Accuracy of visual inspection with acetic acid to detect cervical cancer precursors among HIV-infected women in Kenya

Abstract

Visual Inspection with Acetic Acid (VIA) is becoming a more widely recommended and implemented screening tool for cervical cancer prevention programs in low-resource settings. Many of these settings have a high prevalence of HIV-infected women. We carried out a cross-sectional validation study to define the sensitivity, specificity and predictive values of VIA among HIV-infected women. Women enrolled in HIV-care at the Family AIDS Care and Education Services clinic in Kisumu, Kenya were recruited for participation. All participants underwent VIA followed by colposcopy performed by a second, blinded clinician. At colposcopy, lesions suspicious for cervical intraepithelial neoplasia 2 or greater (CIN2+) were biopsied. Disease status was determined by final histopathologic diagnosis in women who underwent biopsies. A satisfactory colposcopy with no lesions was considered a negative result. From October 2010 to June 2012, 1432 women underwent VIA and colposcopy. Five hundred and fourteen (35.7%) women had a positive VIA, and 179 (12.2%) had CIN2+ confirmed by colposcopically directed biopsy. Sensitivity, specificity, positive and negative predictive value of VIA for CIN2+ were 86.6%, 71.6%, 30.3% and 97.4%. Specificity, but not sensitivity, increased with older age. Among older women, sensitivity was affected by CD4+ count and use of antiretroviral therapy. Although they are impacted by age and immune status, test characteristics for VIA among HIV-infected women are similar to what has been reported for general populations. Recommendations to use VIA as a screening tool should not vary by HIV status.

Associations between highly active antiretroviral therapy and the presence of HPV, premalignant and malignant cervical lesions in sub-Saharan Africa, a systematic review: current evidence and directions for future research

“…Cervical cytology, which has a clinical sensitivity between 55% and 65% for detection of histopathologically confirmed ‘true disease status’ 47 along with low interobserver or intraobserver true correlation can result in even one grade of misclassification introducing a bias in studies assessing regression or incidence of SIL in women on HAART. Moreover, a recent study in Kenya has reported that the sensitivity of VIA is affected in women on HAART and by CD4 count, 48 which in studies ascertaining disease using colposcopy with biopsy solely in cases when lesions appeared suspicious for CIN 2+, may have led to under-ascertainment of true disease: sensitivity 89.9% (95% CI 82.2% to 95.0%) in women under 35 and 78.6% (95% CI 63.2% to 89.7%) in women above 35. 47 …”

Faisabilité du frottis cervico-utérin chez les femmes séropositives pour le VIH vivant au Tchad

“…Au Kenya, parmi les 595 femmes séropositives pour le VIH qui ont réalisé une cytologie avec coloration de Papanicolaou, 22 (8 %) avaient une lésion de haut grade [8]. Dans le même pays, mais en utilisant une visualisation préalable du col à l'acide acétique, 179 des 1 432 femmes séroposi-tives (12,2 %) présentaient une lésion de haut grade (CIN 2) confirmée par biopsie réalisée sous colposcopie [5].…”

Cervical cancer prevention and treatment research in Africa: a systematic review from a public health perspective

“…After applying acetic acid or Lugol’s iodine directly on the cervix, pre-cancerous and cancerous lesions turn white, making them visible to the naked eye [ 54 ]. This method has high sensitivity among HIV-infected and uninfected women [ 55 , 56 ]. Results are immediate, thus women who screen positive for precancerous lesions can theoretically be offered cryotherapy treatment during the same visit, or a “screen and treat” approach, if the health facility has the capacity.…”