Screen-and-treat: a sustainable solution for cervical cancer elimination in low and middle income countries

Cervical cancer is a largely preventable disease, yet over 90% of its global mortality occurs in low and middle income countries(LMICs), reflecting profound inequities in access to screening and treatment. Traditional multivisit cervical cancer prevention models have been inadequate in these settings, largely due to high rates of loss to follow-up and insufficient health system infrastructure. In response, the WHO recommends the screen-and-treat (SAT) approach, which offers treatment based on a positive screening result, without requiring histological confirmation, preferably within a single visit. This narrative review synthesises evidence on the clinical effectiveness and operational feasibility of SAT in resource-constrained settings, with a focus on screening modalities, visual inspection with acetic acid (VIA) and human papillomavirus (HPV) testing and treatment options including cryotherapy, thermal ablation (TA) and large-loop excision of the transformation zone (LLETZ). While VIA is low-cost and provides immediate results, its accuracy is limited by provider-dependent subjectivity. HPV testing, particularly through point-of-care platforms and self-sampling, offers higher sensitivity and improved acceptability and is now the WHO-recommended primary screening modality. For treatment, portable TA devices have emerged as a logistically superior alternative to cryotherapy in LMICs, eliminating the need for compressed gas while maintaining comparable efficacy. Recent evidence further confirms that TA is non-inferior to LLETZ in real-world SAT settings, challenging the long-held perception that ablative therapies are clinically inferior. Concerns about overtreatment persist but must be weighed against the considerably greater risk of undertreatment in fragmented health systems. Women living with HIV require particular attention, given higher HPV prevalence, lower test specificity, more rapid disease progression and substantially lower post-treatment cure rates, necessitating tailored management protocols. The SAT approach represents a pragmatic, evidence-based strategy for achieving cervical cancer elimination in LMICs, but its effectiveness will depend on contextually appropriate implementation, integration within existing primary healthcare services and dedicated strategies for high-risk populations.