Oncoprotein E6 as a Diagnostic Marker in Human Papillomavirus-Associated Cervical Cancer Screening

Oncoprotein E6 as a Diagnostic Marker in Human Papillomavirus-Associated Cervical Cancer Screening | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Oncoprotein E6 as a Diagnostic Marker in Human Papillomavirus-Associated Cervical Cancer Screening Abebe Habteselassie Demissie, Belete Woldesemayat, Jaleta Bulti Tura, and 19 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8093024/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Cervical cancer remains a significant public health challenge in resource-limited settings due to inadequate access to resource-intensive screening methods. This study aimed to evaluate the performance of the OncoE6 cervical test using histology as a reference method. Method A facility-based cross-sectional study was conducted from November 2022 to June 2023. A total of 303 samples were collected from six hospitals across three regions of Ethiopia. The OncoE6 cervical test and Visual Inspection with Acetic Acid (VIA) were evaluated among women with negative and positive histology test results. Statistical analysis was performed using SPSS version 28 and MedCalc version 22.014. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and Receiver Operating Characteristic (ROC) curve were calculated. Result The sensitivity of the OncoE6 test was 59.4% (95% CI: 49.5%-68.9%), and specificity was 98% (95% CI: 94.9%-99.4%). The PPV was 94.0% (95% CI: 85.51–97.68%), while the NPV was 81.8% (95% CI: 78.07–84.97%). The VIA sensitivity, specificity, PPV, and NPV against histology were 95.8% (95% CI: 88.14%-99.12%), 26.4% (95% CI: 16.70%-38.10%), 41.2% (95% CI: 37.69–44.79%), and 92.1% (95% CI: 78.21–97.40%), respectively. The ROC curve showed an AUC of 0.80 for OncoE6 (p < 0.001) and 0.61 for VIA (p < 0.001). OncoE6 positivity increased with higher lesion grades. Additionally, the Sensitivity and specificity of the parallel (either OncoE6 OR VIA positive) were 84.0% (95% CI: 75.57–90.37) and 72.1% (95% CI: 65.26–78.22), respectively. Conclusion In this study, a high specificity of OncoE6 and a high sensitivity of VIA were observed. Using both in a parallel approach improved screening performance and can strengthen cervical cancer screening in resource-limited settings, but further community-based evaluation is still needed. Cervical cancer Evaluation OncoE6 VIA Screening method Figures Figure 1 Figure 2 Figure 3 Introduction Cervical cancer is the fourth most common cancer case and mortality among women, accounting for about 662,000 new cases and 349,000 deaths in 2022 globally ( 1 ). About 291 million women around the world carry Human papillomavirus (HPV) DNA, of whom 32% are infected either with HPV-16, HPV-18, or both ( 2) . Effective screening and early treatment can effectively reduce morbidity and mortality associated with this disease ( 3 ). The association between high-risk human papillomavirus (HR-HPV) infection and invasive cervical cancer (ICC) is well established. HPV genotypes 16 and 18 are responsible for more than 70% of ICC cases ( 4) . ICC is the most frequently diagnosed cancer in 23 countries and the leading cause of cancer death in 36 countries, mostly found in Sub-Saharan Africa ( 5 ). In Ethiopia, the prevalence of ICC is 22 per 100,000, with 7,445 new cases and 5,338 deaths reported in 2020 ( 6 ). A study at Tikur Anbesa Specialized Hospital found that cervical cancer is the most common type of cancer among women (39.7%), followed by breast (18.3%) and ovarian cancer (7.1%) ( 7 ). To eliminate cervical cancer, the World Health Organization (WHO) set a 2030 target of screening 70% of women with a high-performance test twice by the ages of 35 and 45 ( 1 ). Available screening methods include liquid-based cytology, HPV DNA PCR, Visual Inspection with Acetic Acid (VIA), and Visual Inspection with Lugol's Iodine (VILI), which are currently used in Ethiopia ( 6 ). HPV-DNA-based screening is a more effective tool for cervical cancer screening than the other alternatives (8) , and WHO recommends HPV-based screening where resources are available. However, in low-resource settings, VIA remains the primary option, despite its inconsistent accuracy and high false-positive rates (20–50%), which lead to unnecessary referrals, increased costs, and overtreatment ( 7, 9 ). HPV and cytology-based screening methods are rarely feasible in low- and middle-income countries (LMICs) due to cost, infrastructure needs, and the requirement for well-trained staff ( 8 ). This underscores the importance of affordable and effective screening options. In this context, the OncoE6™ Cervical Test presents a possible alternative, as it is a qualitative assay that detects elevated levels of the E6 oncoprotein expressed in cells infected by HPV-16 and HPV-18. High levels of E6, combined with clinical evaluation, suggest the presence or increased risk of precancerous or cancerous lesions ( 10 ). This study evaluated the diagnostic performance of the OncoE6™ test using histology as the reference standard. Additionally, the study compared the performance of the VIA screening method alongside OncoE6™ in detecting cancerous or precancerous lesions. Methods and Materials Study design and settings A facility-based cross-sectional study was conducted from November 2022 to June 2023 in selected health facilities across three regions of Ethiopia: Addis Ababa (Zewditu Memorial Hospital, Abebech Gobena Maternal and Child Hospital, Family Guidance Association Maternal and Child Health Centre), Oromia (Jimma University Specialized Hospital), and Amhara (Felege Hiwot General Specialized Hospital, and Bahirdar University Tibebe Ghion Specialized Hospital). These facilities provide histology services from cervical biopsy samples to diagnose cervical cancer and precancerous changes, as well as screening and treatment programs. Study population All women aged 25 to 75 years who visited the selected health facilities during the study period, met the inclusion criteria, and gave consent to participate were included. Women who agreed to provide samples for OncoE6 and histology but not for VIA were also included. Eligible participants had no prior diagnosis of cervical cancer/precancerous changes, no congenital abnormalities preventing cervical access, and were physically able to undergo routine screening. Pregnant women, those with hysterectomies and those treated for precancerous cervical lesions within the last six months were excluded. Sampling and sample size determination Six health facilities were purposively selected and included in the study based on the availability of cervical biopsy services and their caseload. Furthermore, these health facilities had histology testing setups for pathology services and also had a higher number of cases identified as cervical cancer by histology testing for the last six months. The minimum sample size required for the sensitivity and specificity analysis was calculated by using PASS software (PASS 11, NCSS, LLC). The sample size calculation considered the disease prevalence of 20% ( 11 ), with 80% statistical power and a 95% confidence level for sensitivity and specificity. Based on the above assumptions, the minimum sample size required for this study was determined to be 245. In our study, the final sample size was 303. Test Procedures In this study, each participant provided two cervical samples: the first for the OncoE6™ Cervical Test (Arbor Vita Corporation, Fremont, CA, USA) and the second for histological examination. The VIA technique was performed by experienced nurses or midwives, and results were documented prior to collecting the biopsy sample. This sampling order was maintained consistently throughout collection, storage, and transportation. Samples for the OncoE6™ test were stored at -20°C until testing. Histology specimens were processed according to established protocols of the respective health facility, ensuring proper fixation, sectioning, and staining to facilitate accurate microscopic evaluation. Histopathological examinations were performed at the collection facility based on their standards. Pathologists were blinded to the OncoE6 and VIA results. Slides were reviewed by two pathologists, and in cases of disagreement, a third pathologist was consulted, and the final diagnosis was reached by discussion. The Onco E6 ™ samples were transported to the Ethiopian Public Health Institute (EPHI) national HIV reference laboratory using a triple packaging system with dry ice and temperature monitoring in place. Onco E6 ™ test results were kept confidential and not disclosed to participants. They were recorded in study data collection forms with anonymous identification numbers, age, date, and site, without names and addresses. OncoE6™ testing method Samples were lysed with the kit reagent and centrifuged at 10,000g for 10 minutes. A 200µL aliquot of the supernatant was incubated again with the lysis and conditioning solutions. After five minutes of incubation with solubilized detector monoclonal antibody (mAb) solution, samples migrated over the strip for 55 minutes, then underwent color development with Alkaline Phosphatase (AP) substrate for another 20 minutes, followed by visual inspection. The tests were performed by trained personnel experienced in serological assays, with biopsy results blinded from the tester. All procedures and interpretations followed the manufacturer's instructions ( 10 ). Visual Inspection with Acetic Acid (VIA) In this study, VIA was included as one of the comparator methods and was performed in the selected health facilities. VIA cervical lesion screening technique is performed by applying 3–5% acetic acid solution to the cervix and then visually inspecting any aceto-white changes indicating abnormal cellular activity in the area ( 1 ). Histology test (Reference Method) In the current study, the histology test was used as the reference standard to evaluate the OncoE6™ rapid testing method. After tissue sample collection from the cervix, the sample underwent fixation, was embedded in paraffin wax and stained in the health facility's pathology centre. The Pathologists examine these stained sections under a microscope to identify any histopathological changes (12) . All histology results were given back to each participant for further treatment and patient management. Data collection The questionnaire was developed specifically for this study based on a review of previous literature and expert opinion, and used to collect information on socio-demographic, behavioral and gynecological characteristics of the study participants ( Supplementary file 1). The information was completed by the health care provider and transferred to the study data manager every week. Quality assurance During the evaluation phases, quality assurance was maintained throughout the study. Room and refrigerator temperature monitoring were performed twice a day. The OncoE6 kit includes an internal quality control system with a built-in control line, which the testers followed strictly. Standard operating procedures ensured that tests were performed correctly and results were properly recorded. Data Analysis Statistical analyses were performed using the SPSS statistical package, version 28.0 and MedCalc statistical software, version 22.014. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated with a 95% confidence interval. Thresholds were established for acceptable levels of agreement between the reference technique and the assay being evaluated using the receiver operating characteristic (ROC) curve. Sensitivity and specificity were calculated using histology as the reference standard, where Cervical Intraepithelial Neoplasia 2+ (CIN2+) includes CIN2, CIN3, Carcinoma in Situ (CIS), and invasive carcinoma represented positive cases, and CIN2- (normal, chronic cervicitis, and CIN1) represented negative cases. Ethical Considerations All procedures involving human participants were reviewed and approved by the Ethiopian Public Health Institute Institutional Review Board (EPHI-IRB) with approval number EPHI-IRB-347-2021. