












































Page mackup July-14.qxd


Bangladesh Journal of Medical Science Vol. 13 No. 04 October’14

454

Original article

Visual Inspection with Acetic Acid (VIA) in cervical cancer screening in low resource settings

Shaheen1, Sharma R2, Rashi3

Introduction:

Cervical cancer is the second most common cancer
in women, and 80% of these cases occur in underde-

veloped countries1. It comprises 15% of the cancers
diagnosed in women in underdeveloped countries. It
kills approximately 270,000 women worldwide each
year, with nearly 85% of those deaths occurring in

resource-poor settings2. While the incidence and
mortality rates of cervical cancer have declined in
developed countries since the advent of successful

screening programs3-5, there has been no such trend
in developing countries. Screening programs were
implemented in developing countries since the early
1980’s, yet have failed to reduce the mortality rates.
The WHO in 2002 estimated that only 5% of women
in developing countries are screened appropriately.
Likely reasons for failure in screening programs
include lack of funding, insufficient access in rural
areas where most of the population in developing

countries reside, lack of awareness/education as to
need for screening, and poor follow-up. About 50%
of all cancers occur in developing countries, yet only
5% of resources are spent on the fight against cancer
worldwide. India accounts for one-fifth of the world
burden of cervical cancer and continues to be the

most common genital cancer1. In India approxi-
mately, 90,000 new cases of cancer cervix occur
every year. The incidence in India is 45 per one lakh

women6.
In developing countries as in India, alternative, low-
cost and effective early diagnosis 
methods are needed. Visual inspection with acetic
acid(VIA) is a simple and easy-to-learn method and
does not require laboratory equipment. Test results
are immediate after administration. VIA is an attrac-
tive method for these reasons in underdeveloped

countries7-9. With suspicious lesions detected,

Corresponds to: Prof. R Sharma, 2/65,Vishnupuri, Aligarh, UP (India) 
Email: rajyashri.sharma@gmail.com

Abstract:

Objective: To evaluate the feasibility and validity of visual inspection of the cervix with 
acetic acid (VIA) for screening cervical intraepithelial neoplasia. Materials and Methods: In 
this study, 942 women recruited from gynecology outpatient clinic, were screened using the 
Papanicolaou (PAP) smear, and VIA. The sensitivity and specificity of both the screening 
methods were analyzed. Results: VIA was positive in 29.3%. The sensitivity of VIA 
(74.16%) was much higher than that of the Pap smear (47.83%). The specificity of VIA 
(50.00%) was lower than that of the Pap smear (74.16%), resulting in high false-positive rates 
for VIA. Conclusion: Visual inspection of the cervix with acetic acid is sensitive for ecto-
cervical lesions. The advantage of the VIA method lies in its easy technique, low cost and 
high sensitivity which are important factors for determining the efficacy of any screening 
program in developing countries. 

Keywords: cervical cancer screening; Papanicolaou (PAP) smear; visual inspection of the 
cervix with acetic acid (VIA)

1. Dr. Shaheen, Associate Professor, Department of Obstetrics & Gynecology, JN Medical Collage, AMU,
Aligarh

2. Dr. Rajyashri Sharma, Professor, Department of Obstetrics & Gynecology, JN Medical Collage, AMU,
Aligarh

3. Dr. Rashi, Postgraduate, Department of Obstetrics & Gynecology, JN Medical Collage, AMU, Aligarh

DOI: http://dx.doi.org/10.3329/bjms.v13i4.15019
Bangladesh Journal of Medical Science Vol. 13 No. 04 October '14. Page: 454-459



women are directed to further treatment8,10,11.
Visual inspection-based approaches to cervical can-
cer screening have been extensively investigated in
India. The performance characteristics of unaided
visual inspection (without acetic acid), also known
as ‘‘downstaging’’, has been addressed in several

studies12.
The purpose of this study was to test the validity of

VIA in cervical cancer screening (sensitivity, speci-
ficity, and positive and negative predictive values)
and compare it with findings from the Papanicolaou
test.
Material and Methods:

This hospital based prospective cohort study was
carried out in J N Medical College hospital at
Aligarh in the out patient Department of Obstetrics
and Gynecology between June 2008 and September
2010. Nine hundred forty two women with inclusion
and exclusion criteria were screened for CIN and
early cervical cancer. 
The study protocol was reviewed and approved by
institutional ethical committee and informed consent
was obtained from each woman. Relevant obstetric
and gynecological history was obtained and record-
ed.
Inclusion criteria:

All women exposed to early sexual life, with multi-
ple sexual partners, low socioeconomic status, hav-
ing history of STD’s, with foul smelling discharge
and with post coital bleeding were included in the
study.
Exclusion criteria

Unmarried women, women with frank invasive can-
cer cervix, women with bleeding per vaginum, and
pregnancy were excluded.
All women were subjected for per speculum exam-
ination to observe the size and shape of the cervix,
the external os identified with pinkish squamous
epithelium and reddish columnar epithelium and
transformation zone. The pap smear was taken and
two samples were taken one from ectocervix and
other from endocervix. The pap smear slide was
immediately fixed with 90% ethyl alcohol. Later, the
slide was sent for cytology in the Department of
Pathology, J N, Medical College Hospital, Aligarh.
Pap smear reporting was done according to the
Bethesda classification . After taking pap smear, the
same Women were subjected to visual inspection of
the cervix after application of 5% acetic acid. Using
a cotton swab soaked in acetic acid was applied on
cervix for one minute and then the cervix was care-

fully inspected for any aceto-white lesions, particu-
larly in the transformation zone.
Reporting of test outcome

In the study, test was reported as positive, negative
and inconclusive VIA test. 
Positive test: Visualization of the dense acetowhite
lesion with sharp margins located in the transforma-
tion zone, close to squamo-coloumner junction
(SCJ). 
Negative test: If no acetowhite lesions were
observed on the cervix polyps protruding from
cervix, bluish white in color, nabothian cysts which
appear as button like areas as whitish area or pim-
ples, dot like areas present in the endocervix which
were due  columnar epithelium staining with acetic
acid; if there were shiny pinkish white, cloudy white
or bluish white, faint patchy or doubtful lesions with
ill defined, indefinite margins or irregular, ace-
towhite lesions resembling geographical lesions
away from the SCJ. 
If VIA turns out to be positive the patient was sub-
jected to further investigations such as colposcopy
and guided biopsy.
Statistical analysis 

The results of visual inspection of cervix with acetic
acid (VIA) were correlated with that of pap smear on
the basis of sensitivity, specificity and positive and
negative predictive value.
Results:

Of the 942 women who participated, 45.5% were 31
to 40 years of age and 38.9% were 20 -30 years; the
mean (SD) age was 34.52±2 years. All (100%) were
married, 53.33% 
were married when they were 15 years or younger,
and 39.61% married between the ages of 18 and 20
years. 
In the observations made after the application of the
acetic acid, VIA was negative in 79.7% of the
women and positive in 29.3% of the women (Table
1). Similarly, 80.10% of the women had negative
smear test results and 18.89% had positive smear
test results. When the Papanicolaou test results were
classified according to the Bethesda System, 42.89%
of the women had normal smear test results, 38.22%
of them had an inflammatory smear, 2.12% had
Atypical Squamous Cells of Undetermined
Significance (ASCUS), 0.42% had Atypical
Glandular cell of Undetermind Significance
(AGUS), 9.13% had Low Grade Squamous
Intraepithelial Lesion (LSIL), and 7.22% had High
Grade Squamous Intraepithelial Lesion (HSIL)
(Table 1). Using the Papanicolaou test, the sensitivi-

Visual Inspection with Acetic Acid (VIA) in cervical cancer screening

455



ty of VIA was 74.16% and specificity was 50.00%.
The positive predictive value (PPV) of VIA was
47.83%, and its negative predictive value (NPV) was
75.78% (Table 2).

Discussion:

In our study VIA was positive in 29.30%, which is
almost comparable to studies by Tayyeb et al,

28.9%9,Belinson  et al13 , 27.3%, and Doh et al14,
21.7% (Table 3).
In our study with VIA, results for sensitivity and
specificity were 74.16%, and specificity of 50.0%
which is almost comparable to studies shown in

Londhe et al15 as sensitivity 
72%, and specificity 54% (Table 4). Other studies
were showing the sensitivity of 71% and specificity

of 74% in Belinson et al13, and sensitivity of 67%

and specificity of 83.0% in Denny et al16, in the
Johns Hopkins' Program for International Education

in Reproductive Health (JHPIEGO)11, sensitivity
was 77% and specificity was 64%. Additional results
from other studies are listed in more detail in Table

