Optimizing high risk HPV-based primary screening for cervical cancer in low- and middle-income countries: opportunities and challenges.

Disparities in the incidence and mortality due to cervical cancer between developed and developing countries continue to persist due to suboptimal health care systems in low- to middle-income countries (LMICs) that are unable to implement organized programs for screening which lack the technical, infrastructure and financial resources for adequate coverage and access to quality assured cervical cancer screening services that further reduce their effectiveness. The challenges in introducing quality cytology screening in LMICs led to the evaluation of alternative screening approaches such as visual inspection with acetic acid (VIA) and human papillomavirus (HPV) testing-based screening. Large-scale clinical trials have generated sufficient evidence of efficacy of HPV-based screening for the introduction as the primary technology in cervical cancer screening. Being more objective, automated with better sensitivity than cytology requiring fewer rounds of screening and opportunity for self-sampling, HPV testing is thus poised to be more cost-effective in providing opportunity for wider coverage, making it ideal for incorporating into primary screening programs of LMIC settings that could help reduce regional disparities. But its optimal implementation in public health programmatic settings in LMIC still faces barriers due to high operating cost and logistic challenges. This review summarizes and presents evidence for HPV primary screening leading to higher program efficiency in cervical cancer screening programs. Policy measures and strategies to overcome the resource limitations and weaknesses in health care service delivery in low resource settings need to be assessed and streamlined to leverage the initial high program costs with that of the long term potential benefits for HPV DNA testing to reach its full potential in reducing cervical cancer incidence and mortality.