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Written informed consent was obtained from all individual participants included in the study. Confidentiality was maintained by not collecting identifying information, restricting data access, and using sample code numbers. The sample code number was used to identify each study participant. Written informed consent was obtained from each participant after explanation about the study’s purpose, procedures, risks, and benefits in their preferred language by a trained data collector. Participants were encouraged to ask questions, consult family, and take adequate time before providing written consent. Funding Declaration This research received no external funding. Operational definition Either OncoE6 OR VIA positive Defined as a positive result if a participant or a sample tested positive on at least one of the two methods, OncoE6 or VIA. Performance The ability of a testing method (OncoE6™ or VIA) to identify true negative and positive cases when compared with the reference standard (histology). Positive for histology The standard reporting formats for positive histology are CIN2+, carcinoma in situ and squamous cell carcinoma. Negative for histology Negative for dysplasia, non-specific cervicitis, benign cervical polyp. Results Socio-demographic characteristics of the participants A total of 307 samples were initially included; however, four were excluded due to poor sample quality (bloody or insufficient sample volume), which left 303 for final analysis. The mean age of the participants was 48.4 years (SD ± 10.77). The majority, 109 (37.5%), of participants were between the ages of 50 and 59 years old. More than half of the women, 190 (62.7%), were married. In terms of education, 127 (42.3%) had no formal education, 50 (16.7%) attended primary school, 59 (19.7%) completed secondary education, and 64 (21.3%) had tertiary education. Regarding gynaecologic and behavioural characteristics of participants, the majority, 190 (63.1%), were in the menopause stage, 139 (53.1%) reported their first sexual intercourse between ages 15 and 19, and 139 (53.7%) had two or more sexual partners. Seventy-nine (26.2%) had a history of sexually transmitted infections, while only 1.8% reported smoking. Histology showed that 158 (52.1%) had CIN1, followed by CIN2/3, 56 (18.5%), invasive cancer, 39 (12.9%), and carcinoma in situ, 11 (3.6%) ( Supplementary file 2 ). Diagnostic Performance of OncoE6 and VIA Overall, 67 of 303 women (22.1%) tested positive using the OncoE6 lateral flow assay. Among those who tested positive, 97.7% had HPV-16, 1.7% had HPV-18, and 0.7% had dual infections. VIA was performed on 143 women, 84.6% of whom tested positive. Histology confirmed CIN2 + in 106 women (34.98%). Correlation analysis showed a strong correlation between histology and OncoE6 (r = 0.66, P < 0.0001), while VIA had a weaker correlation with histology (r = 0.34, P < 0.0001) and with OncoE6 (r = 0.27, P < 0.0001 (Fig. 1 ). For OncoE6, sensitivity was 59.4% (95% CI: 49.5–68.9), specificity 97.9% (95% CI: 94.9–99.4), PPV 94.0% (95% CI: 85.5–97.7), and NPV 81.8% (95% CI: 78.1–85.0). Overall accuracy was 84.5% (95% CI: 79.9–88.4), with a kappa of 0.63 (95% CI: 0.53–0.72) (Table 1 ). The ROC analysis showed that the area under the curve (AUC) was 0.80 (p < 0.001), indicating good diagnostic accuracy; the test's ability to distinguish between true positive and true negative was statistically significant (Fig. 2 ). Table 1 Diagnostic performance of OncoE6 and VIA test in selected health facilities in Ethiopia, 2023. Methods True positive (TP) True Negative (TN) False Positive (FP) False Negative (FN) Sensitivity % (95% CI) Specificity % (95% CI) PPV % (95% CI) NPV % (95% CI) Accuracy % (95% CI) Kappa value K (95% CI) OncoE6 63 193 4 43 59.43 (49.46–68.87) 97.97 (94.88–99.44) 94.03 (85.51–97.68) 81.77 (78.07–84.97) 84.48 (79.91–88.37) 0.63 (0.53–0.72) VIA 68 19 53 3 95.77 (88.14–99.12) 26.39 (16.70–38.10) 41.20 (37.69–44.79) 92.06 (78.21–97.40) 50.67 (42.19–59.13) 0.22 (0.11–0.33) Either OncoE6 OR VIA positive 89 142 55 17 83.96%75.57% to 90.37% 72.08%65.26% to 78.22% 61.82%56.04% to 67.29% 89.30%84.26% to 92.86% 76.24%71.04% to 80.92% 0.50 (0.41–0.60) For the VIA evaluation, 143 participants were included; the sensitivity was 95.77% (95% CI: 88.14–99.12), and the specificity was 26.39% (95% CI: 16.70–38.10). The PPV was 41.20% (95% CI: 37.69–44.79), and the NPV was 92.06% (95% CI: 78.21–97.40). The accuracy and Kappa value were 50.67% (95% CI: 42.19–59.13) and 0.22 (95% CI: 0.11–0.34), respectively. The ROC analysis showed that the AUC was 0.61 (P < 0.001) (Table 1 and Fig. 2 ). Additionally, we analysed a parallel strategy (OncoE6 OR VIA positive), sensitivity and specificity were 84.0% (95% CI: 75.6–90.4) and 72.1% (95% CI: 65.3–78.2), respectively ( Table 1 ). Factors Associated with the positivity rates As shown in Tables 2 and 3 , CIN-1 was most common among women aged 40 to 54, and the age group greater than 55 was 61(50%) and 65 (63.73%), respectively. These age groups had significantly higher odds of being with CIN-1, CIN-2/3, and ICC/CIS (P < 0.05). OncoE6 positivity was slightly higher in the age of 40–54 (AOR: 1.67; 95% CI: 0.62–4.48) and 55 + years (AOR: 1.10; 95% CI: 0.38–3.20); however, these associations are not statistically significant (P > 0.05). Married women were more likely to have CIN1 (AOR: 11.7; 95% CI: 1.4–96.9). Women without formal education were significantly associated with OncoE6 and VIA positivity (p 0.05) (Tables 2 and 3 ). OncoE6 positivity increased with disease severity: 54.5% in CIN2/3 and 64.7% in ICC/CIS, while 50% of normal, 92.5% CIN1, and 95.8% CIN2 + were positive for VIA (Fig. 3 ) Table 2 Associations of sociodemographic and behavioral factors with histology results in selected health facilities in Ethiopia, 2023. Variables Biopsy result Normal N (%) CIN-1 CIN-2&3 ICC/CIS N (%) COR (95% CI) AOR (95% CI) P-value N (%) COR (95% CI) AOR (95% CI) P-value N (%) COR (95% CI) AOR (95% CI) P-value age 25- 39yrs 24(35.29) 28 (41.18) 1 1 9(13.24) 1 1 7 (10.29) 1 1 40-54yrs 13(10.66) 61(50) 4.02 (1.79–9.04) 8.4 (2.43–29.3) 0.001* 20 (16.39) 4.1(1.46–11.57) 1.76 (0.51–6.08), 0.369 28 (22.95) 7.4 (2.5–21.5) 6.89 (1.39–34.16) 0.018* 55+ 1(0.98) 65 (63.73) 54.9 (7.1-425.7) 63.2 (6.38–625.9) < 0.001* 24 (23.53) 64.0 (7.5–545.08) 23.7 (2.3- 238.8) 0.007* 12 (11.76) 44.6 (4.9–402.0) 39.4 (2.86–543.11 0.003* Marital status Unmarried 5 (38.46) 3 (23.08) 1 1 5(38.46) 1 1 0 (0) 1 Married 23 (12.1) 105 (55.3) 7.6 (1.70-34.13) 11.7 (1.4–96.89) 0.023* 35 (18.42) 1.52 (0.40–5.85 2.18 (0.39–12.16) 0.372 27 (14.21) - - < 0.001* Divorced 7 (12.73) 27 (49.09) 6.43 (1.23–33.65 10.21 (0.9 -104.2) 0.050 8 (14.55) 1.14 (0.23–5.67 2.08 (0.27–16.18) 0.484 13 (23.6) - - - Widowed 4 (8.89) 24 (53.33) 9.58 (1.61–56.95) 10.3 (0.9–118.8) 0.063 7(15.56) 1.75(0.31–10.02 1.34 (0.15–12.22) 0.795 10 (22.2) - - < 0.001* Educational Status No education 12 (9.68) 35 (28.23) 0.33 (0.11–1.02) 0.22 (0.05–1.01) 0.056 40(32.26) 5.0 (1.21–20.69) 6.04 (0.96–37.97) 0.055 37 (29.84) 9.5 (1.69–53.42) 3.43 (0.44–26.96), 0.241 Primary 6 (12) 30 (60) 0.58 (0.17–1.95) 0.38 (0.08–1.8) 0.224 6(12) 1.5(0.28–8.19) 0.86 (0.11–6.83) 0.882 8 (16) 4.0 (0.59–27.25) 0.59 (0.06–6.21) 0.666 Secondary 11(18.64) 40 (67.8) 0.42 (0.14–1.23) 0.56 (0.14–2.22) 0.412 5(8.47) 0.68(0.13–3.55) 1.15 (0.17–7.82) 0.890 3 (5.08) 0.85 (0.11–6.34) 0.46 (0.04–4.99) 0.520 Tertiary 6 (9.38) 52 (81.25) 1 1 4(6.25) 1 1 2 (3.13) 1 1 Age of first sex < 15yrs 1(3.85) 12(46.15) 2.1 (0.21–21.10) 6.43 (0.35–119.57) 0.212 9(34.62) 12.0 (0.94–153.89) 9.16 (0.35–238.55) 0.183 4 (15.38) - - - 15-19yrs 27(19.42) 59(42.45) 0.4 (0.13–1.33) 1.11 (0.23–5.37) 0.899 30(21.58) 1.48 (0.30–7.23) 1.54 (0.18–13.53) 0.696 23 (16.55) - - - 20-24yrs 6(8.7) 49(71.01) 1.6 (0.41–6.21) 2.15 (0.380–12.111) 0.387 9(13.04) 2.00 (0.32–12.33) 2.42 (0.24–24.31) 0.452 5 (7.25) - - - 25+ 4(13.79) 22(75.86) 1 1 3(10.34) 1 1 0 (0) 1 History of STI Yes 10(12.66) 55(69.62) 1.6 (0.72–3.48) 1.59 (0.56–4.45) 0.382 6(7.59) 0.36 (0.12–1.08) - - 8 (10.13) 0.54 (0.19–1.53) 0.40 (0.08–1.99) 0.265 No 29(13.06) 102(45.95) 1 1 49(22.07) 1 1 42 (18.92) 1 1 AOR, adjusted odds ratios; COR, crude odds ratios; CI, confidence interval. (*) Statistically significant at p ≤ 0.05. CIN: Cervical Intraepithelial Neoplasia; CIS: Carcinoma In Situ; ICC: Invasive Cervical Cancer; VIA: Visual Inspection with Acetic Acid; Table 3 Associations of sociodemographic and behavioral factors with VIA and OncoE6 results in selected health facilities in Ethiopia, 2023. Variables VIA OncoE6 Negative N (%) Positive N (%) COR (95% CI) AOR (95% CI) P-value Negative N (%) Positive N (%) COR (95% CI) AOR (95% CI) P-value age 25- 39yrs 11(16.67) 45 (68.18) 1 1 57(83.82) 11(16.18) 1 1 40-54yrs 10(8.26) 51 (42.15) 0.99(.40-2.49) - 0.724 90 (73.77) 32 (26.2) 1.84(0.86–3.94) 1.67 (0.62, 4.48) 0.313 55+ 0 (0) 17 (16.67) - - - 80(78.4) 22 (21.6) 1.43(0.64–3.17) 1.10 (0.38, 3.20) 0.866 Marital status Unmarried 1(7.69 7 (53.85) 1 1 7(53.85) 6(46.15) 1 1 Married 14 (7.45) 68 (36.17) 0.59 (0.07–5.14) 0.71 (0.05–9.65) 0.800 152(80) 38(20) 3.43 (1.09–10.80) 0.32 (0.07–1.51) 0.151 Divorced 4 (7.41) 27(50) 0.96 (0.09–10.05) 1.31 (0.29–5.7) 0. 337 45(81.82) 10(18.2) 3.86 (1.06–13.98) 0.51 (0.09, 2.84) 0.439 Widowed 3 (6.67) 19(42.22) 0.91 (0.08–10.21) 1.01 (0.04–23.97) 0 .995 32(71.11) 13(28.9) 2.11(0.59–7.49) 0.56 (0.10, 3.10) 0.504 Educational Status No education 6(4.88) 77(62.6) 12.83 (3.15–52.24) 34.27 (1.47–799.5) 0.028* 70(56.45) 54(43.6) 15.69 (4.67–52.72) 16.76 (3.58–78.41) < 0.0001* Primary 4(8) 15(30) 2.80(0.61–12.86) 10.62 (0.44-257.92) 0.147 45 (90) 5(10) 2.26 (0.51–9.95) 1.62 (0.25–10.65) 0.617 Secondary 5(8.62) 18(31.03) 3.60(0.80–16.20) 4.44 (0.21–93.53) 0.337 54(91.53) 5(8.47) 1.88 (0.43–8.25) 2.12 (0.38–11.89) 0.394 Tertiary 5(7.94) 7(11.11) 1 1 61(95.31) 3(4.69) 1 1 Age of first sex < 15yrs 0(0) 12(48) - - - 15(57.69) 11(42.31) 19.8 (2.32-168.66) 4.01 (0.37–43.66) 0.255 15-19yrs 17(12.2) 60(43.17) 1.02 (0.10-10.37) - < 0.001* 101 (72.66) 38(27.3) 10.16 (1.33–77.38) 3.05 (0.32–28.82) 0.331 20-24yrs 4(5.88) 12(17.65) 1.00 (0.08–12.56) - - 63 (91.3) 6(8.7) 2.53 (0.29, 22.04) 1.46 (0.14–15.23) 0.744 25+ 1(3.45) 3(10.34) 1 1 - 28(96.55) 1(3.45) 1 1 History of STI Yes 1(1.3) 40(51.95) 11.65 (1.52–89.38) 15.38 (0.96–247.1) 0.054 73(92.41) 6(7.59) - - - No 21(9.5) 81(36.65) 1 1 161 (72.52) 61(27.5) 1 *indicates level of significance < 0.05 STI: Sexually Transmitted Infection AOR, adjusted odds ratios; COR, crude odds ratios; CI, confidence interval. (*) Statistically significant at p ≤ 0.05 Discussion This study evaluated the diagnostic performance of the OncoE6™ lateral flow test against histology, assessed VIA performance and examined factors associated with test positivity among women over 25 years old in Ethiopia. The study found that the OncoE6 test had moderate sensitivity (59.4%) and high specificity (98%), while VIA demonstrated high sensitivity (95.8%) but low specificity (26.4%). When used in parallel (OncoE6 OR VIA positive), sensitivity improved to 83.7% with a specificity of 71.4%. Age, education, and age at first sexual intercourse were significantly associated with test positivity. In this study, the diagnostic performance of OncoE6 (sensitivity 59.4%, specificity 98%, PPV 94.0%, NPV 81.8%) was consistent with findings from Bangladesh (52% sensitivity, 97% specificity) ( 9 ) and Burundi (58.3% sensitivity, 97.9% specificity among CIN3 + HIV-positive women) ( 14 ). Our results also showed that OncoE6 positivity increased with disease severity, from 2.5% in CIN1 to 54.5% in CIN2/3 and 64.7% in invasive cancer or carcinoma in situ (Fig. 3 ). This pattern has been documented in other studies, where OncoE6 sensitivity rises for higher-grade lesions, particularly CIN3+ ( 9, 13–16 ). This increase is due to its detection of HPV16/18 E6 oncoproteins, which are more strongly associated with advanced lesions ( 17, 18 ). Despite its specificity, OncoE6 may miss cases caused by non-HPV16/18 genotypes, which are prevalent in Ethiopia, where HPV16/18 account for 64–90% of cervical cancers, but non-16/18 types remain significant ( 18, 19 ). Lower sensitivity has also been reported elsewhere, including Zambia (31%) ( 16 ), Burundi (42.1% for CIN2+) ( 14 ), and China (42.4% for CIN2 + and 53.5% for CIN3+) ( 15 ), although specificity consistently exceeded 95% ( 14, 15 ). This variability may reflect differences in genotype distribution, regional E6 gene mutations ( 20 ), and test methodology ( 21 ). For example, Yang et al. ( 20 ) reported E6 gene mutations in HPV16/18 among cervical cancer patients in Southwest China. This suggests that genetic variation may affect assay performance. In our study, VIA showed high sensitivity (95.8%) and low specificity (26.4%), which aligned with reports from Pakistan (93.5% sensitivity) ( 22 ) and the Multicentric Study for Cervical Cancer Screening and Triage with Human Papillomavirus Tests (ESTAMPA) study (85.9% sensitivity for CIN3+) ( 23 ). In Ethiopia, VIA remains the main screening tool where cytology and molecular testing are not accessible ( 24 ). However, a systematic review by Sauvaget et al. (25) reported a higher specificity of 92%. Studies in Congo Kinshasa (sensitivity 55.5%, specificity 64.6%) (26) and Nigeria (sensitivity 60%, specificity 94.4%) (27) showed considerable variation. These variations reflect provider training and