Document resource
Introduction While globally cervical cancer is the fourth most common cancer among women, an estimated 90% of the incidence and 92% of the mortality occurs in low and middle income countries (LMICs), highlighting the disproportionate burden of this disease. 1 Considering that with early detection and timely management of precancerous lesions, cervical cancer is almost entirely preventable, this skewed distribution reflects vast inequities in access to preventative care and treatment services.2 3 There are various factors that contribute to this inequity. One major issue is that screening coverage in many LMICs falls far short of global targets, with only a quarter of eligible women ever having been screened.4 This is compounded by the challenge of linking screening services to appropriate treatment pathways. The traditional model for the management of cervical precancer, which relies on colposcopy and histological diagnosis prior to treatment procedures, is often not contextually appropriate for many LMICs, which contributes to high rates of loss to follow-up and missing the critical window of opportunity for timely management.5 In an effort to mitigate this, in 2013 the WHO officially recommended a reduced visit approach referred to as screen-and-treat (SAT).6 SAT involves offering treatment based on a positive screening test, without the additional step of histological diagnosis of precancer, which eliminates the need for multiple healthcare visits and reduces the burden on both the patient and the health system. While the SAT approach is essential if we are to achieve the WHO’s ambitious ‘90-70-90’ cervical cancer elimination goals, the concern some have with SAT programmes is the risk of overtreatment, owing to the lack of confirmatory tests prior to treatment.7 However, in settings where there is such a high burden of cervical cancer, in large part due to healthcare inequity and poor linkage of services, this concern has to be weighed against the very real danger of undertreatment. Ultimately, undergoing the screening test is only the entry point into cervical cancer prevention programmes and is futile if appropriate management for any detected precancer is not available. While it is important to focus on improving screening coverage in LMICs, it must also be combined with increasing access to treatment. This review evaluates the effectiveness and practicality of SAT in resource-limited settings. By integrating real-world experiences and emphasising contextual factors, it shifts the focus from purely clinical outcomes to operational feasibility, ensuring that treatment quality is maintained while expanding coverage.Methods We conducted a narrative review of the literature to synthesise evidence on the role of SAT programmes in LMICs. The search strategy focused on three key areas to evaluate the clinical efficacy and operational feasibility of the single-visit approach in resource-limited environments. First, it focused on the SAT or single-visit methodology and point-of-care (POC) approaches. Second, the search was narrowed to LMICs, as defined by the World Bank, or other resource-limited settings. 8 There was also a particular effort to identify literature concerning women living with HIV (WLHIV) due to their elevated risk of rapid disease progression, higher treatment failure rates and the higher prevalence of HIV in many LMICs.9 10 Lastly, the strategy incorporated specific screening and treatment modalities, as outlined in the WHO guidelines.7 These included screening with human papillomavirus (HPV) testing, including self-sampling, and visual inspection with acetic acid (VIA), as well as treatment options such as thermal ablation (TA), cryotherapy and large-loop excision of the transformation zone (LLETZ). An initial search of CINAHL and PubMed was conducted, with articles being limited to English-language. Following this, the search was developed iteratively through a review of resulting titles, abstracts and reference lists of relevant articles. Searches were conducted between December 2025 and February 2026. No specific date restrictions were applied, as older literature provides critical context regarding the historical role of SAT in LMICs and facilitates comparisons with programmes implemented prior to the update in WHO recommendations in 2019.11 12 Given the narrative nature of this review, formal inclusion/exclusion criteria were not applied, and quality appraisal tools were not used.Patients and members of the public were not involved in the design, reporting or dissemination plans of this narrative review. The synthesis was based on an analysis of existing literature and public health guidelines. However, the themes explored, specifically the feasibility and acceptability of self-sampling and single-visit care, reflect documented patient preferences and barriers to care identified in the primary studies included in this review.Rationale for SAT It has become increasingly apparent over the past two decades that cytology-based cervical cancer screening is unable to have the same positive impact at a population level in LMICs compared with the success it has had in high-income countries (HICs) at reducing the burden of cervical cancer. 