In the Lira district of northern Uganda, nurse midwives at outpatient clinics used to screen dozens of women each week for cervical cancer using visual inspection with acetic acid, or VIA. They would swab the cervix with dilute vinegar, wait a minute, and look for white patches that signal precancerous lesions. The procedure took less than ten minutes, required no laboratory, and cost roughly US$0.30 per patient. But since early 2025, many of those same clinics have run out of the reagent. The shelves where bottles of acetic acid solution once sat are empty. Some facilities have not received a new supply in six months.

Across Uganda's northern and eastern regions, the impact is measurable: quarterly screening numbers have fallen by 60 percent or more compared to 2023, according to district health officers who spoke on condition of anonymity because they are not authorized to release data. In Gulu, the regional referral hospital recorded only 140 VIA screens in the first quarter of 2026, down from 410 in the same period two years earlier. The decline reflects a broader breakdown in the supply chain for a simple, low-cost tool that the World Health Organization has recommended for low-resource settings since 2009.

Acetic Acid Shortage Leaves Clinics Empty-Handed

Thousands of women who would have been screened are now leaving clinics without an appointment. In Lira, one health center III — the lowest level of government facility that offers VIA — reported that it had turned away roughly 300 women between January and April 2026 because the reagent was unavailable. The nurse midwife in charge described the situation as heartbreaking: women often walk several kilometers to reach the clinic, only to be told to come back another time.

Health facilities have tried to ration their remaining supplies. Some dilute the acetic acid further than the standard 3–5 percent concentration, which reduces sensitivity. Others reserve the reagent only for women with visible symptoms, defeating the purpose of screening asymptomatic individuals. A few clinics have attempted to prepare their own solution using store-bought vinegar, but the concentration is inconsistent and the results unreliable.

The shortage is not localized. According to the Ugandan National Medical Stores, orders for acetic acid solution fell by more than half in 2025 compared to the previous year. James Okello, a procurement officer at NMS, explained that the main global supplier had shifted production lines during the COVID-19 pandemic and never fully restored capacity for the dilute medical-grade solution. Uganda's buffer stocks, which were meant to cover six months of demand, were exhausted by mid-2025, and no emergency procurement mechanism was triggered.

Nurse midwives, who are the backbone of Uganda's cervical cancer screening program, report feeling powerless. "I have nothing to offer them," said Grace Auma, a nurse midwife at Lira Health Center III. "They come expecting help, and I send them home with a promise that we will call when the reagent arrives. But I don't know when that will be."

Why VIA Matters for Cervical Cancer Prevention

Visual inspection with acetic acid is not a perfect test. Its sensitivity ranges from 60 to 80 percent in various studies, lower than the 90 percent or more achieved by HPV DNA testing. But VIA has one critical advantage: it can be performed by a trained nurse midwife in a single visit, with immediate results. If a lesion is detected, the same clinician can treat it with cryotherapy or thermal ablation on the spot. This "screen-and-treat" approach eliminates the need for women to return for results or travel to a distant lab.

The WHO has endorsed VIA as the primary screening method for low-resource settings since its 2021 guideline update, recommending it where HPV testing is not yet available. Uganda adopted VIA in the early 2000s as part of its national cervical cancer control program. By 2020, more than 1,000 health facilities offered VIA screening, and the country had trained over 2,000 nurse midwives in the technique. Coverage, however, remained low — roughly 15 percent of eligible women had ever been screened, according to a 2022 Ministry of Health report.

VIA's reliance on a single reagent — dilute acetic acid — makes it vulnerable to supply disruptions. Unlike Pap smears, which require cytology labs and trained pathologists, VIA needs only vinegar, a speculum, a light source, and a cryotherapy unit. When the reagent runs out, the entire screening program grinds to a halt because there is no alternative that can be performed at the same level of care. Pap smears are not feasible in most rural Ugandan facilities due to a lack of laboratory infrastructure and trained cytotechnicians.

The current shortage has exposed a structural weakness: the national program did not diversify its supply chain or invest in local production of acetic acid solution. Uganda imports nearly all of its medical-grade acetic acid from a single manufacturer in India. When that manufacturer experienced production difficulties, the pipeline dried up with no backup.

