VIAC and how it works

Visual Inspection with Acetic Acid and Camera, or VIAC, is an effective way to prevent cervical cancer in women age 30-50 years old. It involves examining the opening of the womb, or the cervix, for changes that might lead to cancer. If these changes are detected early, the cells can be eliminated before they become cancerous. The cells are usually removed using a method called cryotherapy, or another method called LEEP. Both treatments are briefly described below.

VIAC examinations can also reveal possible advanced cervical cancer and certain noncancerous conditions such as chronic cervitis, pelvic inflammatory disease, and cervical polyps.

Visual inspection with acetic acid and treatment using cryotherapy or LEEP has been well-studied and is endorsed by the World Health Organization. WHO recommends using this “screen-and-treat” approach as an effective, low-cost way to reduce the incidence of cervical cancer in low-income countries. The disease is caused by the human papillomavirus (HPV), and it is the leading cancer killer of women in Zimbabwe and other sub-Saharan African countries.

The Zimbabwe Ministry of Health and Child Care has an established cervical cancer prevention program that offers VIAC screening and treatment at several of the nation’s major hospitals.

The VIAC procedure

  • VIAC begins by swabbing the cervix with a vinegar-like solution of dilute acetic acid.
  • If precancerous cells are present, the vinegar-like solution turns the abnormal cells white. This portion of the exam is the VIA—”visual inspection with acetic acid”—in VIAC.
  • Next, a camera with a special lens is used to photograph the cervix. The photo helps identify the presence of abnormal, precancerous cells.

Figure 1. Left, the location of the cervix in the body. Right, a photo of a healthy cervix taken during a VIAC examination at St. Albert’s Mission Hospital.

Cervical cancer arises in the transformation zone of the cervix

The opening of the cervix is a place where two different types of cells meet. The cells that line the cervical canal (the “endocervix”) are tall, narrow, columnar epithelial cells. The cells that cover the surface of the cervix (the “ectocervix”), on the other hand, are squamous epithelial cells, which are very flat.

The place where the columnar cells meet the squamous epithelium is called the transformation zone. Cell division occurs at this junction, and it is in this junction that cervical cancer

Figure 2. This photo of a cervix taken during a VIAC examination at St. Albert’s shows the white patches formed by precancerous cells.

occurs. Abnormal cells can arise here spontaneously or they can be induced by exposure to carcinogens such as certain strains of hPV or the chemicals produced during tobacco use. If these abnormal cells are not cleared by the immune system, they can progress to cervical cancer.

Why precancerous cells appear white after swabbing with dilute acetic acid

When precancerous cells arise, they have particular characteristics. They have larger nuclei and less cytoplasm, which is evidence of increased cell division (i.e., mitosis). When the cervix is swabbed with dilute acetic acid, the acid denatures the proteins in the precancerous cells, causing them to clump. It also dehydrates the cells. Light cannot penetrate these dense cells and instead is reflected back, making the cells appear white.

Figure 3. Photo taken during a VIAC examination at St. Albert’s showing a cervix with suspected cervical cancer. A definite diagnosis of cervical cancer requires further study of the tissue.

A nurse trained in VIAC can perform the screening exam, but if the exam reveals precancerous changes, possible cancer, or an inconclusive finding, the patient must be seen by a doctor for further care. If the precancerous cells are detected early enough, they are removed using either cryotherapy or LEEP, depending on their extent.

Cervical cancer develops over many years, passing through several stages. The earliest of these is the period in which abnormal cells are present but not yet cancerous. This precancerous stage is called cervical intraepithelial neoplasia (CIN). It is divided into three parts according to the degree of change present in the abnormal cells: CIN 1, CIN 2, and CIN3.

  • CIN 1: The cells are mildly abnormal; they are not treated because they often clear up when left alone;
  • CIN 2: The cells are moderately altered;
  • CIN 3: The cells show a severe degree of change.

Women identified through VIAC screening as having CIN 2 and CIN 3 stage precancer should receive treatment, usually using cryotherapy or LEEP.

Cryotherapy

Cryotherapy, also called cryocautery, destroys precancerous cells by freezing them with ice-cold gas. It is used when the acetic-acid-induced white areas cover less than 75% of the ectocervix and do not extend into the endocervix. It is a simple outpatient procedure, and clients can go home the same day.

Note: After cryotherapy, a disharge from the vagina might continue for two to four weeks. It is generally a mild discharge and does not need treatment.  But if it persists, the woman should see a doctor and a vaginal swab taken for culturing.