experience (e.g., physicians versus nurses), patient age (identifying low-grade lesions can be challenging in elderly patients), and benign conditions that resemble aceto-white changes, such as atrophy, immature metaplasia, and HPV infection ( 26, 28–30 ). When OncoE6 and VIA were combined in a parallel strategy, sensitivity and specificity reached 84.0% and 72.1%, respectively. This finding suggests that using both methods simultaneously could significantly improve the overall diagnostic performance, specifically by enhancing the sensitivity of OncoE6 and the specificity of VIA. Similar improvements with dual testing have been reported in other studies ( 31, 32 ). This approach could improve screening effectiveness in low-resource settings where advanced tests are not available. In this study, age was significantly associated with disease severity. Women over 40 were more likely to develop higher-grade lesions. Married women were more likely to have CIN1, while a lower educational background, particularly women with no formal education, was linked to increased positivity with both VIA and OncoE6. Early sexual debut (15–19 years old) was also associated with VIA positivity. Comparable findings have been reported in Addis Ababa, Ethiopia ( 33 ), and older age, early sexual activity, long marital duration, and low education were associated with CIN ( 34–36 ). The risk of high-grade CIN and cancer is especially elevated in women over 55 due to persistent HR-HPV infections ( 37 ). Limited education may contribute to higher risk by reducing awareness of HPV transmission, reducing access to screening and vaccination, and restricting healthcare access, particularly in rural areas ( 28, 38 ). Limitations This study has some limitations. The study did not include HPV genotyping to understand the distribution of HPV types since OncoE6 is limited to HPV 16/18. Another limitation is that VIA screening was not performed for all participants, which reduced the sample size and may have affected the sensitivity and specificity of the VIA method. Additionally, histology tests were performed by various pathologists at different sites, potentially introducing inter-observer variability. Conclusion Despite the moderate sensitivity of OncoE6 and the low specificity of VIA, our results showed a high specificity for the OncoE6 test and a high sensitivity for the VIA. In this study, we observed that using a parallel method (OncoE6 OR VIA positive) improved screening performance by increasing sensitivity. Integrating the OncoE6 lateral flow test with the existing VIA method offers a practical and effective way for early, on-site detection of cervical lesions. This is particularly valuable in settings where HPV DNA tests or liquid-based cytology are not available. However, this combined method needs more evaluation in larger, community-based studies in resource-limited settings. Abbreviations CIN Cervical Intraepithelial Neoplasia CIS Carcinoma in Situ EPHI Ethiopian Public Health Institute HIV Human Immune Deficiency Virus HPV Human Papilloma Virus HR-HPV High risk human papilloma virus ICC Invasive Cervical Cancer NPV Negative predictive value (NPV) PPV Positive Predictive Value ROCReceiver Operating Characteristic VIA Visual Inspection with Acetic Acid WHO World Health Organization Declarations Ethics approval and consent to participate All procedures involving human participants were reviewed and approved by the Ethiopian Public Health Institute Institutional Review Board (EPHI-IRB) with approval number EPHI-IRB-347-2021. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Written informed consent was obtained from all individual participants included in the study. Confidentiality was maintained by not collecting identifying information, restricting data access, and using sample code numbers. The sample code number was used to identify each study participant. Written informed consent was obtained from each participant after explanation about the study’s purpose, procedures, risks, and benefits in their preferred language by a trained data collector. Participants were encouraged to ask questions, consult family, and take adequate time before providing written consent. Consent for publication Not Applicable Availability of data and materials The data supporting the findings of this study are available from the corresponding author upon request. Competing Interests The authors declare no competing interests Funding This research received no external funding. Authors' contributions Conception and design: Abebe Habteselassie, Ibrahim Heyredin, Belete Woldesemayat and Wudinesh Belete Administrative support: Jaleta Bulti, Minilik Demissie, Gemechu Tadesse, and Getachew Tollera Provision of study materials or patients: Hezkiel Mamo, Kidist Zealiyas, Amelework Yilma, Getenet Hailu, Lemessa Negeri, Wegene Tamene, and Gemechu Gudeta Collection and assembly of data: Kiflu Itefa, Gutema Bulti, Feyiso Bati, and Birra Bejiga Data analysis and interpretation: Belete Woldesemayat, Derbachew Asfaw, Abeje Kebede, Wudinesh Belete, Abebe Habteselassie and Getahun Fetensa, Minilik Demissie Manuscript writing: All authors Final approval of manuscript: All authors Accountable for all aspects of the work: All authors Acknowledgements We extend our sincere gratitude to all individuals and institutions who contributed to this research, including the Ethiopian Ministry of Health and the Amhara Public Health Institute. We also deeply appreciate the dedication of the staff at the selected hospitals and thank all study participants for their willingness to participate in this research Data Sharing Statement The data supporting the findings of this study are available from the corresponding author upon request. Author Contributions Conception and design: Abebe Habteselassie, Ibrahim Heyredin, Belete Woldesemayat and Wudinesh Belete Administrative support: Jaleta Bulti, Minilik Demissie, Gemechu Tadesse, and Getachew Tollera Provision of study materials or patients: Hezkiel Mamo, Kidist Zealiyas, Amelework Yilma, Getenet Hailu, Lemessa Negeri, Wegene Tamene, and Gemechu Gudeta Collection and assembly of data: Kiflu Itefa, Gutema Bulti, Feyiso Bati, and Birra Bejiga Data analysis and interpretation: Belete Woldesemayat, Derbachew Asfaw, Abeje Kebede, Wudinesh Belete, Abebe Habteselassie and Getahun Fetensa, Minilik Demissie Manuscript writing: All authors Final approval of manuscript: All authors Accountable for all aspects of the work: All authors Authors’ disclosures of potential conflicts of interest No potential conflicts of interest were reported by the authors. 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1","display":"","copyAsset":false,"role":"figure","size":41980,"visible":true,"origin":"","legend":"\u003cp\u003eProportion and correlation of VIA, OncoE6 and Histology in selected health facilities in Ethiopia, 2023.\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8093024/v1/70312ce6039b260c92c9a7dd.jpg"},{"id":97351163,"identity":"a30e4d73-9c47-4c04-9fe0-d4aea1adc9d8","added_by":"auto","created_at":"2025-12-03 12:34:00","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":48678,"visible":true,"origin":"","legend":"\u003cp\u003eROC curve analysis of OncoE6 and VIA against Histology in selected health facilities in Ethiopia, 2023.\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8093024/v1/14d6955a341a3307cc7e6516.jpg"},{"id":97351165,"identity":"681b9957-38da-4054-bc4b-08fc252f2515","added_by":"auto","created_at":"2025-12-03 12:34:00","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":189552,"visible":true,"origin":"","legend":"\u003cp\u003eOncoE6 positivity with histology grades in selected health facilities in Ethiopia, 2023.\u003c/p\u003e","description":"","filename":"Picture3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8093024/v1/591a64346a2f8ed4aba12d22.jpg"},{"id":97664642,"identity":"625b4740-637f-41e6-9209-c0979d249fb3","added_by":"auto","created_at":"2025-12-08 09:12:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1877819,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8093024/v1/28862eaf-f534-4165-af0a-681f9bc67504.pdf"},{"id":97371401,"identity":"08b53a6a-1200-450a-97cb-ad90ab53a885","added_by":"auto","created_at":"2025-12-03 16:28:52","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":23730,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8093024/v1/7c22ba79841d45b8b7d84655.docx"},{"id":97351171,"identity":"6897f661-169e-452e-a13e-e9cf0cb209ab","added_by":"auto","created_at":"2025-12-03 12:34:00","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":19049,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-8093024/v1/a8fc07e3b0fbedbf29a0b626.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eOncoprotein E6 as a Diagnostic Marker in Human Papillomavirus-Associated Cervical Cancer Screening\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCervical cancer is the fourth most common cancer case and mortality among women, accounting for about 662,000 new cases and 349,000 deaths in 2022 globally (\u003cb\u003e1\u003c/b\u003e). About 291\u0026nbsp;million women around the world carry Human papillomavirus (HPV) DNA, of whom 32% are infected either with HPV-16, HPV-18, or both (\u003cb\u003e2)\u003c/b\u003e. Effective screening and early treatment can effectively reduce morbidity and mortality associated with this disease (\u003cb\u003e3\u003c/b\u003e).\u003c/p\u003e\u003cp\u003eThe association between high-risk human papillomavirus (HR-HPV) infection and invasive cervical cancer (ICC) is well established. HPV genotypes 16 and 18 are responsible for more than 70% of ICC cases (\u003cb\u003e4)\u003c/b\u003e. ICC is the most frequently diagnosed cancer in 23 countries and the leading cause of cancer death in 36 countries, mostly found in Sub-Saharan Africa (\u003cb\u003e5\u003c/b\u003e). In Ethiopia, the prevalence of ICC is 22 per 100,000, with 7,445 new cases and 5,338 deaths reported in 2020 (\u003cb\u003e6\u003c/b\u003e). A study at Tikur Anbesa Specialized Hospital found that cervical cancer is the most common type of cancer among women (39.7%), followed by breast (18.3%) and ovarian cancer (7.1%) (\u003cb\u003e7\u003c/b\u003e).\u003c/p\u003e\u003cp\u003eTo eliminate cervical cancer, the World Health Organization (WHO) set a 2030 target of screening 70% of women with a high-performance test twice by the ages of 35 and 45 (\u003cb\u003e1\u003c/b\u003e). Available screening methods include liquid-based cytology, HPV DNA PCR, Visual Inspection with Acetic Acid (VIA), and Visual Inspection with Lugol's Iodine (VILI), which are currently used in Ethiopia (\u003cb\u003e6\u003c/b\u003e). HPV-DNA-based screening is a more effective tool for cervical cancer screening than the other alternatives \u003cb\u003e(8)\u003c/b\u003e, and WHO recommends HPV-based screening where resources are available. However, in low-resource settings, VIA remains the primary option, despite its inconsistent accuracy and high false-positive rates (20\u0026ndash;50%), which lead to unnecessary referrals, increased costs, and overtreatment (\u003cb\u003e7, 9\u003c/b\u003e).\u003c/p\u003e\u003cp\u003eHPV and cytology-based screening methods are rarely feasible in low- and middle-income countries (LMICs) due to cost, infrastructure needs, and the requirement for well-trained staff (\u003cb\u003e8\u003c/b\u003e). This underscores the importance of affordable and effective screening options. In this context, the OncoE6\u0026trade; Cervical Test presents a possible alternative, as it is a qualitative assay that detects elevated levels of the E6 oncoprotein expressed in cells infected by HPV-16 and HPV-18. High levels of E6, combined with clinical evaluation, suggest the presence or increased risk of precancerous or cancerous lesions (\u003cb\u003e10\u003c/b\u003e). This study evaluated the diagnostic performance of the OncoE6\u0026trade; test using histology as the reference standard. Additionally, the study compared the performance of the VIA screening method alongside OncoE6\u0026trade; in detecting cancerous or precancerous lesions.\u003c/p\u003e"},{"header":"Methods and Materials","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and settings\u003c/h2\u003e\u003cp\u003eA facility-based cross-sectional study was conducted from November 2022 to June 2023 in selected health facilities across three regions of Ethiopia: Addis Ababa (Zewditu Memorial Hospital, Abebech Gobena Maternal and Child Hospital, Family Guidance Association Maternal and Child Health Centre), Oromia (Jimma University Specialized Hospital), and Amhara (Felege Hiwot General Specialized Hospital, and Bahirdar University Tibebe Ghion Specialized Hospital). These facilities provide histology services from cervical biopsy samples to diagnose cervical cancer and precancerous changes, as well as screening and treatment programs.