Atlas of visual inspection of the cervix with acetic acid for screening, triage, and assessment for treatment

VIA has several limitations, and the most important among them is the subjective nature of the test. The test performance is highly dependent on the skill and experience of the test provider. Appropriate training and periodic refresher courses for the test providers are absolutely critical for the test to achieve the desired impact. It is very challenging to ensure the quality of such an observer-dependent test in a programmatic setting where a large number of providers are performing the test.

The limitations of VIA are the following:

• The specificity (the ability of the test to correctly identify the true negatives, i.e. those without cervical precancer or cancer) is low. This may lead to unnecessary referrals, overtreatment, and adverse psychological consequences to the women.
• The subjective nature of the test demands rigorous training and periodic refresher courses for the providers.
• VIA detects lesions that are present on the ectocervix only; it has a limited accuracy in postmenopausal women and women older than 49 years.
• The test performance is highly variable because of its subjective nature. In some settings, the sensitivity may be very low.
• Ensuring quality is difficult, because the images of the cervix are not documented in conventional VIA.

The next section discusses VIA as a test to triage women positive on the HPV test.