LEEP (Loop Electrical Excision Procedure)

LEEP removes abnormal areas from the cervix using a thin heated electrical wire that is  passed through transformation zone. It is done under local anesthetic on outpatient basis. The affected tissue is sent for histological review. The margin of the excision is coagulated during the procedure, resulting in minimal bleeding. LEEP is used when the white areas cover more than 75% of the transformation zone or extend into the endocervix.

Both treatments have a healing period of two to four weeks, with certain restrictions on a woman’s activity during that time. Complete healing generally takes about a month.

A few women might experience after-effects that must be treated at a health facility. Following either procedure, a woman should return to the treatment location after about six weeks to be checked and to receive her laboratory report.

After any of these treatments

  • Ask the doctor or nurse what to expect during the period of healing. Should you expect a discharge and how long will it last?
  • What activities is it OK for you do and what activities should you avoid?
  • What signs should you watch for that tell you you should return to the doctor?

24 Responses to VIAC and how it works

  1. Tatenda says:

    where can I buy the VIAC equipment

  2. Miriam Chadzingwa says:

    Introduction of VIAC has helped many women in Zimbabwe but however, it will be more effective if LEEP will be readily available just like cryotherapy

  3. Darrell says:

    You must be a physician to perform VIAC.

  4. mercy magava says:

    Where can I get viac treatment in bulawayo and for how much

  5. Darrell says:

    In Bulawayo, VIAC (Visual Inspection with Acetic acid and Cervicograph) is available at United Bulawayo Hospitals, Monday to Friday, according to their website. Their phone numbers is 263.09.252111. I hope this is helpful…Darrell

  6. kundai says:

    For how long will it take for the discharges to clear after cryotherapy

  7. Darrell Ward says:

    Dear Kundai – I am sorry that I hadn’t helped you sooner. I hope you are keeping well and the discharges have stopped. Here is what I learned: After cryotherapy, disharge may continue for two to four weeks. It is generally a mild discharge and does not need treatment. But if it persists, you need to see a doctor. A vaginal swab should be taken for culturing. I hope this is still of some help.
    …Darrell

  8. edmond mupesi says:

    Where is good viac clinic in harare or where is good viac clinic in zimbabwe

  9. Darrell Ward says:

    We suggest that you visit Wilkins Hospital in Harare. I am told that they do trainings in VIAC and that they do VIAC well. If you do visit that clinic, please write us again and let us know if you had a good experience there. Thank you…Darrell

  10. Yvonne says:

    Where can i do viac in pretoria

  11. Florence Moyo says:

    Where do l get LEEP and Cryotherapy in Zimbabwe

  12. Darrell Ward says:

    Any of the provincial hospital or the main hospitals that offer VIAC screening should be able to treat pre-cancerous changes with either cryotherapy or LEEP. Which method they use usually depends on the extent of the changes. If you go for treatment, please write again and let us know what your experience was like.

  13. Darrell Ward says:

    I am sorry, but we are not familiar with VIAC screening in South Africa. However, South Africa issued National Guidelines on Cervical Cancer Screening some years ago, so the government is working to prevent cervical cancer. I suggest you check with your local hospital or with a main or government hospital. You might also ask a local midwife or an ob/gyne, if you have access to one. If the first few people you ask cannot answer your question, please don’t give up. Cervical screening is too important for a woman’s health. Keep checking. Please write again to let us know if you located a center. Best regards…Darrell

  14. nyasha says:

    when VIAC is done for a group of people of lets say 30 using the same object that is inserted in the cervix arent there great risk of contracting diseases like HIV since the examination is done one person after another.

  15. Darrell Ward says:

    Dear Nyasha – Thank for this question. The equipment and supplies used for VIAC examinations are sterilized before they are used, and they are used only once per woman. After a woman is examined, the equipment is cleaned and sterilized in an autoclave before it is used again. (The same is true for surgical equipment.) Each day, before the VIAC screening clinic opens, the hospital sterilizes a number of packs of the equipment needed for an exam. This ensures that clean, sterile equipment is ready when needed for each woman who arrives for screening. I hope this is helpful…Darrell

  16. Rejoice says:

    If you have LEEP done does that mean cancer will be gone for good? I have just been screened and result was positive and am to have LEEP done.

  17. Darrell Ward says:

    Hello, and thank you for your question. It was very good that you sought screening. By doing so, you have identified a problem early, when treatment is easiest and most successful. Your doctor has prescribed the loop electrosurgical excision procedure, or LEEP. It is done to remove abnormal cells on the cervix. Please be sure to return to your clinic and have the LEEP procedure done. It will likely eliminate the problem for good. Should you choose to not get the treatment, there is a very good chance that the abnormal cells will worsen and become cancerous and more difficult to treat. After LEEP treatment, there is a small chance that the problem could occur again in the future. That is not something that you should worry about, however, because the chances are small.

