Comprehensive Visual Inspection of the Cervix with Acetic Acid (VIA) and Lugol’s Iodine (VILI)

About the development of this course

This course has been developed in order to improve the screening skills of healthcare professionals working in the field of cervical cancer screening in low and medium resource incomes countries (LMIC).

What are the minimal requirements before doing this course?

The minimal requirements for reaching the objectives of this course are basic knowledge of the lower genital tract anatomy as well as of the benign cervical abnormalities (such as: polyps, hyperkeratosis, Nabothian cysts and cervicitis).

What are the visual inspections in the prevention of cervical cancer?

The visual inspection techniques include VIA (visual inspection with acetic acid) and VILI (visual inspection using Lugol’s iodine). These approaches are an attractive alternative to cytology-based screening in LMIC.

What is VIA?

VIA is a visual examination of the uterine cervix after application of 3-5% acetic acid. If the cervical epithelium contains an abnormal load of cellular proteins, the acetic acid coagulates the proteins conferring an opaque and white aspect of the concerned area. A precancerous lesion has higher protein content when compared to normal epithelium. As a consequence it becomes white (acetowhite) and is considered to be “VIA positive”. For practical consideration please note that the expected rate of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) in an unscreened or poorly screened population is between 2-4%.

What is VILI?

VILI is a visual examination generally performed after the VIA test and requires the application of Lugol’s iodine, a compound that reacts with glycogen resulting in a brown or black coloration. Normal mature squamous epithelium contains glycogen. When in contact with Lugol’s iodine it becomes black, whereas precancerous lesions and cancer contain little or no glycogen thus turning yellow after Lugol application. Such a reaction is considered to be “VILI positive”.

What is an HPV test?

HPV tests identify the presence of Human Papillomavirus (HPV) that is at the origin of cervical cancer. Women having an HPV-negative test are not at risk for developing cervical cancer in the next 5-10 years. Between 20% and 30% of women (30-50 years old) in sub-Saharan Africa are HPV-positive but only a subgroup of them will have a CIN2+ lesion. The considerable advantage of HPV testing is that the women can perform it themselves (self-HPV).

What is the advantage of VIA/VILI testing in HPV-positive women?

Performing VIA/VILI in HPV-positive women is a screening option recommended by the World Health Organization (WHO). This allows selective VIA testing in high-risk populations. It is worth knowing that the expected rate of CIN2+ in HPV-positive women (30-50 years old) is approximately 8-15%.

Who should be tested for HPV followed by a VIA/VILI test?

Women between the ages of 30 and 50 are eligible for cervical cancer screening using this method.

Who can perform VIA/VILI test?

Any healthcare providers can perform this examination. However, in order to perform VIA/VILI successfully and be efficient in reducing cervical cancer incidence, healthcare providers need to receive formal and practical VIA/VILI training. Providing high-quality VIA/VILI screening is essential and requires continual training and close monitoring of such activity.

More information is available via the IARC website dedicated to cervical anatomy, VIA-based cervical cancer screening and management (http://www.iarc.fr) as well as in WHO | Guidelines for screening and treatment of precancerous lesions for cervical cancer prevention and WHO | Use of cryotherapy for cervical intraepithelial neoplasia.

Special acknowledgements to:

Special acknowledgements to: Prof. Aldo Campana, Ulrike Meyer-Hamme MD, Manuela Undurraga Maliverno MD, Milena Alec MD, Nadia Berkane MD, and Isabelle Navarria-Forney MD, for invested time in the supervision and critical comments on this course.

Course contents