Visual inspection after acetic acid application (VIA) and human papillomavirus (HPV) detection tests have been recommended to screen women for cervical cancer in low and middle income countries. A demonstration project in rural India screened 39,740 women with both the tests to compare their accuracies in real population setting. The project also evaluated the model of screening women in the existing primary health care facilities, evaluating the screen positive women with colposcopy (and biopsy) in the same setup and recalling the women diagnosed to have disease for treatment at tertiary center. Accuracy of VIA and HPV test used sequentially was also studied. VIA was performed by trained health workers and Hybrid Capture II (HC II) assay was used for oncogenic HPV detection. Test positivity was 7.1% for VIA and 4.7% for HC II. Detection rate of CIN 31 disease was significantly higher with HC II than VIA. Sensitivities of VIA and HC II to detect 162 histology proved CIN 31 lesions were 67.9 and 91.2%, respectively after adjusting for verification bias. Specificity for the same disease outcome and verification bias correction was 93.2% for VIA and 96.9% for HC II. Triaging of VIA positive women with HPV test would have considerably improved the positive predictive value (4.0 to 37.5% to detect CIN 31) without significant drop in sensitivity. All VIA positive women and 74.0% of HC II positive women had colposcopy. There was high compliance to treatment and significant stage-shift of the screen-detected cancers towards more early stage.A number of cross-sectional and randomized controlled studies have evaluated the test characteristics of Visual inspection with acetic acid (VIA) as well as that of human papillomavirus (HPV) detection for cervical cancer screening in low and medium income countries.1-4 These studies have convincingly established the utility of these tests and their superiority over conventional Pap smear cytology. The evidence regarding their cost-effectiveness is encouraging and the international organizations have also recommended their use in screening programmes. 5,6 Still the adoption of the new technologies for cervical cancer screening is low in the low or middle income countries (LMIC). Most of these countries continue with the opportunistic, low intensity and ineffectual cytology based screening, even though it is feasible for many of them to implement population based cervical cancer screening using either VIA or HPV detection tests. 7,8 The LMICs are quite diverse in terms of their health system capacities even within the countries. They can follow a "cafeteria approach" and choose from different screening tests and various diagnostic and treatment algorithms (single or multiple visit approaches) depending on the available resources and feasibility. Demonstration projects validating the research observations in real population settings and in convergence with the existing health infrastructure have catalyzed the initiation of VIA based cervical cancer screening programmes in some of the L...
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