Evidence from the Field: Declining Screening Rates

Data from district health information systems tell a stark story. In Lira district, the number of women screened via VIA dropped from 1,240 in the first quarter of 2024 to 510 in the first quarter of 2025, and further to 210 in the first quarter of 2026 — a decline of roughly 80 percent from the 2024 baseline. The district health officer attributed the fall directly to the reagent shortage, noting that other factors such as staffing and demand remained stable.

Gulu Regional Referral Hospital, which serves as a hub for several surrounding districts, reported similar trends. Its VIA screening numbers fell from 410 in Q1 2024 to 170 in Q1 2026. The hospital's gynecologist explained that they have been forced to prioritize symptomatic women — those with abnormal bleeding or discharge — for the limited available tests, while asymptomatic women are deferred indefinitely. Quarterly screening targets set by the Ministry of Health have been missed repeatedly since mid-2025.

Community health workers, who play a key role in mobilizing women for screening, have grown frustrated. In Lira, one village health team member said that women who were previously enthusiastic about screening have stopped coming after being turned away once or twice. "They think the service is no longer available," she said. "Some have told me they will wait until they feel sick, but by then it may be too late."

The decline is not uniform across the country. Some districts in central and western Uganda, closer to the capital Kampala, have maintained more consistent supplies. But in the north and east, where poverty rates are higher and health infrastructure weaker, the shortage has hit hardest. These are also the regions with the highest cervical cancer incidence and mortality in Uganda, according to the Uganda Cancer Institute.

Supply Chain Breakdown Behind the Scenes

The root of the shortage lies in a fragile procurement system. Uganda's National Medical Stores (NMS) is responsible for purchasing and distributing essential medicines and supplies to public health facilities. For acetic acid solution, NMS relied on a single international tender awarded to a manufacturer in India. When that manufacturer experienced a raw material shortage in late 2024, it reduced production of the medical-grade solution. NMS did not have a second supplier on contract, and the tender process to find an alternative took nearly a year.

Local compounding of acetic acid solution is technically possible. Several private pharmacies in Kampala prepare dilute acetic acid for dermatological use. But scaling up production to meet national screening demand would require investment in quality control, packaging, and distribution — steps that no government agency has yet taken. The Uganda National Drug Authority requires that any medical product distributed to public facilities meet strict standards, and no local manufacturer has applied for approval to produce VIA reagent.

Buffer stocks, which are meant to cover supply interruptions of three to six months, were exhausted by mid-2025. In normal times, NMS maintains a three-month buffer for most essential items. But for acetic acid, the buffer had been depleted during the COVID-19 pandemic when screening programs were suspended, and it was never fully replenished. By the time the shortage became apparent, there was no reserve to draw on.

No emergency procurement mechanism was triggered. Unlike for life-saving medicines such as antiretrovirals or malaria drugs, which have expedited procurement pathways, cervical screening reagents do not qualify for emergency status under current Ugandan regulations. The Ministry of Health has acknowledged the problem in internal memos but has not issued a public statement or requested supplementary funding.

What Clinicians Do When Reagent Runs Out

In the absence of VIA reagent, clinicians have improvised — but none of the workarounds are satisfactory. Some refer women to district hospitals that have HPV testing capacity, but those facilities are often dozens of kilometers away. A woman in rural Lira would need to spend roughly US$5–10 on transport to reach the nearest hospital with HPV testing, a significant sum for a household living on less than US$2 per day. Many simply do not go.

Other facilities postpone screening indefinitely, telling women to return in a few months when the reagent might be available. This creates a backlog of unscreened women and erodes trust in the health system. A few clinicians have resorted to using household vinegar — typically 5 percent acetic acid — which is not sterile and may cause irritation. The concentration is also less consistent than medical-grade solution, potentially leading to false negatives or false positives.

Pap smears, the gold standard in high-income countries, are not a realistic alternative. Uganda has fewer than 20 trained cytopathologists, most of whom work in Kampala. Rural hospitals lack the laboratory infrastructure to process Pap smears, and the turnaround time for results can be several weeks. Even if a woman is screened, she may never receive her result or return for follow-up.