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eAll women aged 25 to 75 years who visited the selected health facilities during the study period, met the inclusion criteria, and gave consent to participate were included. Women who agreed to provide samples for OncoE6 and histology but not for VIA were also included. Eligible participants had no prior diagnosis of cervical cancer/precancerous changes, no congenital abnormalities preventing cervical access, and were physically able to undergo routine screening. Pregnant women, those with hysterectomies and those treated for precancerous cervical lesions within the last six months were excluded.\u003c/p\u003e\n\u003ch3\u003eSampling and sample size determination\u003c/h3\u003e\n\u003cp\u003eSix health facilities were purposively selected and included in the study based on the availability of cervical biopsy services and their caseload. Furthermore, these health facilities had histology testing setups for pathology services and also had a higher number of cases identified as cervical cancer by histology testing for the last six months. The minimum sample size required for the sensitivity and specificity analysis was calculated by using PASS software (PASS 11, NCSS, LLC). The sample size calculation considered the disease prevalence of 20% (\u003cb\u003e11\u003c/b\u003e), with 80% statistical power and a 95% confidence level for sensitivity and specificity. Based on the above assumptions, the minimum sample size required for this study was determined to be 245. In our study, the final sample size was 303.\u003c/p\u003e\n\u003ch3\u003eTest Procedures\u003c/h3\u003e\n\u003cp\u003eIn this study, each participant provided two cervical samples: the first for the OncoE6\u0026trade; Cervical Test (Arbor Vita Corporation, Fremont, CA, USA) and the second for histological examination. The VIA technique was performed by experienced nurses or midwives, and results were documented prior to collecting the biopsy sample. This sampling order was maintained consistently throughout collection, storage, and transportation. Samples for the OncoE6\u0026trade; test were stored at -20\u0026deg;C until testing. Histology specimens were processed according to established protocols of the respective health facility, ensuring proper fixation, sectioning, and staining to facilitate accurate microscopic evaluation. Histopathological examinations were performed at the collection facility based on their standards. Pathologists were blinded to the OncoE6 and VIA results. Slides were reviewed by two pathologists, and in cases of disagreement, a third pathologist was consulted, and the final diagnosis was reached by discussion. The Onco\u003cem\u003eE6\u003c/em\u003e\u0026trade; samples were transported to the Ethiopian Public Health Institute (EPHI) national HIV reference laboratory using a triple packaging system with dry ice and temperature monitoring in place. Onco\u003cem\u003eE6\u003c/em\u003e\u0026trade; test results were kept confidential and not disclosed to participants. They were recorded in study data collection forms with anonymous identification numbers, age, date, and site, without names and addresses.\u003c/p\u003e\n\u003ch3\u003eOncoE6™ testing method\u003c/h3\u003e\n\u003cp\u003eSamples were lysed with the kit reagent and centrifuged at 10,000g for 10 minutes. A 200\u0026micro;L aliquot of the supernatant was incubated again with the lysis and conditioning solutions. After five minutes of incubation with solubilized detector monoclonal antibody (mAb) solution, samples migrated over the strip for 55 minutes, then underwent color development with Alkaline Phosphatase (AP) substrate for another 20 minutes, followed by visual inspection. The tests were performed by trained personnel experienced in serological assays, with biopsy results blinded from the tester. All procedures and interpretations followed the manufacturer's instructions (\u003cb\u003e10\u003c/b\u003e).\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eVisual Inspection with Acetic Acid (VIA)\u003c/h2\u003e\u003cp\u003eIn this study, VIA was included as one of the comparator methods and was performed in the selected health facilities. VIA cervical lesion screening technique is performed by applying 3\u0026ndash;5% acetic acid solution to the cervix and then visually inspecting any aceto-white changes indicating abnormal cellular activity in the area (\u003cb\u003e1\u003c/b\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eHistology test (Reference Method)\u003c/h3\u003e\n\u003cp\u003eIn the current study, the histology test was used as the reference standard to evaluate the OncoE6\u0026trade; rapid testing method. After tissue sample collection from the cervix, the sample underwent fixation, was embedded in paraffin wax and stained in the health facility's pathology centre. The Pathologists examine these stained sections under a microscope to identify any histopathological changes \u003cb\u003e(12)\u003c/b\u003e. All histology results were given back to each participant for further treatment and patient management.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eThe questionnaire was developed specifically for this study based on a review of previous literature and expert opinion, and used to collect information on socio-demographic, behavioral and gynecological characteristics of the study participants (\u003cb\u003eSupplementary file 1).\u003c/b\u003e The information was completed by the health care provider and transferred to the study data manager every week.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eQuality assurance\u003c/h2\u003e\u003cp\u003eDuring the evaluation phases, quality assurance was maintained throughout the study. Room and refrigerator temperature monitoring were performed twice a day. The OncoE6 kit includes an internal quality control system with a built-in control line, which the testers followed strictly. Standard operating procedures ensured that tests were performed correctly and results were properly recorded.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eStatistical analyses were performed using the SPSS statistical package, version 28.0 and MedCalc statistical software, version 22.014. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated with a 95% confidence interval. Thresholds were established for acceptable levels of agreement between the reference technique and the assay being evaluated using the receiver operating characteristic (ROC) curve. Sensitivity and specificity were calculated using histology as the reference standard, where Cervical Intraepithelial Neoplasia 2+ (CIN2+) includes CIN2, CIN3, Carcinoma in Situ (CIS), and invasive carcinoma represented positive cases, and CIN2- (normal, chronic cervicitis, and CIN1) represented negative cases.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eEthical Considerations\u003c/h2\u003e\u003cp\u003eAll procedures involving human participants were reviewed and approved by the Ethiopian Public Health Institute Institutional Review Board (EPHI-IRB) with approval number EPHI-IRB-347-2021. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Written informed consent was obtained from all individual participants included in the study. Confidentiality was maintained by not collecting identifying information, restricting data access, and using sample code numbers. The sample code number was used to identify each study participant. Written informed consent was obtained from each participant after explanation about the study\u0026rsquo;s purpose, procedures, risks, and benefits in their preferred language by a trained data collector. Participants were encouraged to ask questions, consult family, and take adequate time before providing written consent.\u003c/p\u003e\u003cp\u003e\u003cb\u003eFunding Declaration\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis research received no external funding.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eOperational definition\u003c/h2\u003e\u003cp\u003e\u003cstrong\u003eEither OncoE6 OR VIA positive\u003c/strong\u003e\u003cp\u003eDefined as a positive result if a participant or a sample tested positive on at least one of the two methods, OncoE6 or VIA.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003ePerformance\u003c/strong\u003e\u003cp\u003eThe ability of a testing method (OncoE6\u0026trade; or VIA) to identify true negative and positive cases when compared with the reference standard (histology).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003ePositive for histology\u003c/strong\u003e\u003cp\u003eThe standard reporting formats for positive histology are CIN2+, carcinoma in situ and squamous cell carcinoma.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eNegative for histology\u003c/strong\u003e\u003cp\u003eNegative for dysplasia, non-specific cervicitis, benign cervical polyp.\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003ch2\u003eSocio-demographic characteristics of the participants\u003c/h2\u003e\n \u003cp\u003eA total of 307 samples were initially included; however, four were excluded due to poor sample quality (bloody or insufficient sample volume), which left 303 for final analysis. The mean age of the participants was 48.4 years (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;10.77). The majority, 109 (37.5%), of participants were between the ages of 50 and 59 years old. More than half of the women, 190 (62.7%), were married. In terms of education, 127 (42.3%) had no formal education, 50 (16.7%) attended primary school, 59 (19.7%) completed secondary education, and 64 (21.3%) had tertiary education. Regarding gynaecologic and behavioural characteristics of participants, the majority, 190 (63.1%), were in the menopause stage, 139 (53.1%) reported their first sexual intercourse between ages 15 and 19, and 139 (53.7%) had two or more sexual partners. Seventy-nine (26.2%) had a history of sexually transmitted infections, while only 1.8% reported smoking. Histology showed that 158 (52.1%) had CIN1, followed by CIN2/3, 56 (18.5%), invasive cancer, 39 (12.9%), and carcinoma in situ, 11 (3.6%) (\u003cstrong\u003eSupplementary file 2\u003c/strong\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003eDiagnostic Performance of OncoE6 and VIA\u003c/h2\u003e\n \u003cp\u003eOverall, 67 of 303 women (22.1%) tested positive using the OncoE6 lateral flow assay. Among those who tested positive, 97.7% had HPV-16, 1.7% had HPV-18, and 0.7% had dual infections. VIA was performed on 143 women, 84.6% of whom tested positive. Histology confirmed CIN2\u0026thinsp;+\u0026thinsp;in 106 women (34.98%). Correlation analysis showed a strong correlation between histology and OncoE6 (r\u0026thinsp;=\u0026thinsp;0.66, P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), while VIA had a weaker correlation with histology (r\u0026thinsp;=\u0026thinsp;0.34, P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) and with OncoE6 (r\u0026thinsp;=\u0026thinsp;0.27, P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001 (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eFor OncoE6, sensitivity was 59.4% (95% CI: 49.5\u0026ndash;68.9), specificity 97.9% (95% CI: 94.9\u0026ndash;99.4), PPV 94.0% (95% CI: 85.5\u0026ndash;97.7), and NPV 81.8% (95% CI: 78.1\u0026ndash;85.0). Overall accuracy was 84.5% (95% CI: 79.9\u0026ndash;88.4), with a kappa of 0.63 (95% CI: 0.53\u0026ndash;0.72) (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The ROC analysis showed that the area under the curve (AUC) was 0.80 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating good diagnostic accuracy; the test\u0026apos;s ability to distinguish between true positive and true negative was statistically significant (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDiagnostic performance of OncoE6 and VIA test in selected health facilities in Ethiopia, 2023.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMethods\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTrue positive (TP)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTrue Negative (TN)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFalse Positive (FP)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFalse Negative (FN)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSensitivity\u003c/p\u003e\n \u003cp\u003e% (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSpecificity\u003c/p\u003e\n \u003cp\u003e% (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePPV\u003c/p\u003e\n \u003cp\u003e% (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNPV\u003c/p\u003e\n \u003cp\u003e% (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAccuracy\u003c/p\u003e\n \u003cp\u003e% (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eKappa value\u003c/p\u003e\n \u003cp\u003eK (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOncoE6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e193\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59.43\u003c/p\u003e\n \u003cp\u003e(49.46\u0026ndash;68.