Beyond Human papillomavirus (HPV): why female genital schistosomiasis must be addressed in Africa’s cervical cancer prevention agenda

Abstract

Cervical cancer remains a leading cause of cancer-related mortality among women in Sub-Saharan Africa, despite the expansion of Human papillomavirus (HPV) vaccination and screening programmes. While HPV is a necessary cause of cervical cancer, prevention strategies that focus exclusively on HPV risk overlooking female genital schistosomiasis (FGS), a neglected tropical disease affecting millions of women and girls in schistosomiasis-endemic regions. FGS causes chronic genital inflammation and mucosal damage that may increase susceptibility to HPV infection, complicate cervical cancer screening, and contribute to diagnostic misclassification, yet female genital schistosomiasis is rarely considered in cervical cancer prevention policies or clinical algorithms. In this Comment, we argue that integrating FGS diagnosis and prevention into HPV-based cervical cancer strategies is essential for achieving equitable progress towards the World Health Organization cervical cancer elimination targets in Africa. Addressing FGS represents a pragmatic, gender-responsive, and context-specific opportunity to strengthen cervical cancer prevention across endemic settings.

Cervical cancer remains a leading cause of cancer-related mortality among women in Sub-Saharan Africa, despite being largely preventable through Human papillomavirus (HPV) vaccination, screening, and timely treatment. Africa bears a disproportionate share of the global cervical cancer burden, reflecting persistent structural barriers to prevention, late diagnosis, and inequitable access to care in the region.¹ In response, the World Health Organization (WHO) launched a global strategy to eliminate cervical cancer as a public health problem, anchored in achieving 90% HPV vaccination coverage, 70% screening coverage with a high-performance test, and 90% treatment of women with cervical disease.^1,2 While HPV is a leading cause of cervical cancer, an exclusive focus on HPV risks overlooks other biologically and programmatically relevant conditions that shape women’s vulnerability to infection, disease progression, and missed opportunities for prevention. One of such condition is female genital schistosomiasis (FGS), a neglected tropical disease affecting millions of women and girls in endemic regions of Africa.3, 4, 5

Female genital schistosomiasis (FGS) results from infection with Schistosoma haematobium, leading to inflammatory and fibrotic lesions of the cervix, vagina, and vulva. FGS is characterised by cervicovaginal mucosal lesions, including sandy patches, rubbery papules, and abnormal blood vessels, which may present clinically with symptoms such as contact bleeding, abnormal vaginal discharge, and dyspareunia.^3,5,6 However, FGS remains largely undiagnosed and under-recognised in reproductive health and cancer prevention services. This condition is rarely considered in cervical cancer screening algorithms, clinical guidelines, or training curricula, even in highly endemic settings.

The potential interaction between FGS and HPV infection remains incompletely understood. Although FGS is characterised by mucosal inflammation, epithelial disruption, and immune modulation, which could plausibly influence susceptibility to HPV infection or its natural history, direct epidemiological evidence supporting an association between FGS and HPV acquisition, persistence, or progression to cervical neoplasia remains limited and inconclusive.^7,8 Existing studies are few, largely cross-sectional, and not designed to establish temporality or causality. A recent systematic review concluded that available data are insufficient to confirm or exclude an association between FGS and HPV or cervical cancer.⁷ In this context, the relationship between FGS and HPV should be considered a hypothesis requiring robust longitudinal and mechanistic investigation rather than an established causal pathway. Although the causality and magnitude of the effect remain to be fully elucidated, the biological plausibility and epidemiological signals warrant serious attention, particularly in regions where both conditions are co-endemic. In addition, the interaction between infectious diseases and cervical carcinogenesis is well established. In particular, HIV infection is known to increase the risk of HPV acquisition, persistence, and progression to cervical neoplasia and has been incorporated into cervical cancer prevention strategies in many high-burden settings.^9,10 However, other co-endemic infections that affect the genital tract remain largely overlooked.

Current cervical cancer prevention strategies in Africa—largely centred on HPV vaccination, molecular HPV testing, and visual inspection with acetic acid (VIA)—do not adequately account for FGS. HPV–based screening may miss women with schistosomiasis-related cervical pathology who test HPV negative but experience chronic symptoms and mucosal damage.^2,11,12 Conversely, FGS lesions may complicate visual screening or be misclassified as precancerous changes, leading to unnecessary procedures or missed diagnoses in the future. Without integrated diagnostic approaches, health systems risk misinterpreting pathology, misallocating resources, and perpetuating inequities in women’s health care (Fig. 1).

Fig. 1.

Intersecting pathways linking FGS, HPV infection, and cervical cancer prevention in Africa. FGS: female genital schistosomiasis; HPV: human papillomavirus.

Addressing FGS within cervical cancer prevention agendas offers an opportunity to strengthen health systems through more integrated, person-centred approaches. Rather than maintaining vertical programmes for neglected tropical diseases and cancer prevention, there is increasing recognition of the need for coordinated service delivery that reflects the realities of co-endemic conditions and overlapping patient pathways.13, 14, 15 Integrating FGS into cervical cancer screening platforms through clinical awareness, risk assessment, and appropriate referral pathways could improve diagnostic accuracy, optimise resource use, and enhance continuity of care for women in endemic settings. Pragmatic approaches include incorporating FGS risk assessment into cervical screening histories, training frontline providers to recognise FGS-compatible lesions, and exploring the role of histopathology and molecular tools in differentiating schistosomiasis-related inflammation from neoplastic changes. Importantly, preventive chemotherapy with praziquantel, which is safe, inexpensive, and widely used in mass drug administration programs, could be leveraged more strategically to protect adolescent girls and women before irreversible genital damage occurs.¹⁶

Integrating FGS into cervical cancer prevention also aligns with the broader goals of gender equity, neglected disease control, and universal health coverage, particularly in settings where women face intersecting structural and health system vulnerabilities.¹⁷ Women and girls living in schistosomiasis-endemic areas often face overlapping vulnerabilities, including limited access to clean water, constrained reproductive health services, and delayed cancer diagnosis. Failure to address FGS perpetuates a cycle in which preventable parasitic diseases compound long-term cancer risk and health system inefficiencies. Recognising and diagnosing FGS is therefore not only a biomedical imperative but also a matter of social justice.

These considerations are also relevant for clinicians and pathologists in high-income countries, including the USA and Europe, where increasing migration from schistosomiasis-endemic regions may bring previously unrecognised cases of FGS into cervical cancer screening pathways. Awareness of FGS as a potential source of genital lesions and diagnostic complexity may help avoid misclassification and improve patient management in these settings.¹⁸

As Africa advances towards the WHO targets for cervical cancer elimination, strategies must be context-specific, inclusive, and based on local epidemiology. Moving beyond the HPV-only paradigm does not weaken cervical cancer prevention; rather, it strengthens it by acknowledging the complex biological and social realities shaping women’s health. FGS should not remain invisible in the cervical cancer discourse. Integrating its diagnosis and prevention into national and regional strategies is an essential step towards more equitable, effective, and comprehensive cervical cancer control in Africa.

Declaration of interests

The author declares no conflicts of interest. The views and opinions expressed in this Commentary are those of the author only and do not necessarily represent those of his affiliated institutions.