A Pragmatic Transition: Positioning VIA and HPV in India’s Roadmap to Cervical Cancer Screening
Subhadra Goala, Joyita Dey, Michael Petros, Priyansh Nathani, Foram Gandhi, Anita GadgilPURPOSE
India bears a disproportionate burden of cervical cancer, accounting for nearly one-fifth of global new cases, yet fewer than 2% of eligible women have ever been screened. While HPV DNA testing represents the future of cervical cancer screening, the rapid displacement of Visual Inspection with Acetic Acid (VIA) risks undermining existing coverage before adequate infrastructure exists. This paper argues for a phased, equity-focused transition that retains VIA as a complementary strategy during scale-up of HPV-based screening.
METHODS
This commentary draws on field observations from primary health centers and community settings in Cachar, Assam, a low-resource district in Northeast India. Qualitative insights were gathered through direct engagement with frontline ANM (Auxiliary Nurse Midwife) workers, community health workers (ASHAs), and program implementers. Observations were contextualized within a review of national programmatic data, WHO guidelines, and peer-reviewed literature on cervical screening strategies in low- and middle-income countries.
RESULTS
Field observations identified critical structural and socio-cultural barriers to both VIA and HPV-based screening. VIA implementation is constrained by inadequate facility infrastructure, subjective interpretation, lack of permanent records for quality control, and gendered decision-making dynamics that undermine same-day treatment, the core advantage of the screen-and-treat approach. Concurrently, HPV testing readiness remains uneven: laboratory capacity, cold-chain logistics, skilled technician retention, and community-level counseling infrastructure are prerequisites not yet uniformly met. Socio-cultural barriers specific to HPV, including stigma linked to sexual transmission and fear of cancer diagnosis, further complicate uptake and follow-up. Notably, combining VIA with Visual Inspection with Lugol's Iodine (VILI) improves specificity and reduces inter-observer variability, offering a viable triage tool for HPV-positive women where colposcopy is unavailable.
CONCLUSION
A uniform, timeline-driven shift to HPV testing risks widening screening gaps in low-readiness districts. India requires a readiness-guided, phased transition in which VIA and VILI serve complementary roles while HPV infrastructure is systematically built. Embedding screening within existing NCD platforms, leveraging digital registries modelled on Ni-kshay, and mobilizing the existing frontline workforce offers a scalable, equitable pathway toward the WHO 90-70-90 elimination targets.