AFJOG

INTRODUCTION The South African National Department of Health's (NDOH) decision to transition from cytology-based screening to primary high-risk human papillomavirus (HPV) testing represents an important move in South Africa’s fight against cervical cancer. This policy change is firmly grounded in global best practice and national disease burden, aligning with the World Health Organization’s (WHO) vision to eliminate cervical cancer as a public health problem by 2030. LIMITATIONS OF CYTOLOGYAND BENEFITS OF HPV TESTING While cytology (Pap smear) has been shown to reduce cervical cancer incidence in countries with population based screening programmes, its inadequate sensitivity, dependence on skilled cytotechnicians, and need for frequent repeat testing limit its effectiveness, particularly in resource-constrained settings. In contrast, primary HPV testing is more sensitive and its negative predictive value enables extended screening intervals and more efficient resource allocation. (1,2) THE SOUTH AFRICAN CONTEXT South Africa bears one of the highest burdens of cervical cancer worldwide, with approximately 7,644 new cases recorded in 2023—making it the second most frequent cancer among women, the most common cause of cancer death among women and the leading cancer among those aged 15–44 years (3) . The situation is compounded by a high HIV prevalence of approximately 13% in the general population, reaching 25–30% among reproductive-age women, which dramatically increases the prevalence of persistent HPV infection and progression to high-grade disease. NATIONAL POLICYAND WHO ELIMINATION TARGETS South Africa has committed to theWHO's "90-70-90" targets for 2030 (90% of girls vaccinated, 70% of women screened with a high-performance test, and 90% of women with cervical disease treated). Primary prevention in the form of school-based HPV vaccination was implemented in South Africa in 2014. In 2024 the HPV vaccination campaign, aiming to vaccinate nine year old grade 5 girls attending public schools, has vaccinated 405,299 learners (reported as 88.6% of the target population). This programme has now been extended to include learners attending private schools . (1) Regarding secondary prevention, the Department has now transitioned from cytology screening to primary HPV testing as a key strategy to boost early detection, with priority given to HIV-positive women. (1) According to this new screening policy, HIV positive women (HPW) should start screening at age 20 years, with a screening interval of three years. HIV negative women (HNW) should start screening at age 25 years and if negative, should repeat screening every five to ten years. SOUTH AFRICAN EVIDENCE Local data from the DiaVACCS trial demonstrated that primary high-risk HPV (hrHPV) testing, particularly when paired with HPV16/18 genotyping and reflex cytology, yields significantly higher sensitivity and specificity in both HNW and HPW, outperforming cytology alone and all forms of visual inspection. (2) These findings provide robust evidence for implementing HPV-based screening algorithms tailored to South Africa’s epidemiologic and health system realities. PLANNED MANAGEMENT OF HPV-POSITIVE SCREENING Several undeniable challenges have postponed the acceptance of the HPV-screening test – a few will be mentioned. Firstly, it needs to be communicated primarily as a test for cancer risk rather than a virus test, to address stigma - in the same way that the HPV and Hepatitis B vaccines are marketed as “cancer vaccines”. Secondly, it requires a paradigm change to treat women on the basis of “risk” rather than to treat a “lesion”. Thirdly, the high expected positivity rates pose a logistical challenge for the health system. The Department of Health could not address all challenges, but several important choices were made related to the first and last challenge. Important to limit stigma and confusion, HPW and HNW are managed the same (apart from onset and interval of screening). Then, the conscious choice was made to use cytology triage for all hrHPV-positive women, which will reduce the treatment burden and over-treatment. This divides high risk HPV positive women into two groups, namely the highest risk ones who should have immediate treatment, and the intermediate risk group. The improved sensitivity of the HPV-test in comparison with cytology, relies entirely upon the successful tracing and intensified follow-up of the intermediate risk group. This is why the immediate treatment of those with one of the most oncogenic virus types (HPV16, 18, 45) remains a very attractive option to improve programme efficiency. IMPLEMENTATION CHALLENGES AND OPPORTUNITIES Transitioning to HPV testing also introduces challenges related to the laboratory transition, such as higher immediate test cost, the need for reliable laboratory infrastructure and a new test platform, supply chain management for consumables, and developing the intra- laboratory reflex triage systems to immediately send samples for cytology and manage combined test reporting. Many of these systems were already boosted during the Transitioning to Primary HPV-Based Cervical Cancer Screening in South Africa Leon C Snyman, Greta Dreyer Gynaecological Oncology Unit, Department Obstetrics & Gynaecology, University of Pretoria EDITORIAL African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 3 | 2025 | 02