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Performance of alternative strategies for primary cervical cancer screening in sub-Saharan Africa: systematic review and meta-analysis of diagnostic test accuracy studies

BMJ 2015; 351 doi: (Published 03 July 2015) Cite this as: BMJ 2015;351:h3084
  1. Joël Fokom-Domgue, research fellow12,
  2. Christophe Combescure, senior scientist3,
  3. Victoire Fokom-Defo, clinical trial monitor4,
  4. Pierre Marie Tebeu, associate professor1,
  5. Pierre Vassilakos, senior scientist5,
  6. André Pascal Kengne, associate professor6,
  7. Patrick Petignat, professor2
  1. 1Department of Gynecology and Obstetrics, Faculty of Medicine and Biomedical Sciences, University of Yaoundé, Yaoundé, Cameroon
  2. 2Division of Gynecology, Department of Gynecology and Obstetrics, Geneva University Hospitals, 1211 Geneva 14, Switzerland
  3. 3Division of Clinical Epidemiology, Geneva University Hospitals, Geneva, Switzerland
  4. 4Division of Infectious and Chronic Diseases, Department of Internal Medicine, Yaoundé Central Hospital, Yaoundé, Cameroon
  5. 5Geneva Foundation for Medical Education and Research, Geneva, Switzerland
  6. 6South African Medical Research Council and University of Cape Town, Cape Town, South Africa
  1. Correspondence to: J Fokom-Domgue fokom.domgue{at}
  • Accepted 21 May 2015


Objective To assess and compare the accuracy of visual inspection with acetic acid (VIA), visual inspection with Lugol’s iodine (VILI), and human papillomavirus (HPV) testing as alternative standalone methods for primary cervical cancer screening in sub-Saharan Africa.

Design Systematic review and meta-analysis of diagnostic test accuracy studies.

Data sources Systematic searches of multiple databases including Medline, Embase, and Scopus for studies published between January 1994 and June 2014.

Review methods Inclusion criteria for studies were: alternative methods to cytology used as a standalone test for primary screening; study population not at particular risk of cervical cancer (excluding studies focusing on HIV positive women or women with gynaecological symptoms); women screened by nurses; reference test (colposcopy and directed biopsies) performed at least in women with positive screening results. Two reviewers independently screened studies for eligibility and extracted data for inclusion, and evaluated study quality using the quality assessment of diagnostic accuracy studies 2 (QUADAS-2) checklist. Primary outcomes were absolute accuracy measures (sensitivity and specificity) of screening tests to detect cervical intraepithelial neoplasia grade 2 or worse (CIN2+).

Results 15 studies of moderate quality were included (n=61 381 for VIA, n=46 435 for VILI, n=11 322 for HPV testing). Prevalence of CIN2+ did not vary by screening test and ranged from 2.3% (95% confidence interval 1.5% to 3.3%) in VILI studies to 4.9% (2.7% to 7.8%) in HPV testing studies. Positivity rates of VILI, VIA, and HPV testing were 16.5% (9.8% to 24.7%), 16.8% (11.0% to 23.6%), and 25.8% (17.4% to 35.3%), respectively. Pooled sensitivity was higher for VILI (95.1%; 90.1% to 97.7%) than VIA (82.4%; 76.3% to 87.3%) in studies where the reference test was performed in all women (P<0.001). Pooled specificity of VILI and VIA were similar (87.2% (78.1% to 92.8%) v 87.4% (77.1% to 93.4%); P=0.85). Pooled sensitivity and specificity were similar for HPV testing versus VIA (both P≥0.23) and versus VILI (both P≥0.16). Accuracy of VIA and VILI increased with sample size and time period.

Conclusions For primary screening of cervical cancer in sub-Saharan Africa, VILI is a simple and affordable alternative to cytology that demonstrates higher sensitivity than VIA. Implementation studies are needed to assess the effect of these screening strategies on the incidence and outcomes of cervical cancer in the region.


  • The fellowship of JF-D at the maternity of Geneva University Hospitals was supported by the Federal Commission for Scholarships for Foreign Students.

  • Contributors: JF-D designed the study, formulated the research question, and identified PICOS components. JF-D and VF-D performed the literature searches, designed the data extraction form, and performed data extraction. JF-D and CC analysed the data. JF-D and VF-D wrote the paper. APK, CC, PP, PV, and PMT critically reviewed subsequent drafts. JF-D is the guarantor.

  • Funding: Statistical analyses were funded by the International Solidarity of Geneva. However, researchers are fully independent from funders. The organisation that financed statistical analyses did not have a role in study design, data collection, data analysis, data interpretation, and writing of the manuscript. The corresponding author had the final responsibility for the decision to submit the report.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: support from the International Solidarity of Geneva for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not required.

  • Data sharing: Details of how to obtain additional data from the study (technical appendix, statistical code and dataset) are available from the corresponding author at fokom.domgue{at}

  • The lead author (the manuscript’s guarantor) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

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