Cervical Cancer Screening in Women Living with HIV in South Africa: Addressing Health Disparities Through Integrated Prevention Strategies

Abstract

Background

South Africa confronts a syndemic triple burden of HIV, tuberculosis, and cervical cancer. Women living with HIV (WLHIV) carry a three- to six-fold elevated cervical cancer risk—a biological synergy reflected in persistently high mortality despite progressive screening policies. This review synthesises evidence for why policy has not achieved population-level impact and proposes an integrated prevention model anchored in existing HIV infrastructure.

Methods

Following PRISMA-ScR guidelines and the Population–Exposure–Outcome (PEO) framework (Population: WLHIV in South Africa; Exposure: cervical cancer screening and HIV integration strategies; Outcome: screening uptake, cascade completion, and mortality), five databases were searched (2015–2025) yielding 36 included sources. A PRISMA flow diagram is provided as Supplementary Figure 1, and a synthesis summary of all included sources is provided as Supplementary Table S1.

Results

South Africa’s cervical cancer mortality rose 12% between 2014 and 2018—paradoxically coinciding with high ART coverage. This ART paradox reflects the unintended consequence of extending WLHIV lifespan into cancer-vulnerable age cohorts without commensurate screening provision. WLHIV face approximately three times the cervical cancer incidence of HIV-negative women; HPV positivity is more than double (41.5% vs 17.4%), post-treatment clearance substantially lower (39.0% vs 65.2%), and all-cause mortality 52% higher (aHR 1.52; 95% CI 1.06–2.19). Point-of-care single-visit screen-and-treat achieved same-day thermal ablation in 94.6% of eligible women in a South African primary care demonstration. Three structural cascade failure points—service silos, loss to follow-up, and treatment bottlenecks—explain the persistent policy-to-outcome gap.

Proposed Model

An eight-component integrated model is proposed: co-scheduling screening with CCMDD dispensing visits, WBOT cascade navigation, point-of-care HPV self-sampling, single-visit screen-and-treat, and digital cascade monitoring linked to HIV information systems.

Conclusion

Achieving WHO 90-70-90 targets in high-HIV-prevalence settings requires a fourth pillar—HIV-stratified delivery (90-70-90+H)—with WLHIV as a mandatory priority subpopulation. Cervical cancer screening for WLHIV must be reclassified as a standard component of HIV chronic care.

Introduction

Cervical cancer is one of the most prevalent types of cancers. Effective primary prevention through HPV vaccination and secondary prevention through high-performance screening and the treatment of pre-invasive lesions have reduced the incidence of cervical cancer by up to 80% in countries with organised national programmes.¹ South Africa—a middle-income country with progressive cervical cancer policies, the world’s largest antiretroviral therapy (ART) programme, and a functioning primary healthcare network—continues to record among the highest cervical cancer mortality rates globally. This is not a paradox of circumstance; it is a failure of integration.

Cervical cancer is the second most common cancer among South African women and the leading cause of cancer-related deaths among women aged 15–44 years.^2,3 In 2020, approximately 604,000 new cervical cancer cases occurred globally, with 342,000 deaths, of which 90% occurred in low-income and middle-income countries.^4,5 In sub-Saharan Africa, the pooled five-year survival rates are as low as 35%, driven by late-stage presentation, limited treatment access, high HIV co-infection rates, and profound loss to follow-up across the screening-to-treatment cascade.⁶ A 2025 systematic review and meta-analysis of 57 sub-Saharan African studies found a pooled cervical cancer mortality incidence of 32.1%, with HIV-positive status identified as a significant independent predictor of mortality alongside advanced stage at diagnosis.⁷

South Africa’s epidemiological context is shaped by one dominant complicating factor: approximately 7.8 million people live with HIV, representing the largest HIV-positive population in the world and a national adult prevalence of approximately 13%.⁸ Among women of reproductive age, the HIV prevalence is 24–25%.² WLHIV face approximately three times the cervical cancer incidence of HIV-negative women even under high ART coverage (with broader estimates of up to six-fold in studies accounting for all ART coverage levels and outcomes), fundamentally challenging the assumption that ART alone mitigates cervical cancer risk.

