ABCD criteria to improve visual inspection with acetic acid (VIA) triage in HPV-positive women: a prospective study of diagnostic accuracy

Abstract

Objectives: A simple system for visual inspection with acetic acid assessment, named ABCD criteria, has been developed to increase accuracy for triaging of high-risk human papillomavirus (HPV)-positive women. This study aimed to determine the accuracy of ABCD criteria for the detection of histologically confirmed cervical intraepithelial neoplasia grade two or worse (CIN2+) in HPV-positive women living in a low-resource setting.

Design: Prospective study of diagnostic accuracy.

Setting: Cervical cancer screening programme based on a 3T-Approach (test, triage and treat) in the Health District of Dschang, West Cameroon.

Participants: Asymptomatic non-pregnant women aged 30-49 years were eligible to participate. Exclusion criteria included history of CIN treatment, anogenital cancer or hysterectomy. A total of 1980 women were recruited (median age, 40 years; IQR 35-45 years), of whom 361 (18.4%) were HPV-positive and 340 (94.2%) completed the trial.

Interventions: HPV-positive women underwent a pelvic examination for visual assessment of the cervix according to ABCD criteria. The criteria comprised A for acetowhiteness, B for bleeding, C for colouring and D for diameter. The ABCD criteria results were codified as positive or negative and compared with histological analysis findings (reference standards).

Primary outcome measure: Diagnostic performance of ABCD criteria for CIN2+, defined as sensitivity, specificity, negative and positive predictive values.

Results: ABCD criteria had a sensitivity of 77.5% (95% CI 61.3% to 88.2%), specificity of 42.0% (95% CI 36.5% to 47.7%), positive predictive value of 15.1% (95% CI 10.8% to 20.8%), and negative predictive value of 93.3% (95% CI 87.6% to 96.5%) for detection of CIN2 +lesions. Most (86.7%) of the ABCD-positive women were treated on the same day.

Conclusions: ABCD criteria can be used in the context of a single-visit approach and may be the preferred triage method for management of HPV-positive women in a low-income context.

Trial registration number: NCT03757299.

Keywords: community gynaecology; education & training (see medical education & training); gynaecological oncology; preventive medicine; public health.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1

ABCD criteria for VIA interpretation in HPV-positive women. Criterion (A) Acetowhite area touching the transformation zone (absent on the native view and apparent after acetic acid application) is considered positive. Criterion (B) Bleeding without touching or after lightly touching (with a swab or speculum) the cervix is considered positive. Criterion (C) (optional)—colouring with VILI contributes to confirmation or identification of a faint acetowhite lesion. Criterion (D) Diameter of >5 mm (about the size of a pencil eraser) in an acetowhite area is considered positive. ABCD, acetowhiteness, bleeding, colouring and Diameter; diameter; HPV, human papillomavirus; VIA, visual inspection with acetic acid; VILI, visual inspection with Lugol’s iodine.

Figure 2

Flow chart of participants for the 3T-Approach in Cameroon. ABCD, acetowhiteness, bleeding, colouring and diameter; HPV, human papillomavirus.