Challenges in Cervical Screening with VIA: Lessons from Guatemala

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Anita Chary

Anita Chary

Anita Chary, MD PhD, is an anthropologist and resident physician at the Harvard Affiliated Emergency Medicine Residency. She is Research Director of the non-governmental organization Maya Health Alliance | Wuqu' Kawoq, which provides health care and development services in rural indigenous communities of Guatemala.

“Vinegar test saves lives,” many headlines have recently read.   Within the past year, Forbes Magazine, the Washington Post, and the New York Times, among many other media sources, have publicized a new screening exam for cervical cancer.  The “vinegar test” is officially known as “visual inspection with acetic acid,” or VIA, and has been receiving increasing attention worldwide.

Cervical cancer is the leading cause of cancer deaths among women in low- and middle-income countries.  Tragically, it is also one of the most easily preventable cancers.  Until recently, the standard cervical cancer screening exam worldwide was the Pap smear.  During a Pap smear, a sample of cells are taken from a woman’s cervix and examined to detect pre-cancerous changes.  Pap smears require laboratory processing and analysis, which often translates to waiting periods before women can obtain their results.  Detection of pre-cancerous changes may necessitate follow-up procedures (colposcopy and biopsy).  Many of the world’s poorest countries lack laboratory facilities, health personnel with adequate training in cytology, infrastructure for delivering Pap results, and systems to provide follow-up care for patients.

Due to these common difficulties with the Pap smear, the Alliance for Cervical Cancer Prevention and the World Health Organization have promoted VIA as a simple and cost-effective cervical cancer screening method for low-resource settings.  During a VIA exam, a health care provider can apply a dilute solution of vinegar to a woman’s cervix and identify patches of tissue that turn white as pre-cancerous lesions.  A woman’s VIA result is available to her immediately, and if the lesions cover less than 75% of her cervix, she can receive a cryotherapy treatment the same day to eliminate the pre-cancerous tissues.  Few materials are required for a VIA exam—a speculum, 5% vinegar, cotton swabs, and a good light source—and it can be performed by non-specialized medical personnel, such as health promoters and auxiliary nurses.

Aurelio Cordova, a professional nurse trained in VIA, educates women about the importance of cervical screening.  At this campaign, Aurelio also assisted with the instruction and supervision of newly certified VIA examiners.

Aurelio Cordova, a professional nurse trained in VIA, educates women about the importance of cervical screening. At this campaign, Aurelio also assisted with the instruction and supervision of newly certified VIA examiners.

Although VIA sounds like an ideal screening method for low-resource settings, it is not without its challenges.  Over the last year, I have been studying cervical cancer prevention initiatives in Guatemala as part of my dissertation research in medical anthropology.  Some key lessons about cervical cancer screening in low-resource settings have emerged from the Guatemalan experience with VIA.

Guatemala’s profile is similar to that of many countries that are adopting VIA.  The majority of Guatemala’s population lives in rural areas, which have very limited access to state-sponsored health care services and whose geographic isolation poses challenges to coordinating follow-up communication and care.  Guatemala also suffers from a dearth of laboratory facilities and trained cytologists, which means that women who get Pap smears may wait for months before receiving their results, if they get their results at all.  For these reasons, two major players in Guatemala’s health care landscape have embraced VIA as a “locally appropriate” technology: the Guatemalan Ministry of Health, which is trying to expand screening coverage (currently at 18%) through VIA, and the ever-proliferating NGO sector, which is estimated to conduct at least 15% of screening nationwide.

In this context, I conducted observations and received certification in a VIA-cryotherapy training course, visited 30 cervical cancer screening campaigns, and performed interviews with 50 health care providers in Guatemala about their experiences with different cervical screening techniques.  Staff turnover and training quality were two major issues with VIA programming that surfaced repeatedly during site visits and interviews.

Within Guatemalan Ministry of Health facilities and among NGOs, staff turnover of health care providers trained in VIA is a common phenomenon.  The Ministry of Health, for example, has trained over 1000 health care providers in VIA.  However, Central American Ministries of Health rotate their personnel between services every few years, particularly with changes in government.  This means that a nurse who has been trained in VIA might offer the exam in her post in women’s health for one year, until a new administration enters and she is fired or rotated into a new service (e.g. child nutrition, labor and delivery), which has no VIA component.  Indeed, instructors from one NGO-sponsored VIA training course cited these problems as the primary reasons that only about 50% of the government nurses and physicians they train end up using the skill.

Similar problems exist within the NGO sector.  NGOs in Guatemala rely on a large body of foreign volunteers who work for somewhere from a few weeks to a few years before returning home or jetting off to their next volunteering destination.  NGOs also competitively recruit local health care providers for salaried work, but simultaneously suffer frequent budget crises due to ebbs in international financing.  The result is that NGO personnel, including staff who have been trained in VIA, tend to hop entrepreneurially from one NGO job to the next, or, if they are foreign volunteers, relocate when their stint of service is over.