4. When the studies made by using acetic acid in the
recent years are examined, it is seen that the sensitiv-
ity of VIA is between 60% and 95.7% and its speci-

ficity is between 30.4% and 98%9,17-19.
Decreasing VIA specificity means a risk of increased
false-positive patient ratio. For this reason, treatment
may be recommended for some women who have no
neoplasm or have a low-stage disease. Despite such
risks, VIA is still the most cost-efficient prognostic
method for the underdeveloped countries. In our
study, similar to the findings of some other studies
(Table 4) made in other countries, VIA sensitivity
was high, as noted in the outcomes of the compar-
isons of VIA and Papanicolaou test results. This
finding highlights the importance of training and
experience for the clinicians who are completing the
visual evaluations. In our study, VIA specificity was
low, as noted in the outcomes of comparing VIA
with Papanicolaou test results, perhaps in part
because inflammatory lesions become aceto-white.
Also, several other variables affect the performance
of VIA as the light source, which should be white
and condensed and the training and experience of the
observer. The reasons behind the VIA specificity
being high or low in different researches could be
the personnel completing the VIA assessment, clini-
cal criteria not properly used, differences between
the research populations, and women with inflam-
matory conditions included in some but not all of the

studies14,18,20-22 . In our study, when the VIA and
Papanicolaou test results were compared, PPV
(47.83%) was low  and NPV (75.79%) was high,
which means that when a test is negative, the women
can go home reassured that she is not likely to have

Shaheen, Sharma R, Rashi

456

 No. % 

VIA 

 Negative 666 70.7 
 Positive 276 29.3 

 Total 942 100.0 

Papanicolaou Test 

 Negative 764 81.1 
 Positive 178 18.9 

 Total 942 100.0 

Bethesda System   
 Normal 404 42.89 

            Inflammatory Lesions 360 58.04 

 AGUS 4 0.42 

 ASCUS 20 2.12 
 LSIL 86 9.13 

 HSIL 68 7.22 

 Total 942 100.0 

Abbreviation: VIA, visual inspection with acetic acid.

Table 1: Distribution of VIA and Papanicolaue 

Test Results

VIA Positive Negative Total 

Positive  132 144 276 

Negative 46 144 190 
Total 178 288 464 

Table 2: Sensitivity and Specificity of VIA versus 

Papanicolaou Test Outcome

Abbreviation: NPV, negative predictive value; PPV, 

positive predictive value, VIA, visual inspection 

with acetic acid.

Sensitivity: 74.16%; PPV, 47.83%; specificity, 

50.00%; NPV, 75.79%.

PAPANICOLAOU TEST

Table 3: Results of VIA for Other Countries

Author(s) (Year) VIA

Positive (%)

Country No. of 

Women 

Londhe et at (1997) 52.96 India 372 
Ardahan et al (2011) 9.7 Turkey 350 

Belinson et al (2001) 27.3 China 1977 

Denny et al  (2002) 18.1 Africa 2754 

Tayyeb et al (2003) 28.9 Pakistan 501 
Goel et al (2005) 12.5 New Delhi 400 

Doh et al (2005) 21.7 Cameroon 4813 

Present study (2011) 29.3 Aligarh(India) 942 



a neoplastic cervical lesion; eliminating the need for
follow-up visits. However, the low PPV of VIA does
present the problem of many false positives, discour-
aging the see-and-treat method. However, PPV is
dependent on incidence and if a see-and-treat
method were implemented in a high-risk population
with a high incidence of cervical cancer, the qualities
of the VIA test may improve. Therefore, the “see-
and-treat” method with VIA could be accepted by
patients in developing countries like India.
Conclusion:

VIA is an adequate and acceptable screening method

for cervical cancer. Furthermore, in low-resource
areas like India, VIA can be better than cytology for
its ease of use and low cost. Cytology based screen-
ing programmes are difficult to organize owing to
limited infrastructure, trained personnel, and funds.
Our results outline the potential benefits of using
VIA based screening at all levels of health care sys-
tems in developing countries. There is therefore, the
time has come, to integrate VIA based screening pro-
grams at the primary care level of health services,
and to downstage cancer cervix in our country.

Visual Inspection with Acetic Acid (VIA) in cervical cancer screening

457

Author(s) Country No. of 

Women 

Sensitivity Specificity 

Megevand et al (1996) South Africa 2426 65 98 
Londhe et al (1997) India 372 72 54 

Zimbabwe University JHPIEGO 

(1999) 

Zimbabwe 2203 77 64 

Denny et al (2000) Africa 2944 67 83 
Belinson et al (2001) China 1977 71 74 

Tayyeb et al (2003) Pakistan 501 93.9 30.4 

Wu et al (2003) China 1997 70.9 74.3 
Bhatla et al (2004) India 100 87.5 63 

El – Shalakany et al (2004) Egypt 2049 85.5 96.8 

Ghaemmahani et al (2004) Iran 1200 74.3 94 

Sankaranarayanan et al (2004) India 18675 60.3 86.8 
Goel et al (2005)  New Delhi 400 96.7 36.4 

