The gynecology ward's outdoor waiting room in Gonaives, Haiti, is bright, airy, and clean. More than 70 women have gathered here in this public hospital to learn about the signs and symptoms of women's cancers and receive screenings for cervical cancer.
One of these women, Gertrude, 47, sits on a bench outside the ward. She owns a small business in Gonaives but took the day off to come to the screenings. Last year, her cervical cancer screening test at a nearby town came back negative. Gertrude is sure that this year's screening will be negative as well. Besides, she doesn't know anyone who has had cervical cancer before. When it is her turn, Gertrude lies down on the exam table and the nurse takes a speculum and a cotton swab dipped in acetic acid to begin the procedure.
The value of the procedure Gertrude is about to get is hotly debated within the NGO community, not just in Haiti but in other low-income countries as well. Some think it is not reliable and therefore a waste of time and money while others see no good alternatives available in these low-resource settings. Known as "Visual Inspection with Acetic Acid," or VIA, it has been around since the 1990s. Using a diluted mixture of acetic acid and water, the health worker swabs the solution on a woman's cervix and watch for color changes. If part of a woman's cervix turns white, she theoretically has pre-cancerous lesions in her cervix.
Unlike PAP smears, which require separate visits for the PAP smear, biopsy, and treatment, the combination of VIA and cryotherapy in "screen and treat" programs allows women to get tested and treated on the same day. In a developing country where women often don't have reliable phone numbers or addresses, this quick turnaround is priceless.
The VIA screening technique quickly grew in popularity when it was first introduced almost 3 decades ago. However, enthusiasm among experts has waned in recent years. While initial studies of VIA showed that it detected 80-90% of pre-cancerous lesions in women, newer studies show that VIA may only detect 20-30% of pre-cancerous lesions, meaning that 70-80% of women in need of treatment will not test positive.
Other studies have measured the percentage of women who test positive and actually have the disease, otherwise known as the positive predictive value (PPV). These studies show that the VIA PPV is around 20% which, if these studies are correct, would mean that only 20% of the women who test positive actually have pre-cancerous lesions. While cryotherapy is not harmful to women, the expense of treating women who don't actually need treatment can quickly add up, especially in a country like Haiti.
Because of these results, some experts are hesitant to advocate for VIA screenings for women like Gertrude in Haiti, as well as women in other low-income countries. Patti Gravitt, PhD, Ms, a leading expert in cervical cancer and HPV natural history, has been involved with several studies to test the efficacy of different screening tests—and she says VIA always comes up last in its ability to get the right women into treatment. Gravitt describes VIA as a "cross your fingers and hope you save some lives" approach to cervical cancer screening. Because VIA has such low sensitivity, women should be screened every couple of years. Despite the initial low cost of VIA, the total costs for multiple screenings over several years can add up very quickly.
In fact, there are better tests on the market. The HPV DNA test will catch 93% of women who have lesions compared to VIA's 20-30%. Pap smears also catch more women than VIA.
But the practical ability to implement these tests in developing countries remains challenging. Both the HPV DNA test and Pap smears need laboratory equipment, which is often not available in a country like Haiti. Both tests are also more expensive. VIA costs around $2 per woman while the HPV DNA test costs around $8 per woman. In Haiti, where the majority of women can expect to make around 50 cents a day, the HPV DNA test is too expensive to be practical, even when subsidized by NGOs and the Ministry of Health.
VIA is so cheap that NGOs can often afford to cover the cost for women like Gertrude, who only came to the screenings because she knew she could get both the test and treatment for free. The logistical benefits of VIA are immense, according to Gravitt. "It's immediate, cheap, and there is no need for advanced training," says Gravitt. When programs are on limited budgets, and doctors are scarce, VIA can seem like the best option.
Is it better to implement an ineffective program with VIA than none at all? Vincent Degennaro, MD, MPH, a medical doctor working in Haiti, says yes. And he is following up on that by implementing a VIA screening program in 9 sites around Haiti.
So far over 4,000 women, including Gertrude, have been screened with VIA in Innovating Health International's program. While he admits that there are more effective screening options out there, Degennaro strongly pushed back on the idea that people should not use VIA screenings in low-income countries. "It does not matter what screening modality you use, it only matters that you are screening," he says.
Practically speaking, VIA is the only screening option that makes sense in Haiti right now. Seven of the 19 public hospitals in Haiti have gone on strike in the past year, forcing screening programs to be shut down at a moment's notice. Due to the low-tech nature of VIA, the program can be stopped and started with little harm to the equipment. With other screening technologies that require labs and highly-skilled healthcare workers, strikes every few months can cost thousands of dollars and hours of time collecting the samples.
As the nurse swabs acetic acid into her cervix, the nurse sees white lesions appear. Gertrude has tested positive for pre-cancerous lesions. She is surprised. Nothing has changed in her personal life since the screening one year prior. Gertrude gets in line for cryotherapy behind five other women. She is lucky she can get treatment the same day she tests positive but no one can tell whether she is one of the 80% of women who unnecessarily receive treatment due to a false positive.