This study makes three main contributions to the literature. First, it critically analyzes the dominant assumptions in South Africa’s cervical cancer prevention approach, including the counterintuitive finding that ART success has amplified, rather than resolved, population-level cervical cancer vulnerability. Second, it integrates the latest 2024–2025 evidence on point-of-care HPV testing, thermal ablation, and the WHO 90-70-90 elimination targets into a contextually grounded strategic framework. Third, it proposes a concrete, operationally feasible integrated model that leverages South Africa’s existing HIV infrastructure as its primary prevention asset rather than building parallel systems.

The Epidemiological Landscape: Understanding the Dual Burden

Cervical Cancer Burden in South Africa

South Africa’s age-standardised cervical cancer incidence rate has declined by approximately 0.9% per annum in recent decades, but this decline lags substantially behind countries with comparable income levels and organised screening programmes.⁹ Temporal trend analysis of cervical cancer mortality from 1999 to 2018 revealed a net drift of 1.5% increase over the study period, with a particularly alarming 12% rise in mortality between 2014 and 2018, the period in which ART coverage was consolidated at high levels.⁹ This counterintuitive finding is discussed in The Screening Programme: A Policy-Implementation Gap. Women aged 25–60 years experienced increased mortality rates, with the most rapid rise (4.3% per annum) recorded among women aged 30–34 years, reflecting the concentrated impact of the HIV-cervical cancer syndemic in the young adult demographic most susceptible to both infections.⁹

Approximately 64% of invasive cervical cancers in South Africa are attributed to HPV types 16 and 18.² The country’s current school-based HPV vaccination programme, introduced in 2014 for grade 5 girls using the bivalent Cervarix vaccine, achieved an initial coverage exceeding 80%, demonstrating infrastructure capacity. However, the COVID-19 pandemic disruptions created cohort gaps, and equity concerns persisted around restrictions on public school delivery, leaving out-of-school girls and those in private schooling without coordinated access.¹⁰

HIV as the Primary Biological Amplifier

The relationship between HIV infection and cervical cancer is mechanistic, quantifiable, and highly actionable. HIV-induced immunosuppression, characterised by CD4+ T-cell depletion, impairs cell-mediated immune surveillance and the mechanism through which most HPV infections are spontaneously cleared. In HIV-negative women, approximately 90% of HPV infections clear naturally within 2 years, and in WLHIV, persistence rates are significantly higher, creating a persistent high-risk HPV infection that is the necessary precursor to cervical neoplasia.² The three biological pathways operate synergistically.

• Persistence: WLHIV demonstrate substantially higher rates of persistent hrHPV infection, creating a sustained oncogenic stimulus required for neoplastic progression.

• Progression: Progression from CIN to invasive cancer is more rapid in immunocompromised women, compressing the clinically available window for detection and treatment.

• Recurrence: Post-treatment recurrence rates are significantly elevated among WLHIV, indicating that the standard screening intervals designed for immunocompetent women are clinically inadequate.

Quantitative evidence for the HIV-cervical cancer relationship has strengthened considerably with recent large-cohort data. A 2024 International Journal of Cancer study using IeDEA-SA data from insured women compared cervical precancer and cancer incidence by HIV status across South African health system settings, confirming substantially elevated incidence rates in WLHIV, even accounting for screening access differences.^11–14 A Khayelitsha point-of-care demonstration study found HPV positivity rates of 41.5% among WLHIV compared to 17.4% among HIV-negative women, a more than two-fold difference that persisted after the application of treatment eligibility criteria.¹³ Among HIV-positive cervical cancer patients who received treatment, all-cause mortality was 52% higher than in HIV-negative patients (adjusted hazard ratio 1.52; 95% CI: 1.06–2.19). HIV-positive patients were less likely to undergo surgery and more likely to present at advanced stages.¹⁴

The HIV-Attributable Fraction and Global Context

Africa has a disproportionate cervical cancer burden, with annual age-standardised mortality rates nearly triple the global average.¹⁵ Notably, one in five cervical cancer cases in Africa is attributable to HIV, a population-attributable fraction below 2% in all other global regions.^4,16 This makes South Africa’s HIV epidemic not merely a comorbidity, but also a structural driver of cervical cancer incidence that cannot be addressed through cervical cancer policy alone. Any prevention strategy that treats HIV and cervical cancer in parallel will systematically fail women at the highest risk.

