Table 2.

Policy summary

Background	Access to effective cervical cancer prevention in LMICs is currently limited, and women living with HIV are at a sixfold increased risk of cervical cancer. In 2020, the WHO launched a global strategy to eliminate cervical cancer as a public health problem and recommends ‘90–70–90’ intervention targets by 2030. These are that (1) 90% of girls are fully vaccinated against HPV by 15 years of age; (2) 70% of women are screened using a high-performance test by 35 years of age and again by 45 years of age; and (3) 90% of women identified with cervical pre-cancer or invasive cervical cancer are provided adequate treatment and care. To facilitate the implementation of the elimination strategy, the WHO updated its 2013 cervical screening and treatment guidelines in 2021 under the auspices of the Guidelines Development Group for Screening and Treatment to Prevent Cervical Cancer, which comprises a range of scientists, healthcare providers, implementers, ministry of health representatives, systematic reviewers, program implementation experts and representatives from civil society. A specific evidence review was performed for women living with HIV to inform the guidelines update for cervical screening in this population.
Main findings and limitations	In women living with HIV, primary HPV testing with triage at a 5-yearly interval was more effective at reducing cervical cancer cases and deaths than screening with VIA every 3 years. Screening with primary HPV testing every 3 years was the most effective option for reducing cervical cancer incidence. The inclusion of triaging strategies in HPV+ women living with HIV resulted in minimal loss in efficacy while simultaneously reducing the number of pre-cancer treatments by 11–52%, depending on the screening technology and interval. Therefore, the benefits of HPV screening can be realized while mitigating potential harms of overtreatment in this group by implementing HPV screening in a screen, triage and treat algorithm.
Policy implications	Based on evidence review, together with the findings of this analysis, the WHO has recommended using HPV as the primary screening test (rather than VIA or cytology) in women living with HIV. For women living with HIV, a 3–5-yearly screening interval offers an appropriate balance of benefits to harms. Although it is recommended that women in the general population receive HPV screening with or without triage, the WHO recommends implementing an appropriate triaging strategy for women living with HIV (HPV 16/18 genotyping, colposcopy, cytology or VIA) to reduce the expected overall burden and subsequent harm of overtreatment in this group. The development of practical and effective programmatic models of HPV screen, triage and treat for women living with HIV will depend on the availability of affordable HPV and triage tests, appropriate linkages with reproductive and HIV services and effective registry mechanisms for recalling women for surveillance follow-up or referring them for further management.