title: Evaluation of a cervicography-based program to ensure quality of visual inspection of the cervix in HIV-infected women in Johannesburg, South Africa.
abstract: OBJECTIVE
  To determine whether a quality assurance (QA) program using digital cervicography improved the performance of a visual inspection with acetic acid (VIA) to detect cervical intraepithelial neoplasia grade 2 or worse (CIN 2+) in HIV-infected women in Johannesburg, South Africa.
  
  
  METHODS
  Visual inspection with acetic acid was performed among HIV-infected women, aged 18 to 65 years, in Johannesburg, South Africa. Nurses received 2 weeks of training on the VIA procedure. The VIA interpretation was performed in real time. The VIA results were then photographed using a retail available digital camera. A gynecologist and medical officer reviewed the VIA digital images within 2 weeks of the procedure. Colposcopic biopsy was performed on all women with positive VIA and 25% negative VIA results. Sensitivity and specificity of VIA for the detection of CIN 2+ were compared between the nurses and physicians at the beginning and at the end of the study.
  
  
  RESULTS
  Positive VIA results were found in 541 (45%) of the 1,202 participating women. The sensitivity of VIA to predict CIN 2+ was improved from 65% to 75% (p = .001) with the addition of digital cervicography and specialist review. There was no statistical difference in the sensitivity of the VIA readings when comparing the first 600 participants to the final 593 participants between the nurses (p = .613) and physicians (p = .624).
  
  
  CONCLUSIONS
  Quality assurance performed by specialists using digital cervicography improved the sensitivity of VIA. There was no difference in sensitivity in interpreting VIA between the beginning and the end of the study. Quality assurance should form a cornerstone of any VIA program to improve sensitivity in detecting CIN 2+ lesions.
authors.affiliation: 1Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand; and 2Right to Care, Johannesburg, South Africa; 3Gillings School of Public Health, University of North Carolina, Chapel Hill, NC; 4Centre for HIV and STIs, National Institute of Communicable Diseases (National Health Laboratory Service); and 5University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa.
authors.forename: Cynthia
authors.initials: C
authors.lastname: Firnhaber
authors.forename: Lu
authors.initials: L
authors.lastname: Mao
authors.forename: Simon
authors.initials: S
authors.lastname: Levin
authors.forename: Mark
authors.initials: M
authors.lastname: Faesen
authors.forename: David A
authors.initials: DA
authors.lastname: Lewis
authors.forename: Bridgette J
authors.initials: BJ
authors.lastname: Goeieman
authors.forename: Avril J
authors.initials: AJ
authors.lastname: Swarts
authors.forename: Ntombiyenkosi
authors.initials: N
authors.lastname: Rakhombe
authors.forename: Pam M
authors.initials: PM
authors.lastname: Michelow
authors.forename: Sophie
authors.initials: S
authors.lastname: Williams
authors.forename: Jennifer S
authors.initials: JS
authors.lastname: Smith
mesh_terms: D019342:Acetic Acid; D003127:Colposcopy / Q000379:methods*; D005260:Female; D015658:HIV Infections / Q000150:complications*; D006801:Humans; D061848:Optical Imaging / Q000379:methods*; D011785:Quality Assurance, Health Care / Q000379:methods*; D012680:Sensitivity and Specificity; D013019:South Africa; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis*; D002578:Uterine Cervical Dysplasia / Q000175:diagnosis*
chemical_list: D019342:Acetic Acid