Why Standard Prevention Approaches Fail Women at Highest Risk: A Critical Analysis

The ART Paradox: Success Creating New Vulnerability

A critical examination of South Africa’s cervical cancer epidemiology reveals a clinically important and underappreciated dynamic: the success of South Africa’s ART programme has amplified the cervical cancer risk at the population level. This is not a failure of ART; it is an unintended epidemiological consequence of extended survival that the policy has been slow to address.

In the pre-ART era, WLHIV died disproportionately from AIDS-defining conditions before reaching age cohorts (35–50 years) at the greatest risk of progression from HPV infection to invasive cervical cancer. The expansion of ART from 2004 onwards dramatically extended the life expectancy for WLHIV, an unambiguously beneficial development, but simultaneously expanded the population of WLHIV living in cancer-vulnerable ages while carrying persistent high-risk HPV infections acquired during earlier immunosuppressed periods. The 12% increase in cervical cancer mortality between 2014 and 2018, precisely the period of high ART coverage consolidation, is consistent with this dynamic.^9,17 Age-specific burden analyses confirmed that the relative risks for cervical cancer in WLHIV in sub-Saharan Africa have strengthened considerably in the cART era as WLHIV survive into the demographic where cervical cancer risk concentrates.¹⁸

The policy implication is direct and underappreciated. ART programs that do not systematically integrate cervical cancer screening save women from AIDS-related deaths only to expose them to preventable cervical cancer deaths. ART infrastructure and cervical cancer prevention must be considered co-dependent components of a unified chronic disease management strategy, not separately administered programmes with occasional coordination.

The Screening Programme: A Policy-Implementation Gap

South Africa’s cervical cancer policy framework is progressive by regional standards. South African Society of Obstetricians and Gynaecologist (SASOG) 2024 Clinical Guideline specifies HPV DNA testing as the primary screening method, with immediate thermal ablation for women positive for HPV types 16, 18, and 45, and reflex cytology triage for other high-risk HPV types.^2,19 For WLHIV, the recommended protocol initiates screening at age 25 at HIV diagnosis, with three-yearly intervals rather than the ten-yearly interval recommended for HIV-negative women over the age of 30. However, the implementation science literature identifies a fundamental gap: the existence of evidence-based guidelines does not predict their implementation, particularly in high-burden, resource-constrained health systems.²⁰

Kawonga (2024) argued explicitly that South Africa’s persistently high cervical cancer incidence reflects implementation failure rather than policy failure and that deploying effective interventions ineffectively is as damaging as deploying ineffective interventions. Key implementation failures include continued reliance on cytology in districts where HPV DNA testing infrastructure exists but has not been operationalised, absence of a systematic registry linkage between HIV care and cervical screening records, and referral pathways to colposcopy that functionally operate as loss-to-follow-up pipelines rather than care escalation mechanisms. A clinical audit at Charlotte Maxeke Johannesburg Academic Hospital found that only 44.7% of WLHIV attending an HIV clinic had been screened in the preceding three years, and only 51.6% of unscreened women were referred for screening during the same consultation²¹—a sobering illustration of the gap between guideline aspiration and clinical practice even in tertiary settings with direct gynaecological access. These findings echo the calls for urgent guideline revision and stronger integration mandates for cervical cancer screening in HIV-endemic settings.²²

The Contrarian View: Against Stand-Alone Cervical Cancer Campaigns

A significant body of public health programming in South Africa and regionally has approached cervical cancer prevention as a discrete intervention: awareness campaigns, targeted screening days, mobile colposcopy units, and community mobilisation activities that operate independently of the health system structures women already engage in routinely. This approach is understandable, given the urgency of the problem and the need for visible action; however, it contains a structural flaw.

Stand-alone cervical cancer campaigns require women to take additional health-seeking actions—to attend a screening event or visit a facility specifically for cervical screening—in addition to their existing health-seeking behaviours. In populations where competing priorities (childcare, economic activity, transport costs, and stigma) already constrain health seeking, adding an additional discrete engagement requirement systematically reaches the women least at risk while missing those most vulnerable. In contrast, embedding cervical screening into healthcare encounters that women already attend—ART collection visits, viral load monitoring, and antenatal care—eliminates the additional behaviour change requirement and reaches women precisely when they are already engaged with the health system. The empirical case for integration is clear; the political and institutional inertia maintaining vertical programme structures is a barrier.

