Visual Inspection with Acetic Acid (VIA) Positivity Among Female Sex Workers: a Cross-sectional Study Highlighting One-year Experiences in Early Detection of Pre-cancerous and Cancerous Cervical Lesions in Kampala, Uganda

Abstract

Background: Although cervical cancer is preventable, most women in sub-Saharan Africa (SSA) do not receive routine screening and few treatment options exist. Female Sex Workers (FSWs) are among the Ugandan female population at highest risk of acquiring sexually transmitted infections (STIs) including HIV and human papilloma viruses (HPV), the cause of cervical cancer. We report one-year experiences of visual inspection with acetic acid (VIA) positivity among FSWs in the early detection of pre-cancerous and cancerous cervical lesions in Kampala, Uganda.Methods: Between June 2014 and July 2015, we enrolled FSWs into a cross-sectional study at a research clinic. The women were screened using the VIA method (application of 3-5% acetic acid to the cervix). All VIA positive women were referred to a tertiary hospital for colposcopy, biopsy, and immediate treatment (if indicated) at the same visit according to national guidelines. Data on socio-demographic, sexual behaviour, sexual reproductive health and clinical characteristics were collected. We used logistic regression to identify factors associated with VIA positivity.Results: Of 842 women assessed for eligibility, 719 (85%) of median age 30 (IQR 26, 35) were screened, and 40 (6%) women were VIA positive. Of the 24 histology specimens analysed, 6 showed inflammation, only 1 showed cervical intraepithelial neoplasia (CIN) 1, 13 women showed CIN2/3, while 4 women already had invasive cervical cancer. The overall prevalence of HIV was 43%, of whom only 35% were receiving ART. In the age-adjusted analysis, VIA positivity was more likely among women who reported having >100 life-time partners (aOR=3.34, 95%CI: 1.38-8.12), and HIV positive women (aOR=4.55; 95%CI: 2.12 - 9.84).Conclusion: We found a relatively low proportion of VIA positivity in this population. The experience from our program implies that the VIA results are poorly reproducible even among a category of trained professional health workers. VIA positivity was more likely among women with a high number of sexual partners and HIV infection. Interventions for improving cervical cancer screening should be recommended as part of HIV care for FSWs to reduce the disease burden in this population.

Genotyping the human papillomavirus and associated risk factors in mono- and co-infection with human immunodeficiency virus among women attending KIU-TH

“…Of the 32% VIA positive, 26% were VIA and HIV positive, 1% were ASCUS and HIV negative, and 2% were ASCUS and HIV positive. The findings are consistent with two other studies, one conducted in Kampala, Uganda by Namale, G et al, 2021 (26), who also reported the prevalence of VIA among HIV-positive patients, and another conducted by TASO HIV Clinic at Mulago facility, Kampala (27), also reported 44% of VIA and HIV positive patients. Hence, UNAIDS, 2018 (28) reported that the prevalence of HIVpositive women within the age-15-49 was at 5.4%.…”

Human Papilloma Virus infection and cervical cancer among women who sell sex in Eastern and Southern Africa: A scoping review

“…They argue that VIA screening could be integrated in HIV treatment, thereby addressing and treating abnormal results promptly. Namale et al’.s 18 research in Uganda, however, contradicts these findings. The VIA had low sensitivity in their study, even though administered by trained health workers.…”

“…Afzal et al 10 note in their South African study that there are long delays in addressing abnormal Pap smears. Indeed, Namale et al 18 note that, despite their reticence regarding VIA, the same day linkage of the VIA screen-positives to the diagnosis and treatment facility was critical. They call for careful consideration of the feasibility of the ‘screen and treat’ strategy for preventing cervical cancer recommended by the WHO for low-resource countries.…”

Cervical cancer prevention and control in women living with human immunodeficiency virus

“…67 Likewise, VIA and Pap test specificity is influenced by HIV infection and its control, probably as a result of their influence on HPV prevalence, as shown in one study that controlled for the presence of HPV. 193 VIA positivity is higher (and its specificity is lower) for WLWH (vs HIV-negative wo men) 182,194,195,196,197,198,199,200 and, among WLWH, for those with lower CD4 counts 183,201 and lack of ART use. 57 Pap test positivity is higher (and its specificity is lower) for WLWH (vs HIV-negative women) 71,202 with higher CD4 cou nts 71,183,193,203,204,205,206,207,208 and lower HIV viral loads.…”