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BackgroundWhile many studies have compared the efficacy of Pap cytology, visual inspection with acetic acid (VIA) and human papillomavirus (HPV) DNA assays for the detection cervical intraepithelial neoplasia and cancer, few have evaluated the program effectiveness.Methods and FindingsA population-based sample of 5603 women from Medchal Mandal in Andhra Pradesh, India were invited to participate in a study comparing Pap cytology, VIA, and HPV DNA screening for the detection of CIN3+. Participation in primary screening and all subsequent follow-up visits was rigorously tracked. A 20% random sample of all women screened, in addition to all women with a positive screening test result underwent colposcopy with directed biopsy for final diagnosis. Sensitivity, specificity, positive and negative predictive values were adjusted for verification bias. HPV testing had a higher sensitivity (100%) and specificity (90.6%) compared to Pap cytology (sensitivity  =  78.2%; specificity = 86.0%) and VIA (sensitivity = 31.6%; specificity = 87.5%). Since 58% of the sample refused involvement and another 28% refused colposcopy or biopsy, we estimated that potentially 87.6% of the total underlying cases of CIN3 and cancer may have been missed due to program failures.ConclusionsWe conclude that despite our use of available resources, infrastructure, and guidelines for cervical cancer screening implementation in resource limited areas, community participation and non-compliance remain the major obstacles to successful reduction in cervical cancer mortality in this Indian population. HPV DNA testing was both more sensitive and specific than Pap cytology and VIA. The use of a less invasive and more user-friendly primary screening strategy (such as self-collected swabs for HPV DNA testing) may be required to achieve the coverage necessary for effective reduction in cervical cancer mortality.

Objective: To study the current diet and nutritional status of rural adolescents in India. Design: Cross-sectional study with household as the unit of randomization. Setting: National Nutrition Monitoring Bureau collected information in the rural areas of the nine States. Methods: In each State, 120 villages were selected from eight districts. From each of the selected villages, 20 households (HHs) were selected from five clusters. The information on socio-demographic profile was collected in all the 20 HHs, while anthropometric data such as weight, height and clinical signs of nutritional deficiency was collected on all the available adolescents in the selected households. In every fourth sampled household, ie five HHs, dietary information on all the members was collected using 24 h dietary recall. The outcome measures for nutritional status were proportion of underweight ( < median 7 2 s.d. of NCHS standards of weight for age), stunted ( < median 7 2 s.d. of NCHS standards of height for age) and body mass index. The nutrient intakes were compared with recommended dietary allowances (RDA). Results: Anthropometric and socio-economic information on 12 124 adolescent boys and girls and dietary information on 2579 individuals in 1996 -1997 was available for the analysis. The major occupation of the heads of the households surveyed was agriculture. More than a third (37.3%) of the families with adolescents did not possess any land. The per capita income per month was about Rs 250=-at 1996 -1997 prices. About 23% of the adolescent girls were married before the age of 18 y. About a quarter of the married adolescent girls had short stature and 18.6% were underweight. They considered as 'at risk'. About 39% of the adolescents were stunted ( < Median 7 2 s.d. of NCHS height for age) irrespective of sex. The prevalence of undernutrition ( < median 7 2 s.d. of NCHS weight for age) is higher (53.1%) in boys than in girls (39.5%). The extent of stunting was higher (42.7%) among adolescents belonging to the scheduled caste community. In the case of girls, the extent of underweight was considerably less in each age group than their male counterparts. About 70% of adolescents consumed more than 70% of RDA for energy. The intakes of micronutrients such as vitamin A and riboflavin were woefully inadequate. Conclusions: The extent of undernutrition was high among adolescents and was higher among boys than girls. Adolescent girls in the rural areas could be at greater risk of nutritional stress because of early marriage and early conception before completion of their physical growth.

Objectives: Visual inspection of the cervix after acetic acid application (VIA) is widely recommended as the method of choice in cervical cancer screening programs in resource-limited settings because of its simplicity and ability to link with immediate treatment. In testing the effectiveness of VIA, human papillomavirus DNA testing, and Pap cytology in a population-based study in a peri-urban area in Andhra Pradesh, India, we found the sensitivity of VIA for detection of cervical intraepithelial neoplasia grade 2 and worse (CIN2+) to be 26.3%, much lower than the 60% to 90% reported in the literature. We therefore investigated the determinants of VIA positivity in our study population.Methods: We evaluated VIA positivity by demographics and reproductive history, results of clinical examination, and results from the other screening methods.Results: Of the 19 women diagnosed with CIN2+, only 5 were positive by VIA (positive predictive value, 3.1%). In multivariate analysis, VIA positivity (12.74%) was associated with older age, positive Pap smear, visually apparent cervical inflammation, and interobserver variation. Cervical inflammation of unknown cause was present in 21.62% of women. In disease-negative women, cervical inflammation was associated with an increase in VIA positivity from 6.1% to 15.5% (P < 0.001). Among the six gynecologists who performed VIA, the positivity rate varied from 4% to 31%.Conclusions: The interpretation of VIA is subjective and its performance cannot be readily evaluated against objective standards.Impact: VIA is not a robust screening test and we caution against its use as the primary screening test in resource-limited regions.

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Objectives: Our aim was to determine if (1) Hybrid Capture 2 and a PCR-based method were comparable for detection of high-risk human papillomavirus (HPV) clinician-collected and self-collected samples were equally efficient to detect HPV and cervical cancer precursor lesions, and (3) if participation rates improved with home-based versus clinic-based self collection. Methods: Samples were selected from women participating in a cervical cancer screening study according to HPV, visual inspection with acetic acid, or Pap smear screening results. From 432 of 892 selected women, split sample aliquots were tested for HPV DNA using both the Hybrid Capture 2 assay and the Roche prototype line blot assay. Women from a subset of villages were recruited at two separate time points for clinic-based self-collection and home-based self-collection, and participation rates were compared. Results: Pairwise agreement between self-and clinician-collected samples was high by both Hybrid Capture 2 (90.8% agreement, K = 0.7) and PCR (92.6% agreement, K = 0.8), with significantly increased highrisk HPV detection in clinician-collected specimens (McNemar's P < 0.01). Ability to detect precursor lesions was highest by PCR testing of cliniciancollected samples and lowest by Hybrid Capture 2 testing of self-collected samples (11 of 11 and 9 of 11 cases of cervical intraepithelial neoplasia grade 2/3 and cancer detected, respectively). Participation in homebased screening was significantly higher than clinicbased screening (71.5% and 53.8%, respectively; P < 0.001) among women ages 30 to 45 years.

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