Current Prevention Landscape: Progress, Gaps and Paradoxes

Primary Prevention: HPV Vaccination

South Africa’s school-based HPV vaccination programme, initiated in 2014, targets grade 5 girls (approximately 9 years of age) in public schools using the bivalent Cervarix vaccine, which targets HPV 16 and 18 and is responsible for approximately 64% of South African cervical cancers.² The initial programme coverage exceeded 80%, demonstrating the operational feasibility of the school health delivery platforms. The 2025 Gavi, the Vaccine Alliance replenishment raised $9 billion—short of the $11.9 billion target—raising concerns about sustained funding for HPV vaccination programmes in the 76% of African countries relying on Gavi support.¹⁵ South Africa, as an upper-middle-income country, faces financing challenges outside the Gavi eligibility threshold.

The global momentum toward cervical cancer elimination is accelerating. The 78th World Health Assembly in May 2025 adopted a resolution designating 17 November as the World Cervical Cancer Elimination Day, reinvigorating political commitment to WHO’s 90-70-90 targets: 90% of girls vaccinated by age 15, 70% of women screened twice in a lifetime, and 90% of women with cervical disease treated.²³ South Africa’s school vaccination programme places it ahead of most African countries in the vaccination pillar, but the screening and treatment pillars represent critical gaps.

Secondary Prevention: The HPV DNA Testing Transition

South Africa’s transition from cytology to HPV DNA testing as the primary screening modality represents the most recent advancement in policy. HPV DNA testing offers substantially higher sensitivity for CIN2+ detection than cytology (0.95 vs 0.69 in pooled analyses), a longer valid screening interval, and compatibility with self-collected vaginal specimens—a feature with transformative implications for access.⁴ SASOG’s 2024 updated guidelines formalise the differential screening protocol: for HIV-negative women, HPV DNA testing every 10 years from age 30 (with a policy transition to age 25); for WLHIV, HPV DNA testing every three years from age 25 or HIV diagnosis, with immediate treatment eligibility for HPV 16/18/45 positives without additional triage.²

The SASOG 2024 guidelines’ explicit recommendation for self-sampling as a validated alternative to clinician-collected specimens is a significant operational advancement. Self-sampling acceptability and diagnostic equivalence to clinician collection have been validated in South African settings (agreement κ = 86.7; p < 0.001), with evidence that offering self-sampling substantially increases screening uptake, particularly among women deterred by speculum examination.¹³ The SASOG explicitly recommends nationwide development of thermal ablation and LLETZ treatment on indication, with same-visit treatment as the preferred approach when ablation eligibility is met.

The Cascade Failure: Where Women are Lost

Despite these policy advances, the incidence rate remains relatively high. The explanation lies not in policy inadequacy but in systematic cascade failure at three critical junctions. Table 1 maps the cervical cancer prevention-to-treatment cascade, identifying the principal failure points and their population health consequences.

Table 1.

The Cervical Cancer Prevention-to-Treatment Cascade in South Africa: Key Stages, Failure Points, and Health Consequences

Cascade Stage	Target Population	Primary Failure Point	Health Consequence
1. Vaccination	Girls aged 9–14 in public schools	COVID-19 cohort gaps; public school restriction excluding out-of-school girls; vaccine hesitancy amplified by social media misinformation	Incomplete herd immunity; equity gaps by school attendance status
2. Screening Uptake	Women aged 25+ (WLHIV) and 30+ (general)	Service silos: WLHIV routinely attending ART clinics not offered cervical screening; cytology still used in HPV-DNA-capable districts; stigma and fear deterring presentation	Undetected precancerous lesions progressing to invasive cancer
3. Result Return & Triage	Screen-positive women	Delayed laboratory results requiring repeat visit; no systematic notification systems; high loss between screening and result receipt	Screen-positive women never entering triage pathway
4. Treatment	HPV-positive/triage-positive women	Colposcopy referral as primary pathway creates geographic, financial, and waiting-list bottlenecks; shortage of LLETZ equipment; absence of same-visit thermal ablation at primary level	Progression to invasive cancer during treatment wait; highest-burden women receiving no treatment
5. Post-Treatment Follow-up	Treated women, especially WLHIV	No systematic recall systems; WLHIV with elevated recurrence risk not tracked; re-integration into routine HIV care encounters not standardised	Undetected recurrence; missed re-treatment opportunities

Abbreviations: WLHIV, Women Living with HIV; LLETZ, Large Loop Excision of the Transformation Zone.