Vuyst et al (2005) Nairobi (Kenya) 853 73.3 80.0 

Shastri et al (2005) Mumbai (India) 4039 59.7 88.4 
Doh et al (2005) Cameroon 4813 70.4 77.6 

Eftekhar et al (2006) Iran 200 95.7 44.0 

Sodhani et al (2006) India 472 86.7 90.7 
Chumwonathayi et al (2008) Thailand 648 60.0 93.9 

Cagle et al (2009) China 1839 69.5 89.0 

Ardhahan et al (2011) Turkey 350 82.4        50 

Present study India 942 74.16 50.0 

Table 4: Comparison of Sensitivity and Specificity of VIA with Other Studies



Shaheen, Sharma R, Rashi

458

References:

1. Sankaranarayanan R, Budukh AM, Rajkumar R.
Effective screening programmes for cervical cancer in
low-and middle-income developing countries. Bull
World Health Organ. 2001;79(10):954-962.

2. Ferlay J et al., GLOBOCAN 2002: cancer incidence,
mortality and prevalence world wide, version 2.0,
Lyon, France: International Agency for Research on
Cancer, 2004, <http://www.dep.iarc.fr/globocan/data-
base.htm>, accessed May 16, 2008.

3. Haydaroglu A. Epidemiology in Gynaecologic
Cancers. Izmir, Turkey: Gynaecologic Oncology
Symposium; 2004.

4. Nygard JF, Skare GB, Thoresen SO. The cervical can-
cer screening programme in Norway. 1992-2000:
changes in pap smear coverage and incidence of cervix
cancer. J Med Screen. 2002;9(2):86-91.
http://dx.doi.org/10.1136/jms.9.2.86

5. Yuan CC, Wang PH. New strategies and advances in the
management of cervical carcinoma. Gan To Kagaku
Ryoho. 2002;29(1):143-149.

6. Saraiya U. Relevance cytology services in India today.
J Obstet Gynecol India 1986; 36:374-384.

7. Gates B, Gates M. Pap smears: an important but imper-
fect screening method. Alliance Cervical Cancer
Prevention. Program for Appropriate Technology in
Health (PATH). Washington, DC: Alliance
Coordinating Agency; 2003.

8. Sing V, Schgal A, Parashari A, et al. Early detection of
cervical cancer through acetic acid application an aided
visual inspection. Singapore Med J. 2001;42(8):351-
354.

9. Tayyeb R, Khawaja NP, Malik N. Comparison of visu-
al inspection of cervix and pap smear for cervical can-
cer screening. J Coll Physicians Surg
Pak.2003;13(4):201-203.

10. JHPIEGO Cervical Cancer Project. Visual inspection
with acetic acid for cervical cancer screening: test qual-
ities in a primary care setting. Lancet.
1 9 9 9 ; 3 5 3 ( 9 1 5 6 ) : 8 6 9 - 8 7 3 .
http://dx.doi.org/10.1016/S0140-6736(98)07033-0

11. Ahmed T, Ashrafunnessa, Rahman J. Development of
a visual inspection programme for cervical cancer pre-
vention in Bangladesh. Reprod Health Matters.
2 0 0 8 ; 1 6 ( 3 2 ) : 7 8 - 8 5 .
http://dx.doi.org/10.1016/S0968-8080(08)32419-7

12. Sankaranarayanan R et al. Visual inspection as a
screening test for cervical cancer control in developing
countries. In: Franco E, Monsonego J, eds.New devel-
opments in cervical cancer screening and prevention.
Oxford, Blackwell Science, 1997: 411–421.

13. Belinson JL, Pretorius RG, Zhang WH, et al. Cervical
cancer screening by simple visual inspection after
acetic acid. Obstet Gynecol. 2001;98(3):441-444.
http://dx.doi.org/10.1016/S0029-7844(01)01454-5

14. Doh AS, Nkele NN, Achu P, et al. Visual inspection
with acetic acid and cytology as screening methods for
cervical lesions in Cameroon. Int J Gynecol Obstet.
2005;89(2):167-173. 32.

15. Londhe M, George SS, Seshadri L. Detection of CIN
by naked eye visualization after application of acetic
acid. Indian J Cancer. 1997;34(2):88-91.

