Table 1.

Policy summary table

Background	Access to effective cervical cancer prevention in LMICs is currently limited, and the burden of cervical cancer is disproportionally experienced in LMICs. Only 9–11% of women in LMICs have ever had a screening test, and VIA is the primary screening test in most of these settings, which has low sensitivity in a programmatic setting. 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 fully vaccinated against HPV by 15 years of age; (2) 70% of women 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 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. Guidance was provided by 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 of civil society. The guidelines update was informed by a range of evidence sources, including an updated systematic review on screening test performance and treatment efficacy and a modeled evaluation using the Policy1-Cervix modeling platform.
Main findings and limitations	Primary HPV testing approaches, considering a range of screen-and-treat options or different triaging methods, were the most effective approaches to screening, reducing age-standardized cervical cancer mortality rates by 63% or more over a lifetime when offered at 5-yearly intervals and if 70% coverage is achieved. Primary HPV testing was also the most cost-effective screening approach. Strategies involving triaging HPV+ women before treatment (with 16/18 genotyping, cytology, VIA or colposcopy) had close-to-equivalent effectiveness to HPV screening without triage and resulted in fewer pre-cancer treatments. Screening with VIA or cytology every 3 years was less effective and less cost-effective than screening with HPV every 5 years. Furthermore, primary screening with VIA generated more than double the number of pre-cancer treatments compared to screening with HPV. As expected, offering HPV testing only twice in a lifetime was less effective than offering it every 5 years but still reduced age-standardized mortality rates by at least 41%.
Policy implications	Primary HPV testing is the most effective and cost-effective approach to cervical screening in LMICs. These findings have directly informed updated cervical screening and treatment guidelines by the WHO, published in 2021, which recommend using primary HPV screening in a screen-and-treat or screen-triage-and-treat approach, starting at the age of 30 years with screening every 5 years or 10 years for the general population of women. This primary screening approach allows for delivery models involving self-collected HPV samples and/or point-of-care testing, which should help to facilitate more effective screening and treatment solutions, co-designed with the community. However, the availability of affordable and appropriately clinically validated HPV and triage test technologies will be key to realizing the effective implementation of HPV screening, and, thus, realizing cervical cancer elimination, in LMICs.