Evidence Base for the Proposed Strategy

Point-of-Care HPV Testing and Single-Visit Screen-and-Treat

The most compelling recent evidence for the proposed integrated strategy comes from a demonstration study in Khayelitsha, South Africa, where 3,062 women aged 30–65 years (44% WLHIV) were screened using point-of-care (POC) Xpert HPV testing with same-day result delivery and thermal ablation for eligible screen-positive women.¹³ Key findings were operationally significant: 94.6% of eligible screen-positive women underwent thermal ablation on the same day as their HPV test with no serious adverse events. HPV positivity was observed in 41.5% of WLHIV and in 17.4% of HIV-negative women. Twelve months post-treatment, HPV clearance rates were 65.2% in HIV-negative women and 39.0% in WLHIV, an important difference confirming that WLHIV require more intensive follow-up schedules than HIV-negative comparators.¹³

These data establish three critical proof points for the proposed integrated model: first, that POC HPV testing with same-day result return is operationally feasible in a South African primary care setting; second, that single-visit screen-and-treat virtually eliminates the cascade stage at which most women are currently lost; and third, the differential clearance rates between WLHIV and HIV-negative women justify the three-yearly follow-up interval recommended in SASOG guidelines and necessitate active WLHIV tracking systems.

The Xpert HPV platform has an additional strategic advantage in the South African context: GeneXpert machines were introduced widely across South Africa for tuberculosis diagnosis, creating an existing installed-base infrastructure that can accommodate HPV testing modules without capital investment in new equipment.²⁴ This is a material cost and scale-up advantage rarely present in comparable low- and middle-income settings.

While operationally compelling, these findings must be interpreted in light of South Africa’s substantial internal heterogeneity. Khayelitsha is a peri-urban township in the Western Cape, a province with a comparatively stronger health system infrastructure, higher health worker density, and more advanced GeneXpert penetration than the provinces with the greatest HIV and cervical cancer burden. KwaZulu-Natal, Limpopo, and the Eastern Cape, where HIV prevalence among women of reproductive age reaches its highest national levels, present markedly different implementation environments: greater geographic dispersion of facilities, more severe professional nursing shortages, less consistent equipment maintenance capacity, and limited specialist gynaecology services within an accessible distance. A qualitative study of healthcare professionals in Limpopo documented persistent ambiguity in guidelines, training gaps, and equipment shortfalls as key barriers to cervical cancer screening at the primary care level.²⁵ Mathematical modelling specifically for KwaZulu-Natal demonstrated that single-visit screen-and-treat strategies could avert substantially more cervical cancer cases than the current standard of care, but only if coverage reached the highest-risk women, including WLHIV, in that province.²⁶ At present, the WBOT infrastructure in these provinces operates under greater resource strain and higher staff turnover. Corroborating evidence from other sub-Saharan African settings supports the broad intervention logic: Kaboré et al (2020) demonstrated community-based self-sample screen-and-treat feasibility in rural Cameroon, and the WHO guidelines for WLHIV screening drew on multi-country evidence. However, this does not resolve the question of implementation fidelity across South Africa’s diverse provincial contexts. The responsible interpretation of the Khayelitsha data treats it as proof of clinical and operational concepts, rather than as a ready-made implementation template. National scale-up requires province-specific adaptation: differential equipment rollout strategies, targeted nursing capacity investment in rural districts, and model fidelity graduated from the available infrastructure.

HPV Self-Sampling: Expanding Reach Beyond Facility Walls

Self-collected vaginal specimens for HPV DNA testing have demonstrated high diagnostic equivalence to clinician-collected cervical specimens, with studies in South African populations reporting an agreement of κ = 86.7 (p < 0.001).^13,27 Self-sampling enables two transformative programme options: first, WBOT members can distribute self-sampling kits during household visits, enabling women to test without facility attendance; second, self-sampling substantially increases uptake among women deterred by speculum examination, a documented barrier, particularly in the context of sexual violence history, which is highly prevalent in South Africa. The SASOG’s 2024 guidelines formally recognise the validity and feasibility of self-sampling and its potential to significantly increase screening coverage. A systematic review of qualitative evidence from SSA found that self-sampling acceptability is shaped by intrapersonal, interpersonal, and health system factors, underscoring the need for context-sensitive rollout strategies.^2,28 Among WLHIV, the pooled acceptability of HPV self-sampling across the 14 SSA studies was 73%, with 94% reporting comfort with the procedure and 72% finding it easy to use.²⁹