The result is a growing pool of undetected cervical lesions. A modeling study by the Uganda Cancer Institute, published in the Journal of Global Oncology in 2023, estimated that a six-month disruption in screening could lead to a 5–10 percent increase in cervical cancer cases over the following decade, assuming no catch-up screening. That projection may now be conservative, given that the shortage has lasted more than a year in some areas.

HPV Testing as a Stopgap — With Its Own Limits

Human papillomavirus DNA testing has been hailed as a more accurate alternative to VIA, and it does not rely on acetic acid. Uganda has piloted HPV self-collection kits in Kampala since 2024, with promising results: women can collect their own vaginal swab at home and send it to a lab. However, the pilot has been limited to urban areas, and the turnaround time for results is typically two to three weeks, requiring women to return to the clinic or receive a phone call. In rural areas, where phone network coverage is patchy and literacy rates are lower, follow-up is a major challenge.

GeneXpert machines, which can process HPV tests in about an hour, are available in a few regional hospitals but are scarce in primary health centers. Each machine costs roughly US$17,000, and the cartridges cost about US$15 per test — roughly 50 times the cost of VIA. Uganda has about 40 GeneXpert machines nationwide, mostly used for tuberculosis diagnosis. Integrating HPV testing would require additional machines, training, and a steady supply of cartridges, none of which are currently budgeted.

Cost remains the biggest barrier. A single HPV test, including laboratory processing and result communication, costs the health system roughly US$20–30. VIA, by contrast, costs less than US$1 per screen. Scaling HPV testing to cover even 30 percent of eligible women in Uganda would require an annual investment of at least US$10 million, according to Ministry of Health estimates. Donor funding for cervical cancer has not increased proportionally.

Some experts advocate for a hybrid approach: use HPV testing for primary screening in urban and peri-urban areas, while maintaining VIA for rural clinics where the infrastructure for molecular testing is absent. But that strategy assumes VIA will remain available, which is not guaranteed. The current shortage has shown that even a low-tech solution can fail if the supply chain is not resilient.

What Needs to Change to Restore Screening

Restoring cervical cancer screening in rural Uganda will require action on multiple fronts. First, the procurement system for acetic acid must be diversified. The National Medical Stores should contract with at least two suppliers, ideally including a local manufacturer. The Uganda National Drug Authority could fast-track approval for a locally produced VIA reagent, as it has done for other essential products during emergencies.

Second, buffer stocks should be maintained at the district level, not just at the central warehouse. Districts that serve large rural populations, such as Lira and Gulu, need a three-month reserve that is regularly rotated and replenished. The Ministry of Health could designate cervical screening reagents as "essential" items with expedited procurement pathways, similar to vaccines and antiretrovirals.

Third, investment in HPV testing should be accelerated, but with a realistic understanding of its limitations. Placing GeneXpert machines in district hospitals and training laboratory technicians to run HPV tests would reduce reliance on VIA in the long term. However, the cost per test must come down — through bulk procurement, negotiation with manufacturers, or development of low-cost alternatives. The Kampala pilot has shown that self-collection is acceptable to women, but the logistics of result delivery and follow-up treatment remain unresolved.

Finally, the training of nurse midwives in cryotherapy and thermal ablation should be expanded. Even if screening is restored, treatment capacity must keep pace. Currently, many facilities that have VIA reagent lack functioning cryotherapy equipment or trained staff to perform ablation. A screen-and-treat program is only effective if both steps are available.

But these solutions face significant hurdles. Diversifying suppliers requires political will to overhaul procurement rules that favor single-tender awards. Local production of acetic acid would need upfront investment and regulatory approval, which could take years. Scaling HPV testing demands sustained donor funding, which is uncertain given competing health priorities. And maintaining buffer stocks at district level requires reliable transportation and storage infrastructure, which is weak in many rural areas. Without addressing these underlying constraints, even well-intentioned reforms may fall short.

The shortage of acetic acid in Ugandan clinics is not a story of technological failure. It is a story of a simple, cheap tool that works — but only when the supply chain delivers. Until Uganda addresses the fragility behind that supply, thousands of women will continue to leave clinics unscreened, and preventable cancers will go undetected. The solution is not a single new test but a system that can keep the tools it already has in stock.