Determinants of VIA (Visual Inspection of the Cervix After Acetic Acid Application) Positivity in Cervical Cancer Screening of Women in a Peri-Urban Area in Andhra Pradesh, India

Abstract

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.

Accuracy of Visual Inspection with Acetic acid in Detecting High-Grade Cervical Intraepithelial Neoplasia in Pre- and Post-Menopausal Thai Women with Minor Cervical Cytological Abnormalities

“…One of the important determinants for positive VIA testing is clinical symptoms of patients (symptomatic or asymptomatic). Cervical infection or inflammation, and area of transformation zone which is affected by age, menopausal status, parity and route of delivery have been shown to affect the result of VIA testing (Vedantham et al, 2010;Cremer et al, 2011;Castle et al, 2014).…”

Shedding of Epstein-Barr Virus and Cytomegalovirus from the Genital Tract of Women in a Periurban Community in Andhra Pradesh, India

“…Cervical cells were collected from women for cytological and virological investigation, and the cervix was examined with naked eye visual inspection after application of acetic acid (VIA). We found that a positive VIA reading (presence of an acetowhite lesion in the cervical transformation zone) had a surprisingly low sensitivity (26.3%) and moderate specificity (76.4%) for the detection of cervical neoplasia (9,28).…”

“…Cervical cells were collected from women for cytological and virological investigation, and the cervix was examined with naked eye visual inspection after application of acetic acid (VIA). We found that a positive VIA reading (presence of an acetowhite lesion in the cervical transformation zone) had a surprisingly low sensitivity (26.3%) and moderate specificity (76.4%) for the detection of cervical neoplasia (9,28).Given the large number of false-positive VIA readings, we inquired if these lesions might be occurring as a result of infections with Epstein-Barr virus (EBV) or cytomegalovirus (CMV), prevalent latent herpesviruses which are known to be shed from the female genital tract (2, 6, 14, 21). We also examined whether cervical EBV and CMV detection correlated with either cervical HPV detection or other markers of cervical pathology, since these viruses have been postulated to have a possible cocarcinogenic role with human papillomavirus (HPV) for cervical neoplasia (19, 23).…”

Issues in cervical cancer incidence and treatment in HIV

“…Many of these countries have limited funds and capacity for large, widespread screening programs. Those countries that are building capacity for cervical cancer prevention rely mostly on point of care testing and treatment using strategies such as visual inspection with acetic acid (VIA) [10][11][12][13][14]. Although these strategies are better than no strategy, widespread capacity for screening and appropriate follow-up in many of these regions are limited, particularly in rural areas.…”