Efficacy of visual inspection with acetic acid in screening for cervical pre-malignant lisions in Hiv infected women. A cross sectional study

Abstract

Background:

Cancer of the uterine cervix is the most common gynaecological cancer in developing

countries, including Tanzania. There is high prevalence of HIV infection in Tanzania and

studies have shown an increased risk of Cervical Intraepithelial Neoplasia (CIN) in HIV

infected women. Routine cytological screening by Pap smear is not feasible in most

developing countries as it needs highly trained personnel, infrastructures, systems to

communicate results and funding. Visual Inspection with Acetic acid (VIA) is the best

alternative, as it is cost effective, with proven sensitivity and specificity in the population.

The present study evaluated the performance of VIA compared with Pap smear, in the

detection of premalignant lesions of the cervix in HIV infected women.

Methodology:

The study was conducted among HIV infected women attending the Care and Treatment

Centre (CTC) at Muhimbili National Hospital between November 9th 2009 and February

16th 2010. A total of 316 women aged 18-70 years had a Pap smear taken for cytology,

followed by spraying on the cervix with 4% acetic acid and then inspecting it. Cytology

was considered negative when there was no CIN lesion reported from the Pap smear

taken and positive if a CIN lesion (CIN I to Ill) was reported. Detection of a well-

defined, opaque acetowhite lesion close to the squamocolumnar junction or close to the

external cervical os constituted a positive VIA. Results: Out of 316 women, 132 (42.4%) women had acetowhite lesions on VIA, making the proportion of abnormal cervical lesions to be 42.4%. One hundred and one out of 312 women (32.4%) had CIN lesions detected on Pap smear. The proportion of agreement between these two tests was 0.3. The proportion of agreement was moderate in women with advanced WHO HIV clinical stage of the disease and in women not on ART (Anti Retroviral Therapy). Women with CD-4 count less than 200 cells/mm3 had more abnormal cervical lesions.

Conclusion: There is significant proportion of HIV positive women with premalignant lesions of the cervix. The proportion of agreement between VIA and Pap smear is 0.3. Considering the proportion of HIV women with abnormal lesions and the difficulty in logistics of doing Pap smear in low resource settings, it is recommended to introduce screening of premalignant lesions of the cervix using VIA to all HIV infected women.