    When you return for the LEEP procedure, ask the doctor or nurse if and when you should seek screening again in the future. Also ask how to care for yourself after the procedure, what problems might occur and how to care for them if they do. Thank you again for your question and I hope your treatment goes well…Darrell

  18. Sam says:

    hi
    if someone has been diagnosed as having either CIN 1-3 stage can thy hv an option if having their cervix removed? to prevent spreading of the cancer.

  19. Darrell Ward says:

    Dear Emmah – Thank you for your email. Please note that I am not a doctor, but I highly recommend that you see a doctor quickly for an examination. Yes, he or she can do an examination even if you are discharging. A woman who experiences a change in her period, or in the pattern of bleeding, should have the condition checked by a doctor. This is especially true for older women who have completed menopause and who begin bleeding again.
    I wish you the best and please write again if you wish…Darrell

  20. Darrell Ward says:

    Hello, Sam, and thank you for your question – Please note that I am not a doctor or a healthcare professional. I am a science writer who has written for many years about cancer and cancer research at Ohio State University in the United States. First, I encourage you to see a doctor about your concerns. That is very important. Now to answer your question, and to be sure this is correct, I have checked with Dr. Paul Thistle, an obstetrician and gynaecologist at Karanda Mission Hospital.

    CIN is an abbreviation for “cervical intraepithelial neoplasia,” which refers to the presence of abnormal cells on the cervix. The CIN designation is usually used by pathologists when describing the results of a biopsy, which is a small tissue sample taken to determine whether cancer is present or not. CIN describes cells that look abnormal and might be precancerous. These abnormal cells are grouped into one of three CIN categories, depending on how abnormal they appear:

    CIN I — means the cells are mildly abnormal
    CIN II — the cells are moderately abnormal
    CIN III — the cells are severely abnormal

    The treatment for each CIN stage depends on a woman’s age and condition.

    CIN 1 is sometimes left untreated in the United State because it can clear up on its own, but treatment might be appropriate, depending on the woman’s condition and situation.
    CIN 2 would likely be treated using cryotherapy or the LOOP electrosurgical excision procedure (also called LEEP), or it might require a hysterectomy.
    CIN 3 might be treated with a hysterectomy, depending on the woman’s condition and situation.

    Please note: In Zimbabwe and many under-resourced countries, most women are tested for abnormal precancerous cells using visual inspection with acetic acid and cervicography (a photograph of the cervix for quality control), or VIAC. VIAC screening cannot distinguish CIN staging, but VIAC testing also has three possible outcomes:

    VIAC positive — abnormal cells are present and the doctor will determine the best treatment.
    VIAC negative — the cervix looks normal and health and no treatment is needed.
    Suspicious of cancer — cancer might be present. In this case, a biopsy (the small sample of tissue mentioned above) is taken and sent to a laboratory to learn if the cells are cancerous.

    Thank you again, and I hope this answers your question. Best regards…Darrell

  21. Charlotte says:

    Hi am havin problems to conceive tz 5yrs noe no luck what cld be the problem.is viac necessary to be done

  22. Darrell Ward says:

    Dear Charlotte – I am sorry to learn of your difficulty with conception. I do encourage you to go for VIAC screening, however. All women of reproductive age are at risk for cervical cancer, and VIAC screening can detect early changes that can lead to the disease. Treating these early changes can prevent cervical cancer from happening. VIAC does not usually detect problems related to fertility or conception, but when you get screening you can ask the nurse or midwife for direction on how you should learn the cause of the problem. Ideally, you should talk with a physician, one who is trained in obstetrics and gynaecology. I also suggest that you talk with an experienced and compassionate counselor, perhaps at a mission hospital such as St Albert’s or Karanda. Both you and your husband should meet with the counselor, if possible. If that is not possible, talk with a counselor on your own. It can help you emotionally, as well as help you cope with your circumstances and, hopefully, solve the problem. My best to you…Darrell

  23. Egenia Mankola says:

    My mom is in desperate need of a hip replacement operation. Do you do such operations at your hospital?

  24. Darrell Ward says:

    Dear Egenia — I’m sorry to say that St Albert’s Mission Hospital does not do hip replacement surgery. I am checking to learn which hospitals in Zimbabwe do perform this surgery. I’ll write here again as soon as I learn more, though it might not be for a day or two. Thank you and my best to you and our mother…Darrell

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