It took just one loudspeaker for Sallay Carew to find her voice in Freetown, Sierra Leone. "Come to our cervical cancer screening clinic just next door, it's free, it's very important for women over 30 years old...this is a preventable cancer..." she speaks loudly as she moves through local markets, and around the hospitals. When women approach her she answers their questions, and occasionally talks sternly to men who make light of the issue, educating them about the importance of taking their own wives or daughters for cervical cancer screening.

It might not sound like a normal day for a trained nurse. But Sallay Carew is also Sierra Leone's national focal point person on community engagement for cervical cancer. A big part of her role is to ensure people are aware of what cervical cancer is and how screening could save their lives. When she's not in clinics, she goes out in the streets, calling women to get screened. Today, after just 10 minutes of rallying, the empty clinic is filled with women who are curious and ready to be screened.

Sierra Leone is unfairly impacted by cervical cancer. Every year, more than 500 new cases are detected in the country with an estimated 400 women die because of this preventable cancer.

"It wasn't until 2021 that Sierra Leone really started its cervical cancer screening programme. I was one of the first nurses who got trained when this clinic was set up, but initially, we didn't have a lot of demand because people didn't know about cervical cancer," explains Nurse Sallay. "So I felt that it was up to me to raise awareness, so women won't die needlessly in my community. I had to get creative, I went in the streets with my loudspeaker, and I begged my daughter, who works for a radio station, to let me go on their programme to talk about cervical cancer. That really changed things."

From that day, growing numbers of women have started to take up the national offer for their free screening, something that has been available in Sierra Leone since 2021. From June 2021 to December 2023, over 13 000 women were screened across the country.

Frea Sonsiama is one of them, who like so many was encouraged to attend by both Sallay's advocacy and the lack of cost. "I heard Sister Sallay on the radio one day, she talked about symptoms at one point, and I thought I might have felt some discomfort and wanted to go in to check. I'm 47 years old, but I'm divorced and supporting my 2 kids just by selling some food items in the streets, so I only decided to go because it's free."

Sierra Leone primarily uses a common test known as visual inspection with acetic acid (VIA) to screen for cervical cancer. It is cheap, easy and effective. VIA allows the trained health worker to directly see lesions and other changes in the cervix. Unfortunately, when Nurse Sallay carried out the test on Frea she found damaged tissue, which is often a sign of cancer. Sister Sallay performed a biopsy of the tissue and sent it to the lab for further follow-up.

But screening is just one piece of the bigger puzzle of cervical cancer elimination. "Frea came in today again, almost one year after we did the test and treated the lesions, but we still don't have her test results from the biopsy," sighs Sister Sallay. "This is now a major challenge for us. The pathology test results take very long, and people have to pay US$ 15 to do them. Women like Frea just don't have that kind of money, so we still don't know if she has cervical cancer or not."

This highlights some of the challenges facing Sierra Leone in their cervical cancer elimination programme. In addition, funding for the initial screening is not always guaranteed. "We are looking for funding to support HPV testing, some of the screening programmes that were funded before are losing the funding, consumables and supplies can become problems for our facilities. Financing of services for advanced lesions is a big issue, as most women cannot afford the costs," explains Dr Francis Moses, programme manager of the National Reproductive Health and Family Planning at the Ministry of Health. "This year, the supplies of HPV vaccine for Sierra Leone are also interrupted as we heard from the manufacturer. Since 2022 we have offered HPV vaccination routinely for 10-year-old girls, and in October this year, we had planned for a catch-up campaign for 11-18-year-olds. Losing this is unacceptable for us."

Sierra Leone has made a solid 3-year plan in order to address some of these issues and answer the WHO call to be on the road to eliminating cervical cancer by 2030. With limited resources, the country is developing a fully costed plan for screening and treatment, including community engagement and strengthening referral pathways for advanced lesions, integrated with other health services, such as HIV care and treatment clinics, antenatal care and other entry points where patients may access the health system.

Frontline health workers like Nurse Carew are often at the forefront of efforts to prevent and treat cervical cancer. In Sierra Leone, sometimes, they are the first and the only health professionals women encounter. They provide crucial information on vaccines, screening and treatment for cervical cancer. As they support the women in their communities, governments and organization need to urgently step up the effort to support health workers and the work on cervical cancer.