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e97.97\u003c/p\u003e\n \u003cp\u003e(94.88\u0026ndash;99.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94.03 (85.51\u0026ndash;97.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e81.77 (78.07\u0026ndash;84.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e84.48 (79.91\u0026ndash;88.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003cp\u003e(0.53\u0026ndash;0.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVIA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95.77\u003c/p\u003e\n \u003cp\u003e(88.14\u0026ndash;99.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.39\u003c/p\u003e\n \u003cp\u003e(16.70\u0026ndash;38.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.20 (37.69\u0026ndash;44.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e92.06 (78.21\u0026ndash;97.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50.67 (42.19\u0026ndash;59.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003cp\u003e(0.11\u0026ndash;0.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEither OncoE6 OR VIA positive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e142\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83.96%75.57% to 90.37%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e72.08%65.26% to 78.22%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61.82%56.04% to 67.29%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e89.30%84.26% to 92.86%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e76.24%71.04% to 80.92%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003cp\u003e(0.41\u0026ndash;0.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eFor the VIA evaluation, 143 participants were included; the sensitivity was 95.77% (95% CI: 88.14\u0026ndash;99.12), and the specificity was 26.39% (95% CI: 16.70\u0026ndash;38.10). The PPV was 41.20% (95% CI: 37.69\u0026ndash;44.79), and the NPV was 92.06% (95% CI: 78.21\u0026ndash;97.40). The accuracy and Kappa value were 50.67% (95% CI: 42.19\u0026ndash;59.13) and 0.22 (95% CI: 0.11\u0026ndash;0.34), respectively. The ROC analysis showed that the AUC was 0.61 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cstrong\u003eand\u003c/strong\u003e Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Additionally, we analysed a parallel strategy (OncoE6 OR VIA positive), sensitivity and specificity were 84.0% (95% CI: 75.6\u0026ndash;90.4) and 72.1% (95% CI: 65.3\u0026ndash;78.2), respectively \u003cstrong\u003e(\u003c/strong\u003eTable \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cstrong\u003e).\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\n \u003ch2\u003eFactors Associated with the positivity rates\u003c/h2\u003e\n \u003cp\u003eAs shown in Tables \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e, CIN-1 was most common among women aged 40 to 54, and the age group greater than 55 was 61(50%) and 65 (63.73%), respectively. These age groups had significantly higher odds of being with CIN-1, CIN-2/3, and ICC/CIS (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). OncoE6 positivity was slightly higher in the age of 40\u0026ndash;54 (AOR: 1.67; 95% CI: 0.62\u0026ndash;4.48) and 55\u0026thinsp;+\u0026thinsp;years (AOR: 1.10; 95% CI: 0.38\u0026ndash;3.20); however, these associations are not statistically significant (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Married women were more likely to have CIN1 (AOR: 11.7; 95% CI: 1.4\u0026ndash;96.9). Women without formal education were significantly associated with OncoE6 and VIA positivity (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Women who cannot read and write were linked to higher rates of CIN1 (28.2%) and CIN2/3 (32.3%), but these associations were not statistically significant (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Tables \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). OncoE6 positivity increased with disease severity: 54.5% in CIN2/3 and 64.7% in ICC/CIS, while 50% of normal, 92.5% CIN1, and 95.8% CIN2\u0026thinsp;+\u0026thinsp;were positive for VIA (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAssociations of sociodemographic and behavioral factors with histology results in selected health facilities in Ethiopia, 2023.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"13\"\u003e\n \u003cp\u003eBiopsy result\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eCIN-1\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eCIN-2\u0026amp;3\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eICC/CIS\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOR\u003c/p\u003e\n \u003cp\u003e(95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOR\u003c/p\u003e\n \u003cp\u003e(95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOR\u003c/p\u003e\n \u003cp\u003e(95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOR (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOR\u003c/p\u003e\n \u003cp\u003e(95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOR\u003c/p\u003e\n \u003cp\u003e(95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25- 39yrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24(35.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (41.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9(13.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (10.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40-54yrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13(10.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61(50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.02 (1.79\u0026ndash;9.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.4 (2.43\u0026ndash;29.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (16.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.1(1.46\u0026ndash;11.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.76 (0.51\u0026ndash;6.08),\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.369\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (22.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.4\u003c/p\u003e\n \u003cp\u003e(2.5\u0026ndash;21.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.89 (1.39\u0026ndash;34.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.018*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(0.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65 (63.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54.9 (7.1-425.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63.2 (6.38\u0026ndash;625.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24 (23.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e64.0 (7.5\u0026ndash;545.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.7 (2.3- 238.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.007*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (11.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.6\u003c/p\u003e\n \u003cp\u003e(4.9\u0026ndash;402.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39.4 (2.86\u0026ndash;543.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.003*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnmarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (38.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (23.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5(38.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 (12.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e105 (55.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.6 (1.70-34.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.7 (1.4\u0026ndash;96.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.023*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 (18.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.52 (0.40\u0026ndash;5.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.18 (0.39\u0026ndash;12.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.372\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (14.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDivorced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (12.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (49.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.43 (1.23\u0026ndash;33.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.21 (0.9 -104.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.050\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (14.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.14 (0.23\u0026ndash;5.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.08 (0.27\u0026ndash;16.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.484\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (23.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWidowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (8.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24 (53.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.58 (1.61\u0026ndash;56.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.3 (0.9\u0026ndash;118.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.063\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7(15.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.75(0.31\u0026ndash;10.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.34 (0.15\u0026ndash;12.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.795\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (9.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 (28.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.33 (0.11\u0026ndash;1.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.22 (0.05\u0026ndash;1.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.056\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40(32.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.0 (1.21\u0026ndash;20.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.04 (0.96\u0026ndash;37.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.055\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37 (29.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.5 (1.69\u0026ndash;53.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.43 (0.44\u0026ndash;26.96),\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.241\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.58 (0.17\u0026ndash;1.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.38 (0.08\u0026ndash;1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.224\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6(12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.5(0.28\u0026ndash;8.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.86 (0.11\u0026ndash;6.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.882\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.0 (0.59\u0026ndash;27.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.59 (0.06\u0026ndash;6.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.666\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11(18.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40 (67.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.42 (0.14\u0026ndash;1.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.56 (0.14\u0026ndash;2.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.412\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5(8.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.68(0.13\u0026ndash;3.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.15 (0.17\u0026ndash;7.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.890\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (5.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.85 (0.11\u0026ndash;6.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.46 (0.04\u0026ndash;4.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.520\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTertiary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (9.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52 (81.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4(6.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (3.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge of first sex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;15yrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(3.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12(46.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.1 (0.21\u0026ndash;21.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.43 (0.35\u0026ndash;119.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.212\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9(34.