Ž . International Journal of Gynecology & Obstetrics 72 2001 4753 Article Adjunctive testing for cervical cancer in low resource settings with visual inspection, HPV, and the Pap smear  P.D. Blumenthal a,  , L. Gaffikin b , Z.M. Chirenje c , J. McGrath b , S. Womack d , K. Shah d a Department of Obstetrics and Gynecology, Johns Hopkins Bay  iew Medical Center, Baltimore MD, USA b JHPIEGO Corporation, Baltimore MD, USA c Department of Obstetrics and Gynecology, Uni  ersity of Zimbabwe, Harare, Zimbabwe d Department of Molecular Biology, Johns Hopkins School of Hygiene and Public Health, Baltimore MD, USA Received 7 February 2000; received in revised form 21 June 2000; accepted 28 June 2000 Abstract Ž . Objecti  e: To test whether the performance of visual inspection using acetic acid VIA could be improved through adjunctive testing and to determine whether the combination of visual inspection of the cervix and HPV testing could prove useful for identifying those at highest risk of cervical precancer. Methods: Between October 1995 and August 1997, 2199 women willing to be screened for cervical cancer in peri-urban clinics in Harare, Zimbabwe received VIA, Ž . Pap smear and HPV as screening tests. The presence or absence of pre cancer was confirmed via colposcopy with biopsy as indicated for 97% of all women. Computerized simulations of sequential testing scenarios provided Ž . estimates of the joint net test qualities of different paired combinations of the three tests and allowed for comparisons with the individual test qualities. Results: Using HGSILCIN II-III as the reference threshold of disease, the net sensitivity and specificity of VIA and HPV when used sequentially were 63.6 and 81.9%, respectively, compared to 43.3 and 91%, respectively, when Pap smears were followed by HPV testing. VIA followed by the Pap  On behalf of the University of ZimbabweJHPIEGO Cervical Cancer Project, PD Blumenthal and L Gaffikin wrote the paper. The study was designed by PD Blumenthal, L Gaffikin, ZM Chirenje, and KV Shah. Field implementation and study monitoring was done by ZM Chirenje, T Chipato, and the staff of the University of ZimbabweJHPIEGO Cervical Cancer Project. HPV laboratory analysis was performed by S Womack and KV Shah. L Gaffikin, J McGrath, and PD Blumenthal were responsible for all statistical analyses described in this manuscript. Members of the University of ZimababweJHPIEGO Cervical Cancer Project include: Ž . University of Zimbabwe T Chipato, MD ZM Chirenje MD, J Kasule MD, R Makunike, MD, E Ngwalle MD, S Rusakaniko . Ž . JHPIEGO Corporation PD Blumenthal MD MPH, L Gaffikin Dr PH, J McGrath MA, H Sanghvi MD, MPH .  Corresponding author. Department of Obstetrics and Gynecology, Johns Hopkins Bayview Medical Center, 4940 Eastern Ave, Room A125 C, Baltimore, MD 21224, USA. Tel.: 1-410-550-7591; fax: 1-410-550-0245. Ž . E-mail address: pblumen@jhmi.edu P.D. Blumenthal . 0020-729201$20.00  2001 International Federation of Gynecology and Obstetrics. All rights reserved. Ž . PII: S 0 0 2 0 - 7 2 9 2 00 00329-5