16. Denny L, Kuhn L, Pollack A, et al. Evaluation of alter-
native methods of cervical cancer screening for
resource-poor settings. Cancer. 2000;89(4):826-833.
h t t p : / / d x . d o i . o r g / 1 0 . 1 0 0 2 / 1 0 9 7 -
0142(20000815)89:4<826::AID-CNCR15>3.0.CO;2-5

17. Chumwonathayi B, Eamratsameekool W, Kularbkaew
C, et al. Visual inspection with acetic acid test qualities
in a secondary setting. J Obstet Gynaecol Res.
2 0 0 8 ; 3 4 ( 5 ) : 9 0 9 - 9 1 3 .
http://dx.doi.org/10.1111/j.1447-0756.2008.00848.x

18. Goel A, Gandhi G, Batra S, et al. Visual inspection of
the cervix with acetic acid for cervical intraepithelial
lesions. Int J Gynaecol Obstet. 2005;88(1):25-30
http://dx.doi.org/10.1016/j.ijgo.2004.09.018

19. Megevand E, Denny L, Dehaeck K, et al. Acetic acid
visualization of the cervix: an alternative to cytologic
screening. Obstet Gynecol. 1996;88(3):383-386.
http://dx.doi.org/10.1016/0029-7844(96)00189-5

20. Eftekhar Z, Rahimi M, Yarandi F, et al. Accuracy of
visual inspection with acetic acid for early detection of
cervical dysplasia in Tehran, IRAN. Asian Pac J
Cancer Prev. 2005;6(1):69-71.

21. Bhatla N, Mukhopadhyay A, Joshi S, et al. Visual
inspection for cervical cancer screening: evaluation by
doctor versus paramedical worker. Indian J Cancer.
2004;41(1):32-36.

22. El-Shalakany A, Hassan SS, Ammar E, et al. Direct
visual inspection of the cervix for the detection of pre-
malignant lesions. J Low Genit Tract Dis.
2 0 0 4 ; 8 ( 1 ) : 1 6 - 2 0 .
http://dx.doi.org/10.1097/00128360-200401000-00005

23. Basu PS, Sankaranarayanan R, Mandal R, et al. Visual
inspection with acetic acid and cytology in the early
detection of cervical neoplasia in Kolkata, India. Int J
Gynecol Cancer. 2003;13(5):626-632.
http://dx.doi.org/10.1046/j.1525-1438.2003.13394.x

24. Cagle AJ, Hu SY, Sellors JW, et al. Use of an expand-
ed gold standard to estimate the accuracy of col-
poscopy and visual inspection with acetic acid (VIA).
Int J Cancer. 2010;126(1):156-161.
http://dx.doi.org/10.1002/ijc.24719



25. Vuyst DH, Claeys P, Njiru S, et al. Comparison of pap
smear, visual inspection with acetic acid, human
Papillomavirus DNA-PCR testing and cervicography.
Int J Gynaecol Obstet. 2005;89(2):120-126.
http://dx.doi.org/10.1016/j.ijgo.2005.01.035

26. Ghaemmaghami F, Behtash N, Modares GM, et al.
Visual inspection with acetic acid as a feasible screen-
ing test for cervical neoplasia in Iran. Int J Gynecol
Cancer. 2004;14(3):465-469.
http://dx.doi.org/10.1111/j.1048-891x.2004.14306.x

27. Sankaranarayanan R, Shastri SS, Basu P, et al. The
role of low-level magnification in visual inspection
with acetic acid for the early detection of cervical neo-
plasia. Cancer Detect Prev. 2004;28(5):345-351.
http://dx.doi.org/10.1016/j.cdp.2004.04.004

28. Wu LY, Li N, Zhang WH, et al. Value of acetic acid
smear test for cervical cancer screening, Ai Zheng.
2003;22(10):1096-1098.

29. Shastri S.S, Dinshaw K, Amin G, et al. Concurrent
evaluation of visual, cytological & HPV testing as
screening methods for the early detection of cervical
neoplasia in Mumbai (India). Bull World Health
Organization. 2005, 83;(3) doi: 10.1590/S0042-
96862005000300011.

30. Sodhani P, Gupta S, Sharma JK, et al. Test character-
istics of various screening modalities for cervical can-
cer: a feasibility study to develop an alternative strate-
gy for resource-limited settings. Cytopathology.
2 0 0 6 ; 1 7 ( 6 ) : 3 4 8 - 3 5 2 .
http://dx.doi.org/10.1111/j.1365-2303.2006.00351.x

31. Ardahan, Malek, Temel, Ayla. Visual inspection of
acetic acid in cervical cancer screening. Canc. Nursing.
2 0 1 1 , 3 4 ; ( 2 ) : 1 5 8 - 1 5 3 .
http://dx.doi.org/10.1097/NCC.0b013e3181efe69f

Visual Inspection with Acetic Acid (VIA) in cervical cancer screening

459




