Distribution of cervical abnormalities detected by visual inspection with acetic acid in Swaziland, 2011–2014: A retrospective study

Abstract

BackgroundCervical cancer is the fourth most common cancer worldwide among women, with the number of new cases increasing from 493 243 in 2002 to 527 000 in 2012. These numbers are likely to be underestimated because given the lack of registration resources, cervical cancer deaths are usually under-reported in low-income countries.AimTo describe the distribution of and trends in visual inspection with acetic acid (VIA) to detected cervical abnormalities in Swaziland by reviewing records of VIA examinations performed at two main hospitals in Swaziland between 2011 and 2014.SettingMbabane Government Hospital and Realign Fitkin Memorial (RFM).MethodsRecords of cervical screening using VIA at the Mbabane government hospital and RFM hospital between 2011 and 2014 were retrieved. Positivity rates (PRs) of VIA with 95% confidence intervals (95% CI) were calculated and used as proxies of cervical abnormalities. Odds ratios of the association between VIA-detected cervical abnormalities and human immunodeficiency virus (HIV) status were estimated using logistic regressions.ResultsVIA was positive in 1828 of 12 151 VIA records used for analysis (15%, 95% CI: 14.4–15.7). VIA was positive in 9% (36 of 403) women under the age of 20, in 15.5% (1714 of 11 046) of women aged 20–49 years and in 11.1% (78 of 624) of women aged 50–64 years. A decreasing trend of VIA positivity was observed over time at both screening centres (p for trend < 0.001). Of 2697 records with Papanicolaou results, 20% (67 of 331) VIA-positives and only 5% (114 of 2366) VIA negatives had high-grade squamous intraepithelial lesion. Among 4578 women with reported HIV status, 1702 were HIV-positive (37.2%, 95% CI: 35.8–38.6). The prevalence of HIV in VIA-positive women was 62.5% (95% CI: 58.7–66.2), almost double that among VIA-negative women (33.0%, 95% CI: 31.6–34.5) and that among all women screened (p < 0.001). HIV-positive women were 3.4 times more likely to have cervical abnormalities on VIA than HIV-negative women (OR: 3.4, 95% CI: 2.8–4.0, p < 0.01).ConclusionThe high VIA PRs observed over four years in this study may reflect the prevalence of cervical abnormalities, in particular, in HIV-positive women. VIA is not a robust screening test, but it can play a major role in strengthening and expanding cervical cancer screening prevention programmes in resource-limited countries.

Screening for cervical cancer in Africa: A proposal of a different combination of VIA test and cervical smear in Uganda

“…25 Since one of the crucial points of the screening tests is their cost-effectiveness, some studies tend to recommend the VIA test as the best option. [10][11][12] However, the results from the present study show that it has too high a number of false positives (84.2%) with a very low PPV and, especially in a "screen-and-treat" approach, it may lead to overtreatment and excessive use of further examinations. Furthermore, the higher the number of women referred for extra examinations, the fewer the resources available in case of need.…”

“…[7][8][9] However, the VIA test did not show a high accuracy and some studies recommend it only because of its easy application in a low-resource setting. [10][11][12] whereas most of the studies propose a combination of tests. [13][14][15][16][17] The aim of the present study was to evaluate the efficacy and usefulness of the VIA test as well as of the VIA test combined with other screening techniques, such as the cervical smear, in Uganda in order to find possible solutions that may be used in a low-resource setting.…”

Implementing Smartphone-Based Telemedicine for Cervical Cancer Screening in Uganda: Qualitative Study of Stakeholders’ Perceptions

“…This study is the first to report on the implementation of smartphone-based telemedicine and AI in CaCx screening in Uganda. Studies from Tanzania [ 34 , 40 , 42 ], Madagascar [ 39 , 43 , 49 ], Eswatini [ 44 , 45 ], Botswana [ 35 , 77 ], Ghana [ 36 ], and Kenya [ 55 ] have used smartphone-based cervicography and have reported similar results as ours, including the ease of learning and adoption of smartphone-based telemedicine setups by CaCx screening staff, good-quality captured images that allow correct assessment by remote experts, and enhancement of VIA accuracy and clinical data management by such digital tools. Other studies from India [ 38 ] and Costa Rica [ 46 ] have attempted to develop AI models for analysis of cervical images, although clinical deployment has not been fully realized.…”

Epidemiology of pre-cancerous cervical lesion and risk factors among adult women in Tigray, Ethiopia

“…The long time service of cervical screening at family guidances prevents the pre-cancerous lesion from progression to suspicious for cancer. Studies in Swaziland, Cameroon, and Jakarta, Indonesia, showed VIA-positive rates of 15%, 3.33%, and 4.7%, respectively [10,11,12]. Though most are similar, the difference might be because of the skill difference of the care providers, and type of screening used.…”

“…A study in Uganda showed that 99% of women had heard about cervical cancer and 63% believed that family planning was a cause of cervical cancer as well as 85% recognizing inter-menstrual bleeding as a symptom of cervical cancer [9]. Other studies have also revealed the burden and public health importance of cervical cancer in LMICs [10][11][12][13].…”