PATH's Cervical Cancer Prevention Action Planner

Lessons specific to visual inspection with acetic acid

PATH and other Alliance for Cervical Cancer Prevention (ACCP) partners have worked with visual inspection with acetic acid (VIA) programs in the developing world for many years. The evidence in support of VIA as a primary screening method and for treatment selection is strong, and VIA is featured prominently in cervical cancer screening guidance from the World Health Organization, the International Federation of Gynecology and Obstetrics (FIGO), the United Nations Population Programme (UNFPA), the ACCP, the Cervical Cancer Action coalition, PATH, and many other organizations.

WHO's Comprehensive Cervical Cancer Control: A guide to essential practice and ACCP's Planning and Implementing Cervical Cancer Prevention and Control Programs: A Manual for Managers both are excellent, detailed resources on VIA programming.

A set of sample standard operating procedures for cervical cancer screening, diagnosis, treatment, infection prevention, and counseling from India includes information on VIA.

Client- and provider-perceived benefits of VIA

  • VIA is more sensitive than cytology (though less sensitive than HPV DNA testing). However it is less specific than Pap.
  • Results of VIA are available immediately.
  • VIA also provides immediate guidance in treatment selection (e.g., whether the lesions are treatable with cryotherapy or not, and whether there is a suspicion of invasive cancer).
  • VIA screening by an experienced professional requires only 10 to 15 minutes.
  • VIA is relatively inexpensive to provide, but some equipment (exam table, speculum) and supplies (especially vinegar for VIA and CO2 or N2O gas for cryotherapy) are needed.
  • Because results are immediate, in some situations women can be screened and treated (with cryotherapy) during a single visit. But even if cryotherapy is not available at the screening site, with VIA the screen-positive woman can be counseled and referred to treatment during her screening visit. This may result in reduced loss to treatment and likely will be more convenient and less expensive for the women.
  • Nurses and other non-physicians have been successfully trained to perform VIA (and cryotherapy). Training takes only one to two weeks.
  • Investing in VIA now makes sense for many countries because they can begin preventing cancer immediately and will also be preparing themselves to introduce new screening tests when they become affordable. In such cases, VIA may be replaced by HPV DNA testing as a primary screening tool, but VIA still will be useful for treatment selection following a positive HPV DNA test.

Client- and provider-perceived drawbacks of VIA

  • Sensitivity is lower than HPV DNA testing.
  • VIA requires a pelvic exam (unlike vaginal sampling with HPV DNA).
  • VIA requires training and continuing supervision (but much less than Pap).
  • Like Pap, VIA assessments are more subjective than HPV DNA. Results can vary from one provider to another or from one day to another.
  • Because the evidence supporting VIA is relatively new, some health professionals may not be aware of the data and may not accept VIA; they may think of it as "second-class medicine."

Strategies appropriate for VIA

  • Introduce VIA and associated treatment methods as broadly as possible in regions where there are no existing screening programs, where they are weak, or where current coverage with Pap is low.
  • Introduce cryotherapy as broadly as possible. However, due to cost it may be necessary to assign one treatment center to offer cryotherapy serving a number of screening centers. Higher-level facilities offering LEEP or other treatment options also will be necessary to treat cases not appropriate for cryotherapy.
  • Invest in high-quality training in both VIA and treatment, including ongoing quality control and supportive supervision (see training section).
  • In order to meet the demand for screening services, create regional and national training centers focused on teaching VIA and cryotherapy clinical skills and program management.

Messaging specific for VIA

  • Women no longer have to wait a long time for exam results (unlike for Pap). You will have your result immediately.
  • VIA uses the same vinegar we cook with. Don’t say "acetic acid" as the idea of "acid" can be frightening to women.
Photo: PATH/Eric Becker

Woman


Additional resources

Print version: Cervical cancer screening and treatment in low-resource settings (PDF, RHO Cervical Cancer website)

Watch videoScreening and Treatment of Precancerous Lesions video and transcript

Screening and treatment (RHO Cervical Cancer website)

World Health Organization: Comprehensive Cervical Cancer Control: A guide to essential practice (PDF)

Planning and Implementing Cervical Cancer Prevention and Control Programs: A Manual for Managers (PDF)

Evidence-Based, Alternative Cervical Cancer Screening Approaches in Low-Resource Settings

Strategic Plan for Cervical Cancer Prevention and Control in Uganda (PDF)

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