Community Health Worker Effectiveness in HIV-Analogous Interventions

Ward-Based Outreach Teams (WBOTs) represent South Africa’s most substantial community health infrastructure investment and are currently deployed primarily for HIV and TB defaulter tracing, maternal and child health monitoring, and chronic disease management support. Evidence from HIV treatment programmes demonstrates that community health worker-based defaulter tracing substantially reduces loss to follow-up and improves treatment retention—the intervention logic required for cervical cancer screening cascade management. The evidence base for task shifting to community health workers in cervical cancer screening has grown substantially, and pilot programmes in sub-Saharan Africa have demonstrated that nurse- and CHW-driven screen-and-treat protocols achieve outcomes comparable to physician-delivered services.^13,30 A scoping systematic review of SSA health system strategies found that single-visit screen-and-treat, self-sampling, task sharing with non-clinical providers, and integration with HIV clinics were the most effective strategies for improving screening uptake across 17 sub-Saharan African countries.³¹ A cluster-randomised trial in rural Uganda (ASPIRE Mayuge) demonstrated that door-to-door community HPV screening achieved higher treatment attendance than community health day models, although it required a greater personnel investment.³²

A Proposed Integrated Model for Embedding Cervical Cancer Prevention in HIV Care

We propose a structured integrated model for embedding cervical cancer prevention into South Africa’s HIV care infrastructure. Shown in Table 2, it is tagged the INTEGRATE Framework—an acronym comprising eight operational components designed to address the specific cascade failure points identified in Table 1 through evidence-based interventions.

Table 2.

Eight Operational Components of the Proposed Integrated Model for Embedding Cervical Cancer Prevention into HIV Care in South Africa

Component	Operational Action	Delivery Mechanism	Target Population	Evidence Base
I — Integrate scheduling	Align HPV screening with every 3rd viral load visit for WLHIV	CCMDD dispensing points; ART clinic integration	All WLHIV aged 25+	SASOG 2024; WHO 2021; CCMDD programme infrastructure
N — Nominate WBOTs as cervical cancer navigators	Expand WBOT mandate to trace “cervical cancer defaulters”—screen-positive women who did not attend treatment	Existing WBOT structure; expanded job description and training	Screen-positive WLHIV lost to follow-up	HIV defaulter tracing evidence; Kawonga 2024
T — Test at point of care	Deploy Xpert HPV POC testing at primary care facilities; leverage existing GeneXpert infrastructure	Primary health care clinics; CCMDD sites	All eligible women; WLHIV prioritised	Barnabas et al 2023; SASOG 2024
E — Enable self-sampling	Distribute self-sampling kits via WBOTs for home HPV collection; return to clinic or collect by WBOT	WBOT household visits; community collection points	Women deterred by speculum examination; rural and hard-to-reach	SASOG 2024; Taku et al 2020; Barnabas et al 2023
G — Go screen-and-treat same day	Immediate thermal ablation for eligible screen-positive women at the same visit	Primary level clinics; nurse-led	HPV 16/18/45 positive; ablation-eligible lesions	Barnabas et al 2023: 94.6% same-day ablation
R — Refer high-grade with clear pathways	Structured referral pathway with confirmed appointments, transport support, and WBOT escort for non-ablation-eligible cases requiring LLETZ or colposcopy	District hospital; specialist gynaecology	HSIL; non-ablation-eligible lesions; suspected invasive cancer	SASOG 2024; implementation science evidence
A — Adopt digital tracking	Link cervical screening records to HIV electronic health records (TIER.Net); generate WBOT follow-up lists for screen-positive women not yet treated	TIER.Net/DHIS2 system; facility data managers	All screened women; WLHIV tracked separately	HIV clinic monitoring evidence; Kawonga 2024
T — Train and task-shift	Train professional nurses in HPV result interpretation and thermal ablation; train WBOTs in self-sampling distribution, result delivery, and follow-up counselling	District health training; SASOG BetterGyn programme	All primary care nursing staff; WBOTs in pilot districts	Task-shifting evidence; Barnabas et al 2023 nurse-led model
E — Educate through ART platforms	Deliver household-level education via WBOTs explicitly explaining the HIV-HPV biological link; conduct structured HIV-cervical health talks at ART collection points	WBOT household visits; group health education at CCMDD sites	WLHIV and their household members; community influencers	Stigma and knowledge-barrier evidence; community mobilisation literature

Abbreviations: CCMDD, Central Chronic Medicine Dispensing and Distribution; WBOT, Ward-Based Outreach Team; POC, Point of Care; SASOG, South African Society of Obstetricians and Gynaecologists; HSIL, High-Grade Squamous Intraepithelial Lesion.

