South African HPV Guidelines — Questions

• High-risk HPV is very common and usually transient in young women: most infections clear spontaneously, so testing younger women returns many positives that never progress, driving overinvestigation and overtreatment of lesions destined to regress.
• Invasive cervical cancer is rare before age 25: the cancer takes years to develop from persistent infection, so screening earlier averts little cancer while causing harm.
• South Africa still starts at 25, below the WHO general-population floor of 30: the high HIV prevalence and the earlier, faster progression in women living with HIV justify beginning earlier than WHO advises for lower-prevalence settings.

An other-high-risk result with normal triage cytology carries intermediate risk, so the woman repeats HPV testing in twelve months; only persistence or abnormal cytology triggers colposcopy.

Immediate colposcopy, large loop excision of the transformation zone (LLETZ), ten-year recall or hysterectomy all over- or under-treat an intermediate-risk result.

Women living with HIV progress faster, so a negative high-risk HPV result is followed by five-yearly screening for life, not the ten-year interval used when HIV-negative.

Ten years is the HIV-negative recall; annual or one-off screening has no place in the primary HPV algorithm.

HPV18 sits in the highest-risk channel (with HPV16 and HPV45), which goes straight to screen-and-treat. With no visible lesion on visual inspection with acetic acid (VIA), the primary-care treatment is thermal ablation, with HPV follow-up at twelve months.

Recall, delayed repeat, cytology alone or no treatment all under-manage a highest-risk result.

The other-high-risk channel carries intermediate risk, so it is triaged with reflex cytology run on the same sample; only abnormal cytology leads to colposcopy and treatment.

Immediate large loop excision of the transformation zone (LLETZ), routine recall, a five-year repeat or colposcopy for everyone all mismanage an intermediate-risk result.

HPV16, with HPV18 and HPV45, is the highest-risk channel and goes straight to screen-and-treat: assessment under visual inspection with acetic acid (VIA), then thermal ablation if no lesion is seen or colposcopy and large loop excision of the transformation zone (LLETZ) if a lesion is present.

Recall, a twelve-month repeat, reflex cytology first or no action would all delay treatment of a highest-risk result.

A negative high-risk HPV result has a high negative predictive value, so an HIV-negative woman returns at roughly ten-year intervals.

The shorter intervals belong to women living with HIV (five years); annual, one-year or three-year recall is not used after a negative primary HPV test.

A failed cellular control means the sample may not have contained adequate cervical cells, so a negative HPV result is unreliable and the test is repeated. A positive HPV signal stays valid even if the cellular control is out of range.

Reporting the unreliable result either way, or referring straight for colposcopy, or ignoring the control all risk a false-negative screen.

South Africa starts primary HPV screening at age 25 for all women, regardless of HIV status, deliberately lower than the WHO general-population floor of 30 because of the high HIV prevalence and the early-onset disease that follows it.

The other ages fall outside the South African guideline.

The WHO elimination threshold is an age-standardised incidence below 4 per 100,000 women, the goal of the 90-70-90 strategy for 2030.

The other figures are either below the target or well above it.

The middle target is that 70% of women are screened with a high-performance test by age 35 and again by 45.

The two 90s flank it: 90% of girls fully HPV-vaccinated by 15, and 90% of women with cervical disease treated. Cure rates and cytology coverage are not among the targets.

A single HPV test detects around 90% of high-grade precancer and a negative result is highly reassuring, giving higher sensitivity and negative predictive value (NPV) than cytology and letting screening intervals lengthen safely. Its trade-off is lower specificity, which genotyping and triage address.

HPV testing is not more specific, cheaper or more subjective, and it detects viral DNA rather than cellular changes.

WHO recommends starting primary HPV screening at age 30 in the general population, prioritising ages 30 to 49.

South Africa deliberately lowers the start to 25; the younger and older ages fall outside both recommendations.

A high-risk HPV DNA test has replaced cytology as the primary screen, because it detects the cause of disease before cellular changes appear and is more sensitive.

Cytology is now a triage test for HPV-positive samples; visual inspection, colposcopy and serology are not primary screens.

HPV45 is the next most oncogenic type after 16 and 18 and is strongly linked to cervical adenocarcinoma, which cytology screens poorly. Reporting it individually lets the algorithm send it straight to treatment.

It is neither low-risk nor non-oncogenic, is detected by the assay, and its individual reporting is unrelated to vaccine cross-reactivity.

• Higher sensitivity: HPV testing detects the cause of disease before cellular changes appear and finds around 90% of high-grade precancer, more than a single cytology slide.
• High negative predictive value: because nearly all cervical cancer is HPV-driven, a negative result is highly reassuring and lets screening intervals be safely lengthened.
• Objective and reproducible: it is a defined laboratory result rather than a subjective slide read.
• Scalable: it runs on automated high-throughput platforms.
• Better access: it can be performed on a self-collected sample, reaching women who do not attend for a speculum examination. Genotyping the highest-risk types then offsets the lower specificity of testing for a frequently transient infection, and cytology is retained as a triage test on HPV-positive samples.

A complete answer covers the test, who is screened and when, and the genotype-directed actions.

Test and population. Primary screening is a high-risk HPV DNA test for all women from age 25, regardless of HIV status. A clinician-collected sample is taken into liquid medium so reflex cytology can be run from the same vial, and self-sampling is offered to widen coverage.

Interval. HPV-negative women return at routine intervals: about ten years if HIV-negative and five years if living with HIV, for life.

Genotype-directed action on a positive result. A result positive for HPV 16, 18 or 45 goes to screen-and-treat: assessment under visual inspection with acetic acid (VIA), then thermal ablation if no lesion is seen or colposcopy and large loop excision of the transformation zone (LLETZ) if a lesion is present, with HPV follow-up at twelve months. A result positive for other high-risk types is triaged by reflex cytology: normal cytology leads to a repeat HPV test in twelve months, low-grade change to assessment and ablation, and high-grade change to colposcopy and LLETZ. In an HIV-negative woman aged 40 or older, an other-high-risk result may be treated directly without waiting for cytology.