Is VIA Still Relevant for Mass Cervical Cancer Screening? A Systematic Review and Meta-Analysis

Abstract

Introduction: Visual inspection with acetic acid (VIA) remains in use in cervical cancer screening programmes in several resource-limited settings. However, the expansion of high-risk HPV testing as the preferred primary screening method and the continuing role of cervical cytology (Pap smear) require a reassessment of VIA. This study aimed to estimate the sensitivity and specificity of VIA based on available diagnostic-accuracy studies.
Methods: This systematic review followed PRISMA 2020 and the Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy. Studies evaluating VIA as a screening method against an adequate reference standard were eligible. Multiple electronic databases and additional sources were searched without language or publication-year restrictions. Data were analysed using Meta-DiSc 1.4 and RevMan 5.4. The review was registered in PROSPERO (CRD42025645024).
Results: Fourteen articles with 17 study arms were included in the systematic review. Thirteen articles comprising 16 study arms and 65,359 participants provided adequate 2 × 2 data for quantitative synthesis. Recalculation yielded a pooled sensitivity of 75.5% (95% CI 73.7–77.2%) and a pooled specificity of 82.9% (95% CI 82.6–83.2%). Heterogeneity was very high, reflecting differences in populations, reference standards, target-disease thresholds, and verification procedures.
Discussion: VIA shows moderate diagnostic accuracy, but substantial heterogeneity and risk of bias limit generalisability and do not support its designation as the preferred primary method for mass screening on the basis of this analysis alone. In health systems undergoing transition, VIA may remain a contextual option or triage test where HPV testing is not yet uniformly available. High-risk HPV testing remains the preferred primary screening method, while Pap smear cytology retains a role in quality-assured cytology programmes and in triage algorithms. Screening strategies should be selected according to health-system capacity, quality assurance, follow-up, and access to treatment.