title: Direct visual inspection for cervical cancer screening: an analysis of factors influencing test performance.
abstract: BACKGROUND
  The authors evaluated direct visual inspection of the cervix after the application of 5% acetic acid (DVI) as a cervical cancer screening test for use in low-resource settings.
  
  
  METHODS
  Four tests were used to screen 2754 previously unscreened women: DVI with and without x4.5 magnification and differentiating between all lesions and well-circumscribed lesions; testing for high-risk types of human papillomavirus DNA using the Hybrid Capture II assay, cervical cytology, and Cervicography. Women with positive results on any of the four screening tests were referred for colposcopy and histologic sampling. All women were tested for N. gonorrhea, C. trachomatis, T. vaginalis, and human immunodeficiency virus 1.
  
  
  RESULTS
  Histologically confirmed carcinoma was diagnosed in 21 women (0.8%), high-grade squamous intraepithelial lesions (SILs) were diagnosed in 96 women (3.5%), and low-grade SILs were diagnosed in 102 women (3.7%). The estimated sensitivity of DVI when performed without magnification for high-grade SILs was 70%, with an estimated specificity of 79%. Magnification did not significantly improve sensitivity for high-grade SILs (74% with magnification) but significantly reduced specificity (77%). Restricting the definition of a positive DVI test to a well-defined acetowhite lesion reduced sensitivity and significantly improved specificity. Infection with T. vaginalis, N. gonorrhea, and C. trachomatis did not alter sensitivity or specificity.
  
  
  CONCLUSIONS
  This study confirmed the utility of DVI as a primary screening test. Evaluation of the clinical effectiveness of screening with this low-cost and simple test in low-resource settings is necessary.
authors.affiliation: Department of Obstetrics and Gynecology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
authors.forename: Lynette
authors.initials: L
authors.lastname: Denny
authors.forename: Louise
authors.initials: L
authors.lastname: Kuhn
authors.forename: Amy
authors.initials: A
authors.lastname: Pollack
authors.forename: Thomas C
authors.initials: TC
authors.lastname: Wright
mesh_terms: D019342:Acetic Acid; D000328:Adult; D000368:Aged; D002294:Carcinoma, Squamous Cell / Q000175:diagnosis* / Q000473:pathology; D003127:Colposcopy; D004279:DNA, Viral; D005260:Female; D006801:Humans; D008403:Mass Screening; D008875:Middle Aged; D015588:Observer Variation; D030361:Papillomavirus Infections / Q000150:complications; D010808:Physical Examination; D012307:Risk Factors; D012680:Sensitivity and Specificity; D014412:Tumor Virus Infections / Q000150:complications; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis* / Q000473:pathology; D014626:Vaginal Smears; D002578:Uterine Cervical Dysplasia / Q000175:diagnosis* / Q000473:pathology
chemical_list: D004279:DNA, Viral; D019342:Acetic Acid