Aligning with the WHO 90-70-90 Elimination Targets: The South African Case for a 90-70-90+H Framework

The WHO’s Global Strategy to Accelerate the Elimination of Cervical Cancer sets 90-70-90 targets to be achieved by 2030: 90% of girls vaccinated against HPV by age 15, 70% of women screened using a high-performance test by ages 35 and 45, and 90% of women with cervical disease receiving treatment.³³ Mathematical modelling demonstrates that achieving these targets will avert 74 million new cervical cancer cases and 62 million deaths globally in the coming century.³³ In sub-Saharan Africa, where the average screening coverage is estimated at just 4% and only two countries have high-performance HPV DNA testing in their national screening programs, the gap between ambition and reality is acute.¹

We argue that for South Africa and all countries with high HIV prevalence, the 90-70-90 framework requires a fourth pillar: HIV-stratified delivery (the “+H” addition). Thus, screening targets are disaggregated by HIV status, with WLHIV constituting a mandatory priority subpopulation whose 70% screening target must be achieved before overall population targets are considered met, treatment targets that account for WLHIV’s elevated recurrence risk with three-yearly follow-up intervals, and vaccination targets that explicitly include girls living with HIV and young WLHIV not yet reached by school-based programmes.

A multisite survey of 30 HIV clinics across sub-Saharan Africa found that while most sites offered cervical cancer screening services, data systems to monitor WHO global monitoring indicators disaggregated by HIV status existed in only 37% of sites, and data on cancer stage and survival were available in only 37% and 23% of sites, respectively.^34,35 This monitoring gap means that WLHIV, the highest-risk population, are systematically invisible in the data systems that drive resource allocation decisions. The digital tracking component of the proposed model specifically addresses this issue by linking cervical screening records to electronic HIV systems.

Barriers to Implementation and Mitigation Strategies

Table 3 synthesises the principal implementation barriers and proposed mitigation approaches, informed by implementation science frameworks applied to South African health system conditions.

Table 3.

Principal Implementation Barriers and Proposed Mitigation Strategies for the Proposed Integrated Model in South Africa

Barrier	Manifestation in South African Context	Proposed Mitigation
Service Silos	HIV and SRH services operating under separate programme directorates; ART clinics not routinely offering cervical screening; different information systems	National policy directive mandating cervical screen offer at every WLHIV ART collection visit; TIER.Net integration of cervical screening module
Health System Capacity	Shortage of LLETZ equipment and trained colposcopists; thermal ablation not universally available at primary level; nursing staff turnover	Prioritise thermal ablation equipment distribution to primary care facilities serving WLHIV; task-shifting to professional nurses for ablation; establish district LLETZ centres
Stigma and Knowledge Gaps	Cervical cancer associated with death and promiscuity; WLHIV reluctant to disclose HIV status at gynaecology services; limited understanding of HIV-HPV biological link	WBOT household education explicitly framing cervical screening as part of HIV care; group health education at CCMDD points; peer navigator models
Loss to Follow-up	Screen-positive women failing to return for results or treatment; referral for colposcopy acting as pipeline for attrition; transport and childcare constraints	Single-visit screen-and-treat as default for eligible women; WBOT active tracing of defaulters; digital notification systems for result return
Data and Monitoring Gaps	Cervical screening data not disaggregated by HIV status; no systematic registry of screen-positive WLHIV; limited cascade monitoring	DHIS2 dashboard for cervical cancer cascade metrics by HIV status; facility-level performance reports for district health managers; WBOT digital registers
Equity Gaps	Rural-urban disparities in HPV testing and thermal ablation access; out-of-school girls excluded from school vaccination programme; private/public sector divide	Self-sampling kits distributed via WBOTs extend screening beyond facility geography; extend vaccination to community-based platforms for out-of-school girls

Abbreviations: SRH, Sexual and Reproductive Health; TIER.Net, HIV Patient Tracking System; DHIS2, District Health Information System Version 2.

