Performance of visual inspection with acetic acid and human papillomavirus testing for detection of high‐grade cervical lesions in HIV positive and HIV negative Tanzanian women

Abstract

The aim of this cross sectional study was to assess type distribution of human papillomavirus (HPV) among HIV positive and HIV negative women who underwent cervical cancer screening, and to examine the ability of visual inspection with acetic acid (VIA), the standard detection method in Tanzania, and HPV-testing to detect cytologically diagnosed high grade lesions or cancer (HSIL+). Women from different areas in Tanzania were invited by public announcement to cervical cancer screening organized by Ocean Road Cancer Institute (Dar-es-Salaam). A total of 3,767 women were enrolled. Women underwent gynecological examination with collection of cervical cells for conventional cytological examination, and swab for HPV-DNA detection (Hybrid-Capture2) and genotyping (LiPAv2 test). Subsequently VIA was performed. The participants were also tested for HIV. HPV16, HPV52 and HPV18 were the three most common HR HPV types among women with HSIL+ cytology with prevalences of 42.9, 35.7 and 28.6%, respectively, in HIV positive women which was higher than among HIV negative women (30.2, 21.9 and 16.7%). A total of 4.5% of the women were VIA positive, and VIA showed a low sensitivity compared to HPV-testing for detection of HSIL+. The sensitivity of VIA varied with staff VIA experience, HIV status and age. Vaccines including HPV16, HPV52 and HPV18 will likely reduce the number of HSIL+ cases independently of HIV status. The frequency of HSIL+ was high among HIV positive women, emphasizing the importance of establishing a screening program which also reaches HIV positive women. Our results highlight the importance of continuous training of staff performing VIA, and also point to the need for other screening methods such as HPV-testing at low cost.

Cervical cancer screening in low‐resource settings: A cost‐effectiveness framework for valuing tradeoffs between test performance and program coverage

“…Varying specificity within the range of uncertainty (70–90%) has a negligible impact on health benefits and for a test with 80% sensitivity only changes the ICER for 2‐visit HPV testing from I$210 to I$240 per YLS. In women with HIV, specificity of HPV testing may be somewhat lower due to increased prevalence of HPV, leading to increased referrals and possible overtreatment of women; the impact of this potentially unnecessary care on the cost‐effectiveness of population‐based screening is unclear and we have not considered the possible harms of overtreatment in this analysis. However, there may be potential health benefits associated with treating HPV infections prior to progression to precancerous lesions, as evidence suggests that a one‐time positive HPV test is associated with CIN3+ up to 18 years later .…”

Prevention of human papillomavirus (HPV)-related tumors in people living with human immunodeficiency virus (HIV)

“…The most commonly used screening methods include conventional cervical cytology (Pap smears), hrHPV testing, and visual inspection with acetic acid (VIA). Several studies have evaluated the performance of these methods in WLWH [114][115][116][117][118][119][120][121][122][123][124][125]. Generally, hrHPV DNA testing is the most sensitive method for detecting CIN2+ lesions (range 89-95%), followed by conventional cytology (53-93%) and VIA (48-84%).…”

“…Hence, simpler and low-cost approaches that are based on a screen-and-treat strategy may be more feasible. VIA with immediate treatment of abnormalities is considered a safe and acceptable screening method adopted in several countries with limited resources [123]. In addition, hrHPV testing can also be used as a screening method in the screen-and-treat strategy.…”

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

“…In contrast to cervical cytology and HPV testing, which have both been validated against colposcopy and histopathologic specimens in HIV‐infected women in multiple, well‐designed studies, many of the studies validating VIA in HIV‐infected women have been limited by either small sample sizes or use of a nonhistologic reference standard . Recent well‐powered studies of VIA among HIV‐positive women who use colposcopy or histology as the gold standard show a range of values for VIA positivity (15–45%), sensitivity (63–84%) and specificity (66–89%), suggesting that population and provider factors are important determinants of test performance .…”

“…In contrast to cervical cytology and HPV testing, which have both been validated against colposcopy and histopathologic specimens in HIV-infected women in multiple, welldesigned studies, [16][17][18][19][20][21][22] many of the studies validating VIA in HIV-infected women have been limited by either small sample sizes 23 or use of a nonhistologic reference standard. [24][25][26] Recent well-powered studies of VIA among HIV-positive women who use colposcopy or histology as the gold standard show a range of values for VIA positivity (15-45%), sensitivity (63-84%) and specificity (66-89%), suggesting that population and provider factors are important determinants of test performance. [27][28][29][30] Some authors suggest that HIV may increase the likelihood of finding inflammation and acetowhite lesions on colposcopic examination, leading to both decreased specificity and sensitivity for cervical intraepithelial neoplasia (CIN) 2/3.…”