Performance of alternative strategies for primary cervical cancer screening in sub-Saharan Africa: systematic review and meta-analysis of diagnostic test accuracy studies

To assess and compare the accuracy of visual inspection with acetic acid (VIA), visual inspection with Lugol's iodine (VILI), and human papillomavirus (HPV) testing as alternative standalone methods for primary cervical cancer screening in sub-Saharan Africa

Cervical cancer screening in sub-Saharan Africa: a randomized trial of VIA versus cytology for triage of HPV-positive women

Developing countries are interested in using human papillomavirus (HPV) testing as a primary screening test for cervical cancer prevention programs. The low specificity of the HPV assay requires triage testing of HPV-positive women. The aim of the study is to compare visual inspection with acetic acid (VIA) and cytology as triage testing methods in HPV-positive women to detect cervical intraepithelial neoplasia or Grade 2 or higher (CIN2+). The study was conducted in two Cameroonian towns (Yaoundé and Edea) and included 846 eligible women aged 25 to 65 years. All participants performed self-HPV testing. HPV-positive women (n = 259) were randomly assigned to be tested either by VIA (VIA group) or cytology (cytology group). HPV-positive women had both cervical biopsy and endocervical curettage to detect biopsy-confirmed CIN2+. All statistical tests were two-sided. The prevalence of HPV was 38.5%, and the mean age of HPV-positive women was 41.5 ± 10.1 years. One hundred ninety-eight women (97 in the VIA group and 99 in the cytology) were randomly assigned to one of the two testing arms. The sensitivity of VIA was 25.0% (95% CI, 7.1-59.1%), and the sensitivity of cytology was 90.0% (59.6-98.2%). The specificity was 74.2% (95% CI, 64.2-82.1%) for VIA and 85.2% (76.3-91.2%) for cytology. ROC area for cytology was 0.910 against the 0.496 area for VIA. In this trial, VIA was inferior to cytology as a triage test among HPV-positive women. Further investigations are needed to determine the optimal triage method for HPV-positive women