Policy Implications

The proposed integrated model has specific implications for policies at the national, provincial, and facility levels, which extend beyond the operational interventions described.

National Policy

The National Department of Health should issue a directive classifying cervical cancer screening for WLHIV as a mandatory component of HIV chronic care, equivalent to viral load monitoring. This shift in classification from optional addition to standard of care would embed screening in CCMDD protocols, clinical assessment checklists, and performance indicators for district health managers. The 90-70-90+H framework should be formally adopted as South Africa’s cervical cancer elimination substrategy, with HIV-stratified reporting requirements built into the DHIS2.

Health System Financing

The business case for integrated delivery is favourable. Same-visit screen-and-treat eliminates the cost of multiple facility visits, transport subsidies for referral, and the vastly higher cost of treating invasive cancers compared to precancerous lesions. Implementation science modelling in comparable settings demonstrates that integrated delivery is cost-saving relative to current fragmented approaches over a three-to-five-year time horizon. The World Bank’s commitment of at least US$400 million to HPV-related programming through 2027 represents an external financing opportunity, and South Africa should actively pursue thermal ablation equipment and WBOT training.³⁶

Research Priorities: Context-Sensitive Scale-Up

Several evidence gaps require urgent locally conducted research. The current evidence base relies disproportionately on peri-urban Western Cape data; multi-site implementation studies across diverse provincial contexts are a prerequisite before national scale-up protocols can be finalised. Specifically, evidence is needed on the implementation fidelity of point-of-care screen-and-treat in higher-burden, lower-resourced provinces, including KwaZulu-Natal, Limpopo, and the Eastern Cape; the effectiveness of WBOT-delivered self-sampling in rural settings where facility access is most constrained; optimal HPV follow-up intervals for WLHIV on contemporary ART regimens with high CD4 counts; cost-effectiveness of integrated delivery compared to current fragmented standard of care; and the optimal scheduling integration point within the CCMDD dispensing visit for cervical cancer screening. A central finding of this review is that a one-size-fits-all approach to national scale-up is likely to fail. The evidence base is largely derived from peri-urban, Western Cape settings with comparatively strong health system infrastructure. Provinces bearing the greatest HIV and cervical cancer burden, including KwaZulu-Natal, Limpopo, and the Eastern Cape, have markedly different implementation environments. National scale-up protocols must therefore incorporate province-specific adaptation strategies rather than uniform rollout, with phased implementation, context-specific monitoring indicators, and iterative learning built into the programme architecture from the outset.

Conclusion

South Africa possesses every structural prerequisite for dramatically reducing cervical cancer mortality: a national HPV vaccination programme, progressive SASOG guidelines mandating HPV DNA testing and thermal ablation, the world’s largest ART programme creating daily contact with the highest-risk women, a community health workforce in WBOTs proven in comparable HIV programme tasks, and an emerging evidence base—demonstrated at Khayelitsha and supported by comparable sub-Saharan African implementation studies—confirming the operational feasibility of single-visit screen-and-treat with same-day thermal ablation, with the important caveat that national scale-up demands province-specific adaptation rather than uniform rollout from a single peri-urban proof-of-concept.

However, integration is missing. Cervical cancer prevention in South Africa continues to operate as a vertical programme alongside, rather than within, HIV care, a structural failure with lethal consequences. The ART paradox sharpens the urgency; every WLHIV whose life has been extended by South Africa’s ART programme is now living in an age cohort most vulnerable to cervical cancer progression. Failing to screen and treat these women is not merely a missed opportunity; it converts one public health success into a preventable death.

The proposed integrated model is practical, evidence-based, and operationally feasible. It does not require new infrastructure; it requires new instructions for existing infrastructure. The WBOTs have already conducted household visits and require mandatory expansion. GeneXpert machines already exist in primary care facilities and require HPV modules. CCMDD dispensing encounters have already reached WLHIV regularly and require embedded cervical screening. TIER.Net digitally tracks HIV patients and requires cervical cascade fields. These tools are already assembled. The case is made. What is required now is the political and institutional will to integrate them.

Funding Statement

This study did not receive any funding.

Data Sharing Statement

No primary data were generated.

Ethics Approval

This is a narrative review and strategic framework based on published literature.

Disclosure

The author declares no conflicts of interest in this work.