Background:Alternative methods to cytology have been developed to improve cervical cancer screening in limited-resource settings. However, geographical differences have been observed. In sub-Saharan Africa (SSA), many trials have been put in place to investigate accuracy of Visual Inspection with Acetic Acid (VIA), Visual Inspection with Lugol’s Iodine (VILI) and testing for Human Papillomavirus (HPV testing) for cervical cancer screening, but results are equivocal.
Aim:To compare accuracy of VIA, VILI and HPV testing to detect cervical intraepithelial neoplasia grade 2 or worse in SSA
Methods:From a systematic search, we included studies when (i) VIA, VILI or HPV testing were used as standalone tools for primary screening, (ii) study population was not at risk for cervical cancer, (iii) screening procedure was performed by nurses, and (iv) reference standard was colposcopy followed by directed biopsies. We applied bivariate and random-effects models to pool absolute sensitivity and specificity of VIA, VILI and HPV testing. Relative sensitivity and specificity of one test versus any other was also calculated.
Results:Fifteen studies were eligible and provided data on 61.381, 46.435 and 11.322 women for VIA, VILI and HPV testing, respectively. Pooled sensitivity of VILI (95.1%, 95% CI 90.1-97.7) was significantly higher than that of VIA (82.4%, 95% CI 76.3-87.3) and pooled specificity of VILI (87.2%, 95% CI 78.1-92.8) did not differ from that of VIA (87.4%, 95% CI 77.1-93.4). Pooled sensitivity (88.3%, 95% CI 73.1-95.5) and specificity (73.9%, 95% CI 50.7-88.7) of HPV testing were not different from those of VIA or VILI. Although performances of these tests were not affected by study region or place of screening, accuracy of visual methods increased significantly with sample size and publication year.
Conclusions: In the context of primary screening in SSA, VILI is a simple, low-cost and more viable alternative to cytology than VIA for cervical cancer early detection.