2 This is due to the resource-intensive nature of these programmes, which require multiple healthcare visits, referral to specialist facilities, costly laboratory infrastructure and highly skilled medical staff, all of which are not a reality in many LMICs.13 This has led to suboptimal screening coverage rates, with the latest estimates indicating that only 27% of eligible women have ever been screened, which lags behind HICs, with a screening coverage of 84%.4 14To address these disparities, the WHO global strategy for cervical cancer elimination has established the ‘90-70-90’ targets for 2030, mandating that 90% of girls are vaccinated against HPV, 70% of women are screened with a high-performance test at ages 35 and 45 and 90% of those with cervical precancerous disease receive treatment.7 The SAT approach is fundamental to achieving these targets as it aims to increase screening coverage by using tests that are contextually feasible in LMICs and to improve treatment rates by ensuring patient retention. In SAT programmes, women who screen positive, either using VIA or a test for high-risk HPV, are treated based on this result, preferably during the same visit, without histopathological confirmation of disease.7 Despite legitimate concerns regarding overtreatment, the risk of undertreatment due to loss-to-follow-up remains a more substantial barrier to reducing cervical cancer mortality in resource-limited environments.2 15 Not only has this approach been shown to be effective at preventing cervical cancer, but it is also highly acceptable to both patients and healthcare providers, and so serves as a cornerstone of the WHO’s strategy to eliminate cervical cancer as a public health problem.16–18Screening modalities The vast majority of cervical cancers are caused by persistent infection with high-risk, or oncogenic, HPV subtypes. 19 However, there is a long latent period between initial HPV infection, dysplastic transformation and eventually invasive disease, so the detection and treatment of precancerous lesions are particularly important to prevent cancer.20 In this way, screening aims to identify precancerous lesions and treat them to prevent development of cancer.21 In the setting of SAT, there are two main screening options, namely VIA and HPV testing (see table 1 for summary).Table 1Comparison of testing modalities in SAT settings7 17 22 25 26Visual inspection with acetic acidHigh-risk HPV testingProcessApplication of 3%–5% acetic acid to cervix, visual identification of acetowhite lesionsDetection of high-risk HPV using molecular tests on cervical or self-collected samplesInfrastructure requiredTrained provider, good lighting, equipment for pelvic examinationMolecular testing platform, supply chain for consumables, trained healthcare worker/technicianSensitivityModerate (variable)HighSpecificityModerate (variable)ModerateAdvantagesLow cost, immediate results, established use in SAT, feasible without laboratory infrastructureHigh sensitivity, longer screening intervals, self-sampling possible, use of existing POC testing platformsLimitationsSubjective interpretation with accuracy dependent on provider training, resulting in potential overtreatment and undertreatment (missed disease)Higher cost, requires laboratory or POC platforms, specificity could be improved or overtreatment must be toleratedHPV, human papillomavirus; POC, point-of-care; SAT, screen and treat.HPV testing in the context of cervical cancer screening looks at detecting the presence of the virus in a cervical or vaginal sample, which can be collected by a healthcare worker, or for vaginal samples by the patient herself. HPV testing has a very high sensitivity, meaning it is a powerful test that detects also all precancerous lesions when they are present, but it has only moderate specificity because while many women have HPV, only a subset of those women will actually develop precancer or cancer.22 When compared with both VIA and cytology-based screening, HPV testing has been shown to significantly increase in the detection of early-stage cervical cancer, leading to a reduction in the development of advanced-stage cancers and a lower rate of death.23 In light of this, it is considered a high performance test, and is recommended as the primary screening test by the WHO.7 Some research suggests that test specificity can be improved through more selective diagnostic criteria. This includes genotyping to isolate only the most high-risk HPV subtypes, or by establishing specific viral load thresholds to ensure a positive result reflects a clinically