when universal coverage has been achieved and/or more
resources become available. VIA can serve as a platform for
building screening programmes where they do not exist or
where only limited coverage has been attained, and then
substituting better tests when they become available and
affordable.
Having such programmes serves several purposes beyond
helping the women who directly benefit from the screening. It
increases awareness among policy-makers, since it generates
data about the disease burden that has been hidden up to
now and about the availability of feasible interventions. It
demonstrates to health workers and to women in the
community that cervical cancer is preventable and that
women's health and self-care are important to society. This
message has the potential to inspire wider understanding
about the possibility of reducing mortality from other cancers
(like breast and prostate) through early detection
programmes and the role of self-care for other NCDs. It
provides an opportunity to make adjustments to the HIS for
better programme monitoring and to strengthen referral and
specialty care systems. The lessons learned from establishing
a national cervical cancer screening programme using lowcost technology like
VIA can be applied to other cancer and
NCD screening and management programmes, such as those
for breast cancer, diabetes and hypertension.
On the clinical side, training for VIA and cryotherapy
enhances capacity for pelvic evaluation and gynecological
treatment. These skills will be required even when molecular
testing is introduced and they can serve as a foundation for
adding related skills for identifying and managing other
gynecologic conditions like sexually transmitted infections,
cervicitis and uterine prolapse. As noted earlier, VIA can play
an important role in the evaluation of women who are HPV
positive in terms of treatment options.
Finally, screening programmes based on VIA can provide
critical data on the impact of HPV vaccine. Even without
type-specific information, such programmes can generate
baseline rates on cervical precancer in the near term and
later show the extent and timing of a decline in HPV-related
disease. Such data can bolster national commitments to
vaccination programmes so that investments are sustained.
Conclusions
Substantial progress has been made in laying a foundation of
evidence, clinical capacity resources, awareness and
commitment to cervical cancer screening in low- and middleincome settings. We
are now poised for significant advances
in both coverage and impact. Unlike HPV vaccination, which
will require decades to reap the benefits, we have evidence
that VIA-based programmes with adequate precancer
treatment can lead to notable reductions in cervical cancer
mortality in just a few years. While VIA, by its nature, is an
imperfect tool, it is still very useful both as a starting point
and as an adjunct method as better tools become available.
The VIA platform is well suited to the needs of low-resource
settings and deserves continued and even expanded support.
The investments that are made in scaling up the use of VIA
will continue to pay dividends even when better screening
tools become more widely available. l
Professor Vivien Davis Tsu is Associate Director of PATH's
Reproductive Health Global Program and Director of its Cervical
Cancer Prevention project. She is an affiliate Professor of
Epidemiology at the University of Washington (UW). Dr Tsu
holds an MPH from UCLA and a PhD in epidemiology from the
University of Washington. Over the past 20 years she has
conducted studies to validate new screening methods for
cervical cancer like visual inspection and practical strategies like
screen-and-treat in low-resource settings. She headed a team at
PATH that collected ground-breaking data on the feasibility of
delivering HPV vaccine to young adolescent girls in low-income
countries.
Dr Jose Jeronimo is a gynaecological oncologist and the senior
adviser for women's cancers at PATH. Dr Jeronimo received his
MD in Peru in 1989 and subsequently received specialty
training in gynecologic oncology at the National Cancer
Institute in Peru. Dr Jeronimo served six years as staff scientist
at the division of cancer epidemiology and genetics from the US
National Cancer Institute. During his tenure at PATH he has led
projects to evaluate new cervical cancer screening tests and
treatment options for low-resource settings and a standardized
training curriculum for teaching VIA and cryotherapy that has
been used in Latin America.
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