{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T18:09:55Z","timestamp":1788977395681,"version":"build-2803163510"},"reference-count":48,"publisher":"Public Library of Science (PLoS)","issue":"9","license":[{"start":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T00:00:00Z","timestamp":1788912000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Visual Inspection with Acetic acid (VIA) is widely used for detecting cervical (pre)cancer in resource-limited settings due to its simplicity and cost-effectiveness. However, the finding of cervical leukoplakia, poses diagnostic challenges.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This retrospective observational study evaluated the prevalence, associated risk factors, and referral outcomes of cervical leukoplakia among 13,861 women previously screened for cervical cancer in Ghana between June 2016 and May 2024. Screening approaches included VIA alone, mobile colposcopy alone, or VIA\/mobile colposcopy combined with other tests (HPV DNA testing and\/or cytology).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Among 120 women (0.9%) with leukoplakia, 112 (93.3%) did not have acetowhitening on VIA\/mobile colposcopy, and 21 (17.5%) received LEEP. The histopathology results ranged from no Cervical Intraepithelial Neoplasia (CIN) (15) to CIN I (2), CIN II (1), and CIN III (3). High-risk HPV positivity (aOR: 30.27; 95% CI: 3.56\u2013257.37) and HIV infection (aOR: 8.27; 95% CI: 1.18\u201357.69) were associated with higher odds of leukoplakia in VIA-screened women.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Leukoplakia can be clinically important without coexistence with acetowhitening. The association of leukoplakia with hrHPV and HIV, coupled with a high referral default and logistical barriers to biopsy and histopathology, calls for simplified management protocols and point-of-care triage tools for cervical screening in low-resource settings.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0345847","type":"journal-article","created":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T17:38:28Z","timestamp":1788975508000},"page":"e0345847","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Cervical leukoplakia in Ghana: Unveiling diagnostic challenges and informing low-resource screening strategies"],"prefix":"10.1371","volume":"21","author":[{"given":"Kofi","family":"Effah","sequence":"first","affiliation":[{"name":"Cervical Cancer Prevention and Training Centre, Catholic Hospital","place":["Ghana"]},{"name":"Catholic Hospital","place":["Battor, Ghana"],"department":["Department of Obstetrics and Gynaecology"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ethel","family":"Tekpor","sequence":"additional","affiliation":[{"name":"Cervical Cancer Prevention and Training Centre, Catholic Hospital","place":["Ghana"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maxwell","family":"Afetor","sequence":"additional","affiliation":[{"name":"Fred N. Binka School of Public Health, University of Health and Allied Sciences","place":["Ho, Volta Region, Ghana"],"department":["Department of Epidemiology and Biostatistics"]},{"name":"Volta Regional Health Directorate, Ghana Health Service","place":["Ho, Volta Region, Ghana"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joseph Emmanuel","family":"Amuah","sequence":"additional","affiliation":[{"name":"University of Ottawa","place":["Ottawa, ON, Canada"],"department":["School of Epidemiology and Public Health, Faculty of Medicine"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Comfort Mawusi","family":"Wormenor","sequence":"additional","affiliation":[{"name":"University of Ghana Medical Centre","place":["Ghana"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Annita Edinam","family":"Dugbazah","sequence":"additional","affiliation":[{"name":"Cervical Cancer Prevention and Training Centre, Catholic Hospital","place":["Ghana"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stephen","family":"Danyo","sequence":"additional","affiliation":[{"name":"Cervical Cancer Prevention and Training Centre, Catholic Hospital","place":["Ghana"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Seyram","family":"Kemawor","sequence":"additional","affiliation":[{"name":"Cervical Cancer Prevention and Training Centre, Catholic Hospital","place":["Ghana"]},{"name":"Central Laboratory, Catholic Hospital","place":["Battor, Ghana"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Edna","family":"Sesenu","sequence":"additional","affiliation":[{"name":"Cervical Cancer Prevention and Training