The time is now to implement HPV testing for primary screening in low resource settings

Unacceptable disparities in cervical cancer between richer and poorer countries persist and serve as reminders of gross disparities in access to and quality of screening services. HPV testing is well-suited to address some of the barriers to implementing adequate screening programs in low resource settings. HPV testing has considerably better sensitivity than cytology providing the same extent of safety with fewer rounds of screening. New robust HPV testing platforms require little to no skill by laboratory workers and some can be used at the point-of-care. This allows for a round of screening to be accomplished in one or two visits, reducing costs and the inevitable attrition that occurs when women need to be recalled to obtain their results. HPV testing is ideal for incorporating into the new "screen-and-treat" approaches designed to overcome limitations of conventional, multi-visit, colposcopy-based approaches to screening. Visual inspection with acetic acid (VIA) is the screening test that has been used most widely in screen-and-treat programs to date but the performance characteristics of this test are poor. HPV-based screen-and-treat is more effective in reducing disease in the population and reduces over-treatment intrinsic to this approach. HPV testing can be adapted or combined with other molecular tests to improve treatment algorithms. Infrastructure established to support VIA-based screen-and-treat can effectively incorporate HPV testing. We are poised at a critical juncture in public health history to implement HPV testing as part of primary screening and thereby improve women's health in low resource settings.