If VIA were a trivial skill, staff turnover would not raise serious concerns.  However, practicing VIA can be quite complex; the position, color, elevation, vascularity, and size of a lesion are all findings that guide a practitioner’s decision to recommend treatment or referral.  As such, practitioners of VIA typically participate in a 3-5 day training course and must see somewhere from 50-100 patients under supervision before they feel comfortable performing the exam on their own.  Most VIA instructors and providers whom I spoke with agreed that regular practice is necessary to maintain one’s “clinical eye,” and furthermore suggested that refresher courses would be beneficial for VIA practitioners.

Contrary to popular beliefs that “anyone can do the vinegar test,” VIA is a specialized technique that requires training and potentially follow-up training, and it is for this reason that staff turnover creates important problems.  First, when staff trained in VIA take on new jobs in which they no longer practice VIA, they lose their clinical skills, which translates to an inefficient use of limited training resources.  Second, if screening posts are constantly being filled with novice VIA practitioners, the quality of services is dramatically lowered.  Third, if new staff are not trained as replacements, VIA programming often stops.  For government health facilities, this may translate to a temporary—and sometimes prolonged—lull in offering VIA exams until the new women’s health nurse can be trained.  Additionally, numerous NGOs I encountered had raised initial seed money to train staff in VIA.  Once those staff members left for other jobs, the NGOs lacked funds to train others in the technique, which curtailed their screening programs.  “We’d love to have a VIA program again, because it’s so important.  But we just haven’t had the funds to train someone else,” one program director lamented to me after their examiner left for another NGO job.

The quality and regulation of VIA training is another serious issue that merits attention at the global scale.  In Guatemala, VIA courses are offered by the Ministry of Health and NGOs.  The Ministry of Health trains its own personnel, while NGOs train a mixture of their own staff, foreign volunteers, lay health promoters and midwives, and Ministry of Health nurses and physicians.  Some courses rigorously adhere to VIA educational materials developed by JHPIEGO, the Johns Hopkins University Affiliate that designed the global gold standard of VIA training courses.  Other courses last for two or three days and offer only a didactic theoretical training, with no period of clinical supervision.  Although students are supposed to be evaluated through written and practical examinations, trainees who do not officially pass VIA courses can go on to practice VIA because there is no regulatory system preventing them from doing so.


A nurse at a VIA-training course points out cervical abnormalities in front of the class of trainees.

A nurse at a VIA-training course points out cervical abnormalities in front of the class of trainees.


Generally, health care practitioners accepted the quality of VIA courses delivered by two relatively large and well-known NGOs, but described “serious misgivings” about other NGO and government training sessions.  Health care providers described witnessing problems such as examiners using inadequate light sources or no light source at all during exams; sniffing acetic acid to determine its concentration; and manipulating the cervix with tongue depressors that obstructed their vision.  “You wonder what kind of training are they even getting,” one physician, who runs a training course herself, told me, describing her interactions with nurses and health promoters who had been certified in VIA by a visiting medical mission that had since left the country.  Other interviewees reported seeing women whose cervixes had been severely burned by undiluted acetic acid during VIA exams gone awry.  Unnecessary referrals from groups that lacked cryotherapy equipment were also cause for questioning training quality.  “The majority of the women referred to us for cryotherapy didn’t even have lesions,” one NGO VIA program director remarked, frustrated with “poorly-trained practitioners” from government facilities and other NGOs.

Staff turnover and training quality are two important issues that must be considered in implementation of VIA screening worldwide.  The ideal VIA examiner is a well-trained and confident practitioner who regularly practices the skill.  How can governments, NGOs, and local practitioners work together to ensure that that is the rule, rather than the exception?

In Guatemala, some conscientious and dedicated government clinics and NGOs have overcome these problems through strategic long-term planning and budgeting; periodic supervision of VIA practitioners by experienced clinicians; short refresher courses for certified VIA practitioners; and employing former trainees in teaching subsequent VIA courses.  The Ministry of Health has additionally formed a coalition with NGOs to work on a Comprehensive National Cervical Cancer Program, which seeks to standardize and establish regulatory measures for VIA training course curricula.

VIA-cryotherapy programs are growing worldwide, and staff turnover and the quality of training courses will continue to be important challenges to the success of these initiatives in a variety of contexts.  Even relatively low-resource global health technologies require a great deal of infrastructure, planning, and regulation, and these will be the keys to ensuring quality screening services for women across the globe.

One Comment

  1. Peter Thompson
    Posted Aug. 24, 2013 at 12:16 | Permalink

    Just bumped into your article….well done as usual. Are you back to school soon?

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