict appointment-based systems. Other facilitators to cervical cancer screening included offer of services for free, personal experience of friends/family who suffered cervical cancer, peer encouragement, spousal/partner support, and having suspicious signs/symptoms. Barriers were more pronounced in earlier phases and largely centred around myths that spread in communities or clinic waiting rooms. Lack of training among health workers impeded implementation. CONCLUSIONS: Integrating cervical cancer screening with HIV and sexual/reproductive health services was feasible and acceptable, with less pronounced barriers as programs matured. Addressing individual and program-level barriers can optimise uptake of services.