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Cervical Cancer in Guatemala: Using Visual Inspection with Acetic Acid
Screening to Reduce Incidence of and Mortality from Cervical Cancer
Zachary Klock
Sidney Kimmel Medical College at Thomas Jefferson University
Abstract
Guatemala is a developing nation of nearly 16 million in Central America.
Among the many health problems the nation suffers, cervical cancer
remains a leading cause of cancer-related death. Cervical cancer, an
easily detectable cancer, predominantly affects women in developing
nations. Traditional cytology techniques have been used to screen women
in the country for over 25 years, but less than 10% of the Guatemalan
population is screened. The Visual Inspection with Acetic Acid (VIA) is a
simple produce that uses acetic acid to visualize precancerous cervical
lesions and has been proven to be more effective in resource-poor
settings. The screening is less financially burdensome, requires basic
supplies and fewer trained professionals, and can be performed and
treated in one single visit. While Guatemala has implemented VIA
screening in high-burden areas, it is critical that the nation expand
screening programs so that more women have access to treatment.
Screening Technique
VIA in Guatemala
• 
Traditional cytology (Papanicolaou smear) requires more
infrastructure, many trained personnel and separate visits for
screening, receiving results and treatment.
• 
Over 90% of rural Guatemalan women in the pilot study agreed to the
VIA, indicating no clear cultural beliefs that would make widespread
VIA screening difficult.
• 
Visual Inspection with Acetic Acid (VIA) involves visual inspection for
A
damage
followed by placing acetic acid or Lugol’s iodide to visualize
precancerous lesions, which turn white (Figure 2).5
• 
The Cervical Cancer Regional Strategy and Plan of Action introduced
VIA screening to 8 “high burden” health areas in Guatemala in 2008.8
• 
In 2010, 214,046 cervical cancer screenings were performed in
Guatemala. 61% used VIA and 49% of women were treated in the
same visit.8
• 
In San Mateo, Quetzaltenango, Guatemala, only 5.0% of the eligible
population was screened in the first 38 weeks of 2014 (Table 1).
Table 1. 2014 rate of VIA screening through September 19
in San Mateo, Guatemala.
Background
• 
• 
Guatemala is a nation of 16 million people
54% of the population lives below the national poverty line.
Figure 1. Global Distribution
of Cervical Cancer in 2002.
Over 80% of cervical cancer
deaths occur in developing
nations. (Modified from rho.org)
• 
• 
• 
• 
• 
Cervical cancer is the most common cancer in Guatemalan women,
occurring in 17 per 100,000 women.1
In 2005, less than 10% of Guatemalan women were screened.1
In 2013, the Guatemalan Ministry of Health reported 496 cases of
cervical cancer.2
In Latin America, a recent doctor’s visit, increased education and more
money all correlate to more preventative measures and a recent Pap
smear.3
A woman screened once in her lifetime reduces the risk of cervical
cancer by 25-36%4
VIAs performed
Female Population
% Screened
94
1878
5.0%
Conclusions and Recommendations
Figure 2. A normal and precancerous cervix. A is a normal
cervix and B is a cancerous cefvix as evidenced by the white
spot. (Modified from Rao).6
• 
A person trained in VIA screening correctly identified precancerous
lesions 45-79% of the time. This is comparable to traditional
cytology techniques. Specificity, however, is lower in VIA.7
Some Advantages of VIA 5
Basic supplies
Less financially burdensome
Fewer trained personnel needed
Training is simple
Laboratory is not necessary
“Screen and Treat”
• 
VIA is an effective method for screening for cervical cancer in
resource-poor settings, including Guatemala.
• 
Expand VIA screening in Guatemala and develop a specific budget for
these screenings, which does not currently exist
• 
Explore the possibility of using the HPV vaccine, which the government
has expressed interest in.8
• 
Address the social determinants of health underlying poor screening
including education, specifically about preventative medicine and STIs,
and access to health centers, especially in the rural areas.
References
1.  Mathers, L.W., et al. (2005). Screening for cervical neoplasia in an unselected rural Guatemalan population using direct
visual inspection after acetic acid application: a pilot study. Journal of Lower Genital Tract Disease 9 (4): 232-235.
2.  Guatemala Ministry of Public Health www.mspas.gob.gt
3.  Soneji, S. and Fukui, N. (2013). Soceioeconomic determinants of cervical cancer screening in Latin America.
Rev Panam. Salud Publica 33 (3): 174-182.
4.  Goldie, S.J., et al. (2005). Cost effectiveness of cervical screening in five developing countries. NEJM.
5.  Cervical Cancer Action Coalition. New options for cervical cancer screening and treatment in low-resource settings.
6.  Rao, S.J. World J. Obstet. Gynecol. 2012 Dec 10. 1 (4): 46-54.
7.  Sankaranaravanan, R., et al. (2013). Effective screening programmes for cervical cancer in low- and middle-income
developing countries. Bulletin of the WHO 79 (10): 954-962.
8.  Pan American Health Organization. (2011). Preventing Cervical Cancer in Latin America.
9.  Pan American Health Organization. (2010). Cervical cancer prevention and control programs.