Resource-Adapted Triage Strategies for Women Testing HPV Positive With Self-Collected Vaginal Samples in Cameroon

The World Health Organization (WHO) recommends HPV-DNA testing as the primary screening method for cervical cancer in low- and middle-income countries (LMICs), yet guidance on how to triage HPV-positive women remains limited. The 2021 WHO guidelines for LMICs do not incorporate extended HPV genotyping, despite its potential to improve risk stratification and support scalable management strategies. This study evaluated screening strategies based on locally available resources for management of HPV-positive women. We retrospectively analyzed data from the 3T study (Test, Triage, and Treat), conducted between 2018 and 2022, which included HPV self-sampling and VIA triage among women aged 30-49 years. For all HPV-positive participants, HPV testing (stratified into five genotype-based risk groups), cytology, VIA, cervical-biopsy, and endocervical-brush histopathology were available. Thirty-five screening and triage strategies integrating HPV extended genotyping alone or in combination with VIA or cytology were assessed using CIN3+ risk as a guiding principle. Among 868 HPV-positive women, 9% had CIN3+ lesions. HPV types 31/33/35/52/58 were most prevalent, whereas HPV16 and HPV18/45 carried the highest CIN3+ risks. Strategies combining extended genotyping with cytology demonstrated the best balance of sensitivity and specificity. In settings without access to cytology or VIA, direct treatment of the eight highest-risk HPV types, 16/18/45/31/33/35/52/58, showed the best balance between sensitivity and specificity. When cytology or VIA was available, immediate treatment for HPV16 and reflex triage, cytology (treating ≥ ASCUS lesions), or VIA for HPV18/45/31/33/35/52/58 showed the best trade-off. The proposed screening strategies enable risk-adapted triage and guide management decisions based on available resources.