Centre, Catholic Hospital","place":["Ghana"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher","family":"Nyamekye","sequence":"additional","affiliation":[{"name":"Catholic Hospital","place":["Battor, Ghana"],"department":["Department of Obstetrics and Gynaecology"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7476-4578","authenticated-orcid":true,"given":"Emmanuel Timmy","family":"Donkoh","sequence":"additional","affiliation":[{"name":"Screen-and-Treat Research Group, Centre for Research in Applied Biology, School of Sciences, University of Energy and Natural Resources","place":["Sunyani, Ghana"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chrysantus","family":"Kubio","sequence":"additional","affiliation":[{"name":"Volta Regional Health Directorate, Ghana Health Service","place":["Ho, Volta Region, Ghana"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4077-6228","authenticated-orcid":true,"given":"Kofi","family":"Adum-Attah","sequence":"additional","affiliation":[{"name":"Cape Coast Teaching Hospital","place":["Cape Coast, Ghana"],"department":["Department of Family 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A practical manual on visual screening for cervical neoplasia. 2018."},{"issue":"6","key":"pone.0345847.ref016","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0350573","article-title":"A collaborative cervical precancer screening strategy with concurrent HPV genotyping and visual inspection using alumni of a training centre across Ghana: the Rotary \u201cProtect Your Pearl\u201d initiative","volume":"21","author":"K Effah","year":"2026","journal-title":"PLoS One"},{"issue":"1","key":"pone.0345847.ref017","doi-asserted-by":"crossref","first-page":"1744","DOI":"10.1038\/s41598-024-81274-5","article-title":"Nationwide cervical precancer screening in Ghana: concurrent HPV DNA testing and visual inspection under an expanded hub-and-spoke model","volume":"15","author":"K Effah","year":"2025","journal-title":"Sci Rep"},{"issue":"3","key":"pone.0345847.ref018","doi-asserted-by":"crossref","first-page":"134","DOI":"10.4314\/gmj.v56i3.2","article-title":"Application of the hub and spokes model in improving access to cervical cancer screening in Ghana","volume":"56","author":"K Effah","year":"2022","journal-title":"Ghana Med J"},{"issue":"1","key":"pone.0345847.ref019","doi-asserted-by":"crossref","first-page":"428","DOI":"10.1186\/s12913-025-12466-6","article-title":"A community-focused cervical and breast cancer screening program using a sustainable funding model in a training center in Ghana","volume":"25","author":"K Effah","year":"2025","journal-title":"BMC Health Serv Res"},{"key":"pone.0345847.ref020","author":"B Sansure"},{"key":"pone.0345847.ref021","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pgph.0001639","article-title":"Evaluating operational parameters of the careHPV, GeneXpert, AmpFire, and MA-6000 HPV systems for cervical precancer screening: experience from Battor, Ghana","volume":"3","author":"K Effah","year":"2023","journal-title":"PLOS Global Public Health"},{"key":"pone.0345847.ref022","doi-asserted-by":"crossref","first-page":"114709","DOI":"10.1016\/j.jviromet.2023.114709","article-title":"Comparison of the AmpFire and MA-6000 polymerase chain reaction platforms for high-risk human papillomavirus testing in cervical precancer screening","volume":"316","author":"K Effah","year":"2023","journal-title":"J Virol Methods"},{"issue":"6","key":"pone.0345847.ref023","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0218559","article-title":"Performance of careHPV, hybrid capture 2 and visual inspection with acetic acid for detection of high-grade cervical lesion in Tanzania: a cross-sectional study","volume":"14","author":"J Katanga","year":"2019","journal-title":"PLoS One"},{"key":"pone.0345847.ref024","doi-asserted-by":"crossref","first-page":"118","DOI":"10.1016\/j.ygyno.2017.11.002","article-title":"Screening for cervical cancer among HIV-positive and HIV-negative women in Cameroon using simultaneous co-testing with careHPV DNA testing and visual inspection enhanced by digital cervicography: findings of initial screening and one-year follow-up","volume":"148","author":"P Cholli","year":"2018","journal-title":"Gynecol Oncol"},{"key":"pone.0345847.ref025","first-page":"119","article-title":"The AmpFire HPV Technology","author":"JL Belinson","year":"2021","journal-title":"HPV World"},{"key":"pone.0345847.ref026","author":"K Effah","year":"2021"},{"key":"pone.0345847.ref027","unstructured":"WHO. 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