Integrating a “see-and-treat” approach with opportunistic human papilloma virus deoxyribonucleic acid (HPV DNA) based cervical cancer screening in India: a retrospective cross-sectional study

Abstract

BACKGROUND

India lacks an organized national cervical cancer screening program, and while the World Health Organization (WHO) recommends human papillomavirus (HPV) deoxyribonucleic acid (DNA) testing as the primary modality, large-scale evidence on implementation via decentralized treatment pathways in India is limited. We evaluated the effectiveness of opportunistic high-risk HPV (hrHPV) DNA screening, assessing prevalence, genotype distribution, self-testing acceptance, and the diagnostic performance of a community-based “see-and-treat” approach.

OBJECTIVE

To evaluate the prevalence and genotype distribution of hrHPV and assess the diagnostic accuracy, treatment compliance, and clinical viability of a decentralized “see-and-treat” approach within a large-scale opportunistic screening program across 20 Indian states.

STUDY DESIGN

In this retrospective cross-sectional study (January 2022–December 2025), 62,868 women aged 25 to 65 years were enrolled across 20 Indian states via community outreach (75.1%) and hospital-based network (24.9%). Screening utilized clinician-collected or self-collected (10.5%) samples tested via the Cobas 6800 system. hrHPV-positive women were triaged by colposcopy and managed through a decentralized “see-and-treat” approach using thermal ablation (TA) or Large Loop Excision of the Transformation Zone (LLETZ). Primary outcomes included HPV prevalence, diagnostic accuracy (AUC), and treatment compliance.

RESULTS

Overall HPV prevalence was 8.5% (5,354/62,868), with significant regional variation (11.3% in Delhi NCR to 4.7% in Kerala). Non-16/18 high-risk genotypes accounted for 54.6% of infections. Positivity peaked at ages 26 to 30 years (10.1%) and had a minor peak at 51 to 55 years (8.4%). The see-and-treat modality demonstrated high diagnostic accuracy (AUC 0.95; sensitivity 0.98; specificity 0.91) with a program efficacy of 81.2% with 16.3% overtreatment and 21.1% undertreatment. Treatment compliance in the community sub-cohort was 51.3% (1,957/3,813). We identified five women with invasive cancers and 7.8% CIN III (28/357), 9.0% CIN II (32/357), and 26.3% CIN I (94/357) of the histopathology sub-group.

CONCLUSION

Opportunistic hrHPV screening integrated with decentralized “see-and-treat” is a clinically robust strategy for LMICs. Significant regional heterogeneity requires tailored, state-specific policies and digital linkage-to-care frameworks to overcome compliance barriers and meet WHO 2030 cervical cancer elimination goals.