significant infection.5 24VIA involves, as the name suggests, inspection of the cervix without magnification, after the application of 3%–5% acetic acid, and has negligible consumable costs and can be implemented by suitably trained primary healthcare workers or even by lay healthcare workers.17 VIA has long been favoured in lower-resourced settings because it is low-cost, requires no laboratory infrastructure or assays and provides immediate results.25 It is often performed by specially trained nurses or midwives and requires rigorous quality measures to ensure competency and ongoing skill maintenance. Because of this, VIA is highly subjective and provider-dependent, with the accuracy of the test varying greatly based on provider experience and training.17 26 Even in the context of regular training and quality assurance, the sensitivity and specificity of VIA is often only moderate at best, although some programmes have reported better figures.17 25 26 The diagnostic accuracy of visual inspection methods can also be compromised by inadequate visualisation of the cervix owing to lateral vaginal wall collapse around the speculum, even when performed by highly skilled providers.27 Overall, the poor sensitivity and specificity of VIA contributes to the risk of both undertreatment and overtreatment when used in a SAT environment.24Another advantage of VIA is that it is inherently POC, providing immediate results, making it simple to combine screening and treatment into a single visit. HPV testing, on the other hand, can either be sent to a central laboratory for testing or done on-site, using POC testing platforms. There have been questions raised about the applicability of HPV POC testing for LMICs, given the well-established infrastructure-related barriers to the successful scaling of cytology-based screening. However, it has been suggested that one of the reasons that HPV testing is well-suited to lower resourced settings is because of the cost reduction potential. This stems from longer screening intervals, the ability to use existing infrastructure for POC testing, and the need for less intensive healthcare worker training.2 In terms of use of existing infrastructure, HPV testing can be done on the GeneXpert (Cepheid, Sunnyvale, California, USA) platform, which is already used in many LMICs for POC tuberculosis testing.24 As mentioned previously, HPV testing also offers the unique opportunity for testing using patient-collected samples, known as self-sampling, which has similar test accuracy as healthcare worker-collected samples.28 This makes cervical cancer screening more accessible and acceptable to many women, especially those who have previously been hesitant about screening for various sociocultural reasons.29 30With any screening test, there are trade-offs between accuracy, cost and acceptability, and HPV testing and VIA are no different. These differences in test performance also have to be balanced with what is programmatically feasible in different contexts. This is seen acutely in the poor performance of cytology-based screening programmes across many LMICs. Simply considering test performance when designing screening programmes does not necessarily translate to a population-level impact, and some feel that, despite the WHO recommendation to move to HPV testing for primary cervical cancer screening, focusing on scaling existing VIA programmes may improve screening coverage.25Treatment options for SAT Treatment for precancerous lesions can either aim to destroy the transformation zone, like TA or cryotherapy, or remove it entirely, for example, LLETZ. SAT approaches generally rely on ablative methods because they are simpler to implement, more easily used by non-specialists, require less infrastructure and are safer than excisional methods. 31 Prior to the WHO guidelines for TA in 2019, cryotherapy and LLETZ were the most commonly used treatment options, with cryotherapy being used more widely in LMICs.11 Cryotherapy involves freezing the tissue using compressed gas, either nitrous oxide or carbon dioxide, and its effectiveness, specifically in SAT settings, is well-studied.16 32 However, its use is limited by the cost of the compressed gas, in addition to issues associated with procurement and transport in LMICs.33 These challenges have motivated the search for improved treatment options that can be more easily scaled in low-resourced settings.TA which uses localised heat to induce tissue necrosis within the transformation zone has emerged as a promising alternative to cryotherapy in LMICs. While the technology has a long-standing history of use and high clinical cure rates in HICs, specifically within the UK, its adoption in resource-constrained environments has been more recent.34 Newer, portable versions have become available, making this treatment approach far more portable.35 Like cryotherapy, TA does not require the use of local