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.0 (0.94\u0026ndash;153.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.16 (0.35\u0026ndash;238.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.183\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (15.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15-19yrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27(19.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59(42.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.4 (0.13\u0026ndash;1.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.11 (0.23\u0026ndash;5.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.899\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30(21.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.48 (0.30\u0026ndash;7.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.54 (0.18\u0026ndash;13.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.696\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 (16.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20-24yrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6(8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49(71.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.6 (0.41\u0026ndash;6.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.15 (0.380\u0026ndash;12.111)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.387\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9(13.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.00 (0.32\u0026ndash;12.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.42 (0.24\u0026ndash;24.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.452\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (7.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4(13.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22(75.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3(10.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of STI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10(12.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55(69.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.6 (0.72\u0026ndash;3.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.59 (0.56\u0026ndash;4.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.382\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6(7.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.36 (0.12\u0026ndash;1.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (10.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.54 (0.19\u0026ndash;1.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.40 (0.08\u0026ndash;1.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.265\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29(13.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e102(45.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49(22.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42 (18.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"14\"\u003eAOR, adjusted odds ratios; COR, crude odds ratios; CI, confidence interval. (*) Statistically significant at p\u0026thinsp;\u0026le;\u0026thinsp;0.05.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"14\"\u003eCIN: Cervical Intraepithelial Neoplasia; CIS: Carcinoma In Situ; ICC: Invasive Cervical Cancer; VIA: Visual Inspection with Acetic Acid;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab3\" border=\"1\" class=\"fr-table-selection-hover\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAssociations of sociodemographic and behavioral factors with VIA and OncoE6 results in selected health facilities in Ethiopia, 2023.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003eVIA\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003eOncoE6\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNegative\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePositive\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCOR\u003c/p\u003e\n \u003cp\u003e(95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAOR\u003c/p\u003e\n \u003cp\u003e(95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNegative\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePositive\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCOR\u003c/p\u003e\n \u003cp\u003e(95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAOR\u003c/p\u003e\n \u003cp\u003e(95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25- 39yrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11(16.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45 (68.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57(83.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11(16.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40-54yrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10(8.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51 (42.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.99(.40-2.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.724\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e90 (73.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32 (26.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.84(0.86\u0026ndash;3.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.67 (0.62, 4.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.313\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (16.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80(78.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (21.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.43(0.64\u0026ndash;3.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.10\u003c/p\u003e\n \u003cp\u003e(0.38, 3.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.866\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnmarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(7.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (53.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7(53.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6(46.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (7.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68 (36.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.59 (0.07\u0026ndash;5.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.71 (0.05\u0026ndash;9.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.800\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e152(80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.43 (1.09\u0026ndash;10.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.32 (0.07\u0026ndash;1.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.151\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDivorced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (7.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27(50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.96 (0.09\u0026ndash;10.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.31 (0.29\u0026ndash;5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0. 337\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45(81.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10(18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.86 (1.06\u0026ndash;13.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.51 (0.09, 2.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.439\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWidowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (6.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19(42.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.91 (0.08\u0026ndash;10.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.01 (0.04\u0026ndash;23.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 .995\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32(71.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13(28.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.11(0.59\u0026ndash;7.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.56 (0.10, 3.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.504\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6(4.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e77(62.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.83 (3.15\u0026ndash;52.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34.27 (1.47\u0026ndash;799.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.028*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e70(56.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54(43.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.69 (4.67\u0026ndash;52.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.76 (3.58\u0026ndash;78.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.0001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4(8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15(30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.80(0.61\u0026ndash;12.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.62\u003c/p\u003e\n \u003cp\u003e(0.44-257.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.147\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45 (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5(10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.26 (0.51\u0026ndash;9.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.62 (0.25\u0026ndash;10.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.617\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5(8.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18(31.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.60(0.80\u0026ndash;16.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.44\u003c/p\u003e\n \u003cp\u003e(0.21\u0026ndash;93.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.337\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54(91.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5(8.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.88 (0.43\u0026ndash;8.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.12 (0.38\u0026ndash;11.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.394\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTertiary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5(7.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7(11.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61(95.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3(4.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge of first sex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;15yrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12(48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15(57.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11(42.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.8 (2.32-168.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.01 (0.37\u0026ndash;43.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.255\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15-19yrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17(12.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60(43.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.02 (0.10-10.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e101\u003c/p\u003e\n \u003cp\u003e(72.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38(27.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.16 (1.33\u0026ndash;77.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.05 (0.32\u0026ndash;28.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.331\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20-24yrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4(5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12(17.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00 (0.08\u0026ndash;12.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63 (91.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6(8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.53 (0.29, 22.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.46 (0.14\u0026ndash;15.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.744\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(3.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3(10.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28(96.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(3.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of STI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40(51.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.65 (1.52\u0026ndash;89.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.38\u003c/p\u003e\n \u003cp\u003e(0.96\u0026ndash;247.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.054\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e73(92.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6(7.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21(9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e81(36.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e161\u003c/p\u003e\n \u003cp\u003e(72.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61(27.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\"\u003e*indicates level of significance\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\"\u003eSTI: Sexually Transmitted Infection AOR, adjusted odds ratios; COR, crude odds ratios; CI, confidence interval. (*) Statistically significant at p\u0026thinsp;\u0026le;\u0026thinsp;0.05\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study evaluated the diagnostic performance of the OncoE6\u0026trade; lateral flow test against histology, assessed VIA performance and examined factors associated with test positivity among women over 25 years old in Ethiopia. The study found that the OncoE6 test had moderate sensitivity (59.4%) and high specificity (98%), while VIA demonstrated high sensitivity (95.8%) but low specificity (26.4%). When used in parallel (OncoE6 OR VIA positive), sensitivity improved to 83.7% with a specificity of 71.4%. Age, education, and age at first sexual intercourse were significantly associated with test positivity.\u003c/p\u003e\u003cp\u003eIn this study, the diagnostic performance of OncoE6 (sensitivity 59.4%, specificity 98%, PPV 94.0%, NPV 81.8%) was consistent with findings from Bangladesh (52% sensitivity, 97% specificity) (\u003cb\u003e9\u003c/b\u003e) and Burundi (58.3% sensitivity, 97.9% specificity among CIN3\u0026thinsp;+\u0026thinsp;HIV-positive women) (\u003cb\u003e14\u003c/b\u003e). Our results also showed that OncoE6 positivity increased with disease severity, from 2.5% in CIN1 to 54.5% in CIN2/3 and 64.7% in invasive cancer or carcinoma in situ (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). This pattern has been documented in other studies, where OncoE6 sensitivity rises for higher-grade lesions, particularly CIN3+ (\u003cb\u003e9, 13\u0026ndash;16\u003c/b\u003e). This increase is due to its detection of HPV16/18 E6 oncoproteins, which are more strongly associated with advanced lesions (\u003cb\u003e17, 18\u003c/b\u003e).\u003c/p\u003e\u003cp\u003eDespite its specificity, OncoE6 may miss cases caused by non-HPV16/18 genotypes, which are prevalent in Ethiopia, where HPV16/18 account for 64\u0026ndash;90% of cervical cancers, but non-16/18 types remain significant (\u003cb\u003e18, 19\u003c/b\u003e). Lower sensitivity has also been reported elsewhere, including Zambia (31%) (\u003cb\u003e16\u003c/b\u003e), Burundi (42.1% for CIN2+) (\u003cb\u003e14\u003c/b\u003e), and China (42.4% for CIN2\u0026thinsp;+\u0026thinsp;and 53.5% for CIN3+) (\u003cb\u003e15\u003c/b\u003e), although specificity consistently exceeded 95% (\u003cb\u003e14, 15\u003c/b\u003e). This variability may reflect differences in genotype distribution, regional E6 gene mutations (\u003cb\u003e20\u003c/b\u003e), and test methodology (\u003cb\u003e21\u003c/b\u003e). For example, Yang et al. (\u003cb\u003e20\u003c/b\u003e) reported E6 gene mutations in HPV16/18 among cervical cancer patients in Southwest China. This suggests that genetic variation may affect assay performance.\u003c/p\u003e\u003cp\u003eIn our study, VIA showed high sensitivity (95.8%) and low specificity (26.4%), which aligned with reports from Pakistan (93.5% sensitivity) (\u003cb\u003e22\u003c/b\u003e) and the Multicentric Study for Cervical Cancer Screening and Triage with Human Papillomavirus Tests (ESTAMPA) study (85.9% sensitivity for CIN3+) (\u003cb\u003e23\u003c/b\u003e). In Ethiopia, VIA remains the main screening tool where cytology and molecular testing are not accessible (\u003cb\u003e24\u003c/b\u003e). However, a systematic review by Sauvaget et al. (25) reported a higher specificity of 92%. Studies in Congo Kinshasa (sensitivity 55.5%, specificity 64.6%) (26) and Nigeria (sensitivity 60%, specificity 94.4%) (27) showed considerable variation. These variations reflect provider training and experience (e.g., physicians versus nurses), patient age (identifying low-grade lesions can be challenging in elderly patients), and benign conditions that resemble aceto-white changes, such as atrophy, immature metaplasia, and HPV infection (\u003cb\u003e26, 28\u0026ndash;30\u003c/b\u003e).\u003c/p\u003e\u003cp\u003eWhen OncoE6 and VIA were combined in a parallel strategy, sensitivity and specificity reached 84.0% and 72.1%, respectively. This finding suggests that using both methods simultaneously could significantly improve the overall diagnostic performance, specifically by enhancing the sensitivity of OncoE6 and the specificity of VIA. Similar improvements with dual testing have been reported in other studies (\u003cb\u003e31, 32\u003c/b\u003e). This approach could improve screening effectiveness in low-resource settings where advanced tests are not available.\u003c/p\u003e\u003cp\u003eIn this study, age was significantly associated with disease severity. Women over 40 were more likely to develop higher-grade lesions. Married women were more likely to have CIN1, while a lower educational background, particularly women with no formal education, was linked to increased positivity with both VIA and OncoE6. Early sexual debut (15\u0026ndash;19 years old) was also associated with VIA positivity. Comparable findings have been reported in Addis Ababa, Ethiopia (\u003cb\u003e33\u003c/b\u003e), and older age, early sexual activity, long marital duration, and low education were associated with CIN (\u003cb\u003e34\u0026ndash;36\u003c/b\u003e). The risk of high-grade CIN and cancer is especially elevated in women over 55 due to persistent HR-HPV infections (\u003cb\u003e37\u003c/b\u003e). Limited education may contribute to higher risk by reducing awareness of HPV transmission, reducing access to screening and vaccination, and restricting healthcare access, particularly in rural areas (\u003cb\u003e28, 38\u003c/b\u003e).\u003c/p\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThis study has some limitations. The study did not include HPV genotyping to understand the distribution of HPV types since OncoE6 is limited to HPV 16/18. Another limitation is that VIA screening was not performed for all participants, which reduced the sample size and may have affected the sensitivity and specificity of the VIA method. Additionally, histology tests were performed by various pathologists at different sites, potentially introducing inter-observer variability.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDespite the moderate sensitivity of OncoE6 and the low specificity of VIA, our results showed a high specificity for the OncoE6 test and a high sensitivity for the VIA. In this study, we observed that using a parallel method (OncoE6 OR VIA positive) improved screening performance by increasing sensitivity. Integrating the OncoE6 lateral flow test with the existing VIA method offers a practical and effective way for early, on-site detection of cervical lesions. This is particularly valuable in settings where HPV DNA tests or liquid-based cytology are not available. However, this combined method needs more evaluation in larger, community-based studies in resource-limited settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eCIN\u0026nbsp;\u003c/strong\u003eCervical Intraepithelial Neoplasia\u003c/p\u003e\n\u003cp\u003eCIS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Carcinoma in Situ\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEPHI\u0026nbsp;\u003c/strong\u003eEthiopian Public Health Institute\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHIV\u0026nbsp;\u003c/strong\u003eHuman Immune Deficiency Virus\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHPV\u0026nbsp;\u003c/strong\u003eHuman Papilloma Virus\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHR-HPV\u0026nbsp;\u003c/strong\u003eHigh risk human papilloma virus\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eICC\u0026nbsp;\u003c/strong\u003eInvasive Cervical Cancer\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNPV\u0026nbsp;\u003c/strong\u003eNegative predictive value (NPV)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePPV\u0026nbsp;\u003c/strong\u003ePositive Predictive Value\u003c/p\u003e\n\u003cp\u003eROCReceiver Operating Characteristic\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVIA\u0026nbsp;\u003c/strong\u003eVisual Inspection with Acetic Acid\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWHO\u0026nbsp;\u003c/strong\u003eWorld Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures involving human participants were reviewed and approved by the Ethiopian Public Health Institute Institutional Review Board (EPHI-IRB) with approval number EPHI-IRB-347-2021. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Written informed consent was obtained from all individual participants included in the study. Confidentiality was maintained by not collecting identifying information, restricting data access, and using sample code numbers. The sample code number was used to identify each study participant. Written informed consent was obtained from each participant after explanation about the study’s purpose, procedures, risks, and benefits in their preferred language by a trained data collector. Participants were encouraged to ask questions, consult family, and take adequate time before providing written consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting the findings of this study are available from the corresponding author upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConception and design: Abebe Habteselassie, Ibrahim Heyredin, Belete Woldesemayat and Wudinesh Belete\u003c/p\u003e\n\u003cp\u003eAdministrative support: Jaleta Bulti, Minilik Demissie, Gemechu Tadesse, and Getachew Tollera\u003c/p\u003e\n\u003cp\u003eProvision of study materials or patients: Hezkiel Mamo, Kidist Zealiyas, Amelework Yilma, Getenet Hailu, Lemessa Negeri, Wegene Tamene, and Gemechu Gudeta\u003c/p\u003e\n\u003cp\u003eCollection and assembly of data: Kiflu Itefa, Gutema Bulti, Feyiso Bati, and Birra Bejiga\u003c/p\u003e\n\u003cp\u003eData analysis and interpretation: Belete Woldesemayat, Derbachew Asfaw, Abeje Kebede, Wudinesh Belete, Abebe Habteselassie and Getahun Fetensa, Minilik Demissie\u003c/p\u003e\n\u003cp\u003eManuscript writing: All authors\u003c/p\u003e\n\u003cp\u003eFinal approval of manuscript: All authors\u003c/p\u003e\n\u003cp\u003eAccountable for all aspects of the work: All authors\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe extend our sincere gratitude to all individuals and institutions who contributed to this research, including the Ethiopian Ministry of Health and the Amhara Public Health Institute. We also deeply appreciate the dedication of the staff at the selected hospitals and thank all study participants for their willingness to participate in this research\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Sharing Statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting the findings of this study are available from the corresponding author upon request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConception and design: Abebe Habteselassie, Ibrahim Heyredin, Belete Woldesemayat and Wudinesh Belete\u003c/p\u003e\n\u003cp\u003eAdministrative support: Jaleta Bulti, Minilik Demissie, Gemechu Tadesse, and Getachew Tollera\u003c/p\u003e\n\u003cp\u003eProvision of study materials or patients: Hezkiel Mamo, Kidist Zealiyas, Amelework Yilma, Getenet Hailu, Lemessa Negeri, Wegene Tamene, and Gemechu Gudeta\u003c/p\u003e\n\u003cp\u003eCollection and assembly of data: Kiflu Itefa, Gutema Bulti, Feyiso Bati, and Birra Bejiga\u003c/p\u003e\n\u003cp\u003eData analysis and interpretation: Belete Woldesemayat, Derbachew Asfaw, Abeje Kebede, Wudinesh Belete, Abebe Habteselassie and Getahun Fetensa, Minilik Demissie\u003c/p\u003e\n\u003cp\u003eManuscript writing: All authors\u003c/p\u003e\n\u003cp\u003eFinal approval of manuscript: All authors\u003c/p\u003e\n\u003cp\u003eAccountable for all aspects of the work: All authors\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ disclosures of potential conflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo potential conflicts of interest were reported by the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe extend our sincere gratitude to all individuals and institutions who contributed to this research, including the Ethiopian Ministry of Health and the Amhara Public Health Institute. We also deeply appreciate the dedication of the staff at the selected hospitals and thank all study participants for their willingness to participate in this research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention: use of dual-stain cytology to triage women after a positive test for human papillomavirus (HPV). World Health Organization; 2024. available at http://apps.who.int/iris.\u003c/li\u003e\n\u003cli\u003eDe Sanjosé S, Diaz M, Castellsagué X, et al. Worldwide prevalence and genotype distribution of cervical human papillomavirus DNA in women with normal cytology: a meta-analysis. The Lancet Infectious Diseases. 2007;7(7):453-9.\u003c/li\u003e\n\u003cli\u003eFederal Democratic Republic of Ethiopia Ministry of Health. Guideline for cervical cancer prevention and control in Ethiopia. Federal Democratic Republic of Ethiopia Ministry of Health. 2015:pp62.\u003c/li\u003e\n\u003cli\u003eLei J, Ploner A, Lagheden C, et al. High-risk human papillomavirus status and prognosis in invasive cervical cancer: a nationwide cohort study. PLoS Medicine. 2018 Oct 1;15(10):e1002666.\u003c/li\u003e\n\u003cli\u003eSung H, Ferlay J, Siegel RL, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: a cancer journal for clinicians. 2021;71(3):209 − 49.\u003c/li\u003e\n\u003cli\u003eArbyn M, Weiderpass E, Bruni L, et al. Estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis. The Lancet Global Health. 2020;8(2):e191-e203.\u003c/li\u003e\n\u003cli\u003eMulugeta SW, Mulugeta W. Diagnosis and risk factors of advanced cancers in Ethiopia. J Cancer Prev. 2019 Sep;24(3):163 − 72.\u003c/li\u003e\n\u003cli\u003eUnitaid. Screening and treatment of precancerous lesions for secondary prevention of cervical cancer: Technology landscape report. Geneva: World Health Organization; 2019 May. Available from: https://unitaid.org/assets/Cervical_Cancer_Technology-landscape-2019.pdf\u003c/li\u003e\n\u003cli\u003eAra R, Khatun S, Pervin S, et al. Role of molecular biomarker human papilloma virus (HPV) E6 oncoprotein in cervical cancer screening. Gynecologic oncology. 2020 Sep 1;158(3):590-6.\u003c/li\u003e\n\u003cli\u003eArbor Vita Corporation. OncoE6TM Cervical Test Instructions for Use. LBL2000050, Rev. N, 2020. Available from: http://www.arborvita.com/wp-content/uploads/2020/06/LBL2000050_OncoE6-Cervical-Test-Instructions-for-Use_RevN.pdf\u003c/li\u003e\n\u003cli\u003eKassa LS, Dile WM, Zenebe GK, et al. Precancerous lesions of cervix among women infected with HIV in Referral Hospitals of Amhara Region, Northwest Ethiopia: a cross-sectional study. African health sciences. 2019 Apr 22;19(1):1695 − 704.)\u003c/li\u003e\n\u003cli\u003eBulten J, Horvat R, Jordan J, et al. European guidelines for quality assurance in cervical histopathology. Acta Oncologica. 2011 Jun 1;50(5):611 − 20.\u003c/li\u003e\n\u003cli\u003eDerbie A, Mekonnen D, Nibret E, et al. Human papillomavirus genotype distribution in Ethiopia: an updated systematic review. Virology journal. 2022 Jan 15;19(1):13.\u003c/li\u003e\n\u003cli\u003eNdizeye Z, Menon S, Van Geertruyden J-P, et al. Performance of OncoE6TM Cervical Test in detecting cervical precancer lesions in HIV-positive women attending an HIV clinic in Bujumbura, Burundi: a cross-sectional study. BMJ open. 2019;9(9):e029088.\u003c/li\u003e\n\u003cli\u003eZhao F-H, Jeronimo J, Qiao Y-L, et al. An evaluation of novel, lower-cost molecular screening tests for human papillomavirus in rural China. Cancer prevention research. 2013;6(9):938 − 48.\u003c/li\u003e\n\u003cli\u003eChibwesha CJ, Frett B, Katundu K, et al. Clinical performance validation of four point-of-care cervical cancer screening tests in HIV-infected women in Zambia. Journal of lower genital tract disease. 2016;20(3):218.\u003c/li\u003e\n\u003cli\u003ePossati-Resende JC, Fritsch TZ, Souza KC. Risk Profile of High-grade Cervical Lesions and Cervical Cancer Considering the Combination of Cytology, HPV Genotype, and Age among Women Undergoing Colposcopy. Revista Brasileira de Ginecologia e Obstetrícia/RBGO Gynecology and Obstetrics. 2023 Nov;45(11):e689-98.\u003c/li\u003e\n\u003cli\u003eClifford GM, Smith JS, Aguado T, et al. Comparison of HPV type distribution in high-grade cervical lesions and cervical cancer: a meta-analysis. British journal of cancer. 2003 Jul;89(1):101-5.\u003c/li\u003e\n\u003cli\u003eLouie KS, De Sanjose S, Mayaud P. Epidemiology and prevention of human papillomavirus and cervical cancer in sub-Saharan Africa: a comprehensive review. Tropical Medicine \u0026amp; International Health. 2009 Oct;14(10):1287 − 302.\u003c/li\u003e\n\u003cli\u003eYang L, Yang H, Wu K, et al. Prevalence of HPV and variation of HPV 16/HPV 18 E6/E7 genes in cervical cancer in women in South West China. Journal of Medical Virology. 2014 Nov;86(11):1926-36.\u003c/li\u003e\n\u003cli\u003eZhang JJ, Cao XC, Zheng XY, et al. Feasibility study of a human papillomavirus E6 and E7 oncoprotein test for the diagnosis of cervical precancer and cancer. Journal of International Medical Research. 2018 Mar;46(3):1033-42.\u003c/li\u003e\n\u003cli\u003eAdnan Z, Khan AA, Nayyar S, et al. Diagnostic Accuracy of Visual Inspection with Acetic Acid (VIA) and PAP Smear in Diagnosing Cervical Cancer, Taking Histopathology as Gold Standard. Journal of the Society of Obstetricians and Gynaecologists of Pakistan. 2021 Apr 7;11(1):36–40\u003c/li\u003e\n\u003cli\u003eBaena A, Mesher D, Salgado Y, et al. Performance of visual inspection of the cervix with acetic acid (VIA) for triage of HPV screen-positive women: results from the ESTAMPA study. International Journal of Cancer. 2023 Apr 15;152(8):1581-92.\u003c/li\u003e\n\u003cli\u003eTesfaw G, Ahmed Y, Gedefaw L, et al. Liquid-based cytology for the detection of cervical intraepithelial lesions in Jimma town, Ethiopia. BMC cancer. 2020 Jul 29;20(1):706.\u003c/li\u003e\n\u003cli\u003eSauvaget C, Fayette JM, Muwonge R, et al. Accuracy of visual inspection with acetic acid for cervical cancer screening. International Journal of Gynecology \u0026amp; Obstetrics. 2011 Apr 1;113(1):14–24.\u003c/li\u003e\n\u003cli\u003eSangwa-Lugoma G, Mahmud S, Nasr SH, et al. Visual inspection as a cervical cancer screening method in a primary health care setting in Africa. International journal of cancer. 2006 Sep 15;119(6):1389-95.\u003c/li\u003e\n\u003cli\u003eAlbert SO, Oguntayo OA, Samaila MO. Comparative study of visual inspection of the cervix using acetic acid (VIA) and Papanicolaou (Pap) smears for cervical cancer screening. Ecancermedicalscience. 2012 Jul 23;6:262.\u003c/li\u003e\n\u003cli\u003eRaifu AO, El-Zein M, Sangwa-Lugoma G, et al. Congo Screening Study Group. Determinants of cervical cancer screening accuracy for visual inspection with acetic acid (VIA) and lugol’s iodine (VILI) performed by nurse and physician. PLoS One. 2017 Jan 20;12(1):e0170631.\u003c/li\u003e\n\u003cli\u003ePoli UR, Bidinger PD, Gowrishankar S. Visual inspection with acetic acid (via) screening program: 7 years experience in early detection of cervical cancer and pre-cancers in rural South India. Indian Journal of Community Medicine. 2015 Jul 1;40(3):203-7.\u003c/li\u003e\n\u003cli\u003eVahedpoor Z, Behrashi M, Khamehchian T, et al. Comparison of the diagnostic value of the visual inspection with acetic acid (VIA) and Pap smear in cervical cancer screening. Taiwanese Journal of Obstetrics and Gynecology. 2019 May 1;58(3):345-8.\u003c/li\u003e\n\u003cli\u003eJeronimo J, Bansil P, Lim J, et al. A multicountry evaluation of careHPV testing, visual inspection with acetic acid, and papanicolaou testing for the detection of cervical cancer. International Journal of Gynecological Cancer. 2014 Mar 1;24(3):576 − 85\u003c/li\u003e\n\u003cli\u003eQiao YL, Jeronimo J, Zhao FH, et al. Lower cost strategies for triage of human papillomavirus DNA-positive women. International journal of cancer. 2014 Jun 15;134(12):2891 − 901\u003c/li\u003e\n\u003cli\u003eFentie AM, Tadesse TB, Gebretekle GB. Factors affecting cervical cancer screening uptake, visual inspection with acetic acid positivity and its predictors among women attending cervical cancer screening service in Addis Ababa, Ethiopia. BMC women's health. 2020 Dec;20:1 − 0.\u003c/li\u003e\n\u003cli\u003eBhattacharyya AK, Nath JD, Deka H. Comparative study between pap smear and visual inspection with acetic acid (via) in screening of CIN and early cervical cancer. Journal of mid-life health. 2015 Apr 1;6(2):53 − 8.\u003c/li\u003e\n\u003cli\u003eLouie KS, De Sanjose S, Diaz M, et al. Early age at first sexual intercourse and early pregnancy are risk factors for cervical cancer in developing countries. British journal of cancer. 2009 Apr;100(7):1191-7.\u003c/li\u003e\n\u003cli\u003eEze JN, Emeka-Irem EN, Edegbe FO. A six-year study of the clinical presentation of cervical cancer and the management challenges encountered at a state teaching hospital in southeast Nigeria. Clinical Medicine Insights: Oncology. 2013 Jan;7:CMO-S12017.\u003c/li\u003e\n\u003cli\u003eChen HC, Schiffman M, Lin CY, et al. Persistence of type-specific human papillomavirus infection and increased long-term risk of cervical cancer. Journal of the National Cancer Institute. 2011 Sep 21;103(18):1387-96.\u003c/li\u003e\n\u003cli\u003eDarwati L and Nikmah K. The Relationship Between Educational Factors and Early Detection Behavior Cervical Cancer in Fertile Age Women. STRADA Jurnal Ilmiah Kesehatan. 2020;9(2):1481–1488. doi: 10.30994/sjik.v9i2.491.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cervical cancer, Evaluation, OncoE6, VIA, Screening method","lastPublishedDoi":"10.21203/rs.3.rs-8093024/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8093024/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eCervical cancer remains a significant public health challenge in resource-limited settings due to inadequate access to resource-intensive screening methods. This study aimed to evaluate the performance of the OncoE6 cervical test using histology as a reference method.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e\u003cp\u003eA facility-based cross-sectional study was conducted from November 2022 to June 2023. A total of 303 samples were collected from six hospitals across three regions of Ethiopia. The OncoE6 cervical test and Visual Inspection with Acetic Acid (VIA) were evaluated among women with negative and positive histology test results. Statistical analysis was performed using SPSS version 28 and MedCalc version 22.014. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and Receiver Operating Characteristic (ROC) curve were calculated.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e\u003cp\u003eThe sensitivity of the OncoE6 test was 59.4% (95% CI: 49.5%-68.9%), and specificity was 98% (95% CI: 94.9%-99.4%). The PPV was 94.0% (95% CI: 85.51\u0026ndash;97.68%), while the NPV was 81.8% (95% CI: 78.07\u0026ndash;84.97%). The VIA sensitivity, specificity, PPV, and NPV against histology were 95.8% (95% CI: 88.14%-99.12%), 26.4% (95% CI: 16.70%-38.10%), 41.2% (95% CI: 37.69\u0026ndash;44.79%), and 92.1% (95% CI: 78.21\u0026ndash;97.40%), respectively. The ROC curve showed an AUC of 0.80 for OncoE6 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and 0.61 for VIA (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). OncoE6 positivity increased with higher lesion grades. Additionally, the Sensitivity and specificity of the parallel (either OncoE6 OR VIA positive) were 84.0% (95% CI: 75.57\u0026ndash;90.37) and 72.1% (95% CI: 65.26\u0026ndash;78.22), respectively.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eIn this study, a high specificity of OncoE6 and a high sensitivity of VIA were observed. Using both in a parallel approach improved screening performance and can strengthen cervical cancer screening in resource-limited settings, but further community-based evaluation is still needed.\u003c/p\u003e","manuscriptTitle":"Oncoprotein E6 as a Diagnostic Marker in Human Papillomavirus-Associated Cervical Cancer Screening","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-03 12:33:55","doi":"10.21203/rs.3.rs-8093024/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-02T15:39:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"282136079522784340855361575904387243297","date":"2026-03-16T12:59:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"123966067182635836957417138420853372188","date":"2026-03-15T17:47:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"335385556108867034226092651859164393339","date":"2025-12-02T00:03:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-02T00:00:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-01T23:55:36+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-26T11:32:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-25T12:09:06+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2025-11-25T12:03:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ea0f76fc-bf38-4821-a055-200058c9c70f","owner":[],"postedDate":"December 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-03T12:33:56+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-03 12:33:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8093024","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8093024","identity":"rs-8093024","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}