anaesthesia and can be implemented by a wider range of healthcare providers, making it similarly well-suited for lower-resource settings.11 The comparative cure rates for cryotherapy and TA are very similar, although there is some variation between studies.36 Notably, TA does have some distinct advantages: it offers shorter treatment times, does not use consumables like compressed gas and many healthcare providers feel that the device is easier to use.31 35 Newer non-gas-based cryotherapy options are being developed and these hold promise both for clinical effectiveness and scalability in LMIC contexts.37 The WHO has outlined specific eligibility criteria for the use of ablative therapies, these are summarised in table 2.Table 2Eligibility criteria for ablative treatmentTZCompletely ectocervical and fully visible (type 1 TZ) orPartially endocervical but still fully visible (type 2 TZ)Lesion characteristicsLesion covers <75% of the ectocervix andEntire lesion must be visible and not extend into the endocervical canal or onto vaginal wall andProbe tip must be able to achieve complete coverage and ablation of the lesion and the TZSuspicion of malignancyThere should be no suspicion of invasive cancerTZ, transformation zone.Conversely, LLETZ requires specialist healthcare workers, surgical equipment and the administration of local anaesthesia, preferably in a hospital setting.38 The procedure involves removing the transformation zone and lesion using a thin, electrically heated loop of wire, making it more technically difficult.6 LLETZ, which is the standard of care in many HICs, is often considered the gold standard of precancer treatment, both because it has been thought to have better efficacy than ablative treatment, and because it provides a histological sample that can be used to confirm the presence of precancer and decide if it has been completely removed.39 40 However, it has also been shown that LLETZ, as with other excisional treatment methods, is associated with higher rates of obstetric complications in future pregnancies, such as an increased risk of preterm birth, low birthweight infants and premature rupture of membranes.41 These are all of particular concern in settings with inadequate access to maternal and neonatal health services.In addition to the lack of obstetric risk, TA is considered safer than LLETZ, with less chance of complications or serious adverse events.40 Common side effects include lower abdominal or pelvic pain and watery vaginal discharge, whereas LLETZ has also the additional risk of bleeding.32 Recent evidence confirms that TA is highly effective, safe and well-accepted by both patients and providers.40 42 In a large randomised control trial by Basu et al, TA was shown to be as effective as LLETZ for treating precancer in real-world SAT settings.38 This is an important step in addressing the idea that TA is the less effective option and really only best suited for low-resourced settings.32Much of the hesitancy around using a SAT approach is the risk of overtreatment. While this is understandable when considering the risks of treatments like LLETZ, particularly the increased risk of obstetric complications, ablative options, specifically TA, have been shown to not only be safe, but also highly acceptable to women.5 31 38 43 Considering this and the very real risk of undertreatment or delayed treatment in these settings, SAT with TA seems a fairly straightforward choice. That being said, while LLETZ is more technically demanding, it still remains an essential treatment for women who are not eligible for ablation. Ultimately, the choice of treatment depends on specific eligibility criteria, provider training, and resource availability, but ablative therapies should not be seen as the lesser of the treatment options (table 3).38Table 3Comparison of treatment options31 33 35 39 40CryotherapyThermal ablationLLETZCategoryAblativeAblativeExcisionalMechanismUses refrigerant gas (nitrous oxide or carbon dioxide) to freeze abnormal tissueUses a probe heated to 100°C to destroy abnormal tissueUses an electrosurgical loop to excise the transformation zonePower sourceNone (requires gas cylinders)Battery-operated or mains-operated; electricity for chargingElectricity (requires an electrosurgical unit)DurationApproximately 11 min (double-freeze method)20–40 s per applicationVaries (surgical excision)AnaesthesiaUsually noneUsually noneLocal anaesthesia requiredPortabilityLow (heavy gas cylinders)Depends on machine, but generally high (lightweight, handheld, cordless)Low (requires clinical infrastructure and electricity)HistologyNo tissue specimen available for analysisNo tissue specimen available for analysisProvides a tissue specimen for pathologyProvider trainingRequires trainingRequires trainingSpecialised, highly trainedCommon useTraditional standard for LMIC screen-and-treat programmesEmerging preference for LMICs due to logistical easeStandard in high-income countries; used for larger/complex lesions in LMICsLLETZ, large-loop excision of the transformation zone; LMIC, low-income and middle-income country.Real-world implementation of SAT SAT programmes have demonstrated significant success across various LMICs, including Peru, Malawi, Zambia and South Africa. In Peru, the Proyecto Precáncer initiative used a phased approach to transition from cytology and VIA-based methods to HPV testing followed by visual assessment for treatment. 15 By addressing systemic barriers and decentralising TA to primary care settings, the programme doubled the retention of screen-positive women from 30.2% to 67.4% within just 6 months.44 Similarly, Zambia’s long-term sustainability since 2012 stems from a strong nurse-led model, using task-shifting and the strategic integration of services within existing HIV care infrastructure.45 46 These strategies allowed for same-day treatment in over 75% of cases and facilitated a transition towards government-embedded funding.46 High feasibility and acceptability are further evidenced in Malawi and South Africa, where studies using VIA or POC HPV testing alongside TA achieved same-day treatment rates exceeding 90% and 94%, respectively.5 18 Importantly, many studies in these contexts have shown substantial reduction in incidence of cervical precancer when comparing SAT programmes to those that require delayed treatment following histological confirmation.16 47 Collectively, these examples illustrate that integrating SAT into primary healthcare and leveraging local infrastructure are critical drivers for sustainable cervical cancer prevention in resource-limited settings.Women living with HIV The HIV epidemic poses a critical issue in terms of cervical cancer prevention, particularly in sub-Saharan Africa. WLHIV are a subset of women who need special attention when it comes to the prevention of cervical cancer for many reasons. The main one being that WLHIV have a six times higher risk of developing cervical cancer due to higher rates of HPV infection, lower rates of viral clearance and faster disease progression. 9 10 48 While the use of antiretroviral treatment has been shown to decrease the prevalence of high-risk HPV in WLWH, their rates of cervical cancer remain significantly elevated.48 49 These factors have meant that these women have generally been offered more screening than the general population. However, one issue is that HPV testing in WLHIV has lower specificity, resulting in an increased risk of overtreatment and a higher number of referrals in SAT settings.50 Because HPV prevalence is so high in this demographic, sometimes more than 40%, screening so frequently may identify transient HPV infections that lack clinical significance, and therefore increasing the risk of overdiagnosis and treatment.5 This has the potential to overwhelm clinical infrastructure in already constrained environments. To minimise this, the WHO recommends a ‘screen, triage and treat’ approach, with VIA triage following a positive HPV test.7 However, there is significant concern that using VIA as a triage test prior to treatment might risk missing early precancers in a group that has such a high risk of rapid disease progression.50 This is compounded by the fact that WLHIV have higher rates of treatment failure regardless of the treatment modality. For example, recent trials have shown success rates for TA as low as 62.7% in WLHIV, compared with much higher efficacy in the general population.5 38 51 This is of particular concern because of the high prevalence of HIV in many resource-constrained countries where SAT approaches are otherwise well-suited. It remains unclear whether these higher failure rates are due to the persistence of the original HPV infection or the acquisition of new strains due to immune suppression.38 Another issue is that WLHIV often present with larger or more advanced disease, which may mean that they are eligible for ablative treatment and therefore necessitating more invasive management.9 This highlights that SAT programmes need to cater to varying needs or at least be well linked to referral centres. Ultimately, these challenges highlight the urgent need to better understand the biological reasons for the higher treatment failure rates and what can be done to improve outcomes for WLHIV, such as more frequent screening intervals or the integration of viral load thresholds.5Discussion The implementation of cervical cancer prevention in LMICs is currently at a crossroads between striving for high clinical accuracy and ensuring broader population-level coverage. While advances in molecular diagnostics and excisional treatment techniques have improved the clinical management in HICs, these approaches have not translated into equivalent public health gains in resource-constrained settings. This is largely due to systematic failures rather than any innate biological difference in the disease. In this way, the SAT model should not be seen as a compromise in quality of care, but rather a necessary reorientation of priorities towards feasibility, continuity of care and patient retention.One of the key strengths of SAT lies in its ability to address loss to follow-up, which remains a significant contributor to preventable cervical cancer mortality in many LMICs.5 Multivisit programmes that require referral for colposcopy and histopathological confirmation prior to treatment assume women have reliable transport and flexible working conditions, in a health system with consistent laboratory infrastructure, all of which are frequently untrue in many settings.13 By providing screening and treatment in the same visit, SAT minimises reliance on traditional multistep care pathways that can be challenging to sustain in many LMIC health systems.However, demonstrating clinical efficacy in research trials does not necessarily ensure successful implementation in real-world settings. Similarly, the introduction of HPV testing and portable TA devices does not automatically resolve entrenched structural barriers. Health system readiness, including supply chain stability, supervision structures, data systems and health workforce retention, remains the determining factor in programme scalability.52 Evidence suggests that even well-designed programmes struggle when basic consumables are intermittently unavailable or when trained staff rotate out of primary care settings, both of which are common issues in many LMICs.52 One way to potentially mitigate this is to integrate SAT programmes into existing primary healthcare services, rather than taking a vertical, standalone approach. For example, integrating cervical cancer prevention into established HIV care services can leverage established patient–provider relationships and reduce the burden of additional travel for the patient, making the programme more sustainable and scalable.50Adding to this is the growing shift away from cryotherapy towards TA and the important evolution that this represents in the treatment component of SAT. By eliminating the need for compressed gas, TA overcomes a significant operational barrier in many LMIC settings, while maintaining treatment efficacy comparable to excisional approaches. Importantly, emerging data comparing TA with LLETZ challenge the long-standing perception that ablative therapies are clinically inferior. Instead, the evidence suggests that when eligibility criteria are followed, ablative treatments provide a clinically sound and operationally advantageous alternative.38 This shift has profound implications for decentralising care to primary clinics and rural outreach services, thereby reducing many long-standing geographic inequities.53Nonetheless, the debate surrounding overtreatment remains central to SAT implementation. From a strictly diagnostic standpoint, treating all screen-positive women, particularly those who are HPV-positive, inevitably exposes some women to unnecessary procedures. Yet this needs to be contextualised within the reality of high loss to follow-up which results in delayed or missed care. In settings where women may only engage with the health system sporadically, the harm associated with missed or delayed treatment may far exceed the relatively low complication profile of modern ablative therapies. Importantly, the favourable safety and acceptability profile of TA is an important consideration, as when the risk of adverse events is low, and procedures are well tolerated, same-visit treatment becomes a more justifiable approach.38Unfortunately, the application of SAT among WLHIV is more complex. Higher HPV prevalence, lower test specificity, more rapid disease progression and poor post-treatment cure rates all complicate standard protocols. The WHO-recommended ‘screen, triage and treat’ approach introduces VIA triage after a positive HPV test to mitigate overtreatment, but this risks missing early lesions in a population already prone to rapid progression.50 High treatment failure rates, irrespective of modality, raise further concerns about the adequacy of once-off management.38 Tailored adaptations are therefore needed, including shorter screening intervals, enhanced triage using genotyping or viral load thresholds, and integration within HIV care services, which offer established follow-up infrastructure that can help mitigate these risks.5 24Beyond clinical and systems considerations, psychosocial barriers remain persistent determinants of programme uptake. Fear of cancer diagnosis, stigma associated with gynaecological examinations, gender power imbalances and misinformation continue to limit screening participation.54 In this regard, HPV self-sampling represents a unique opportunity to improve screening acceptability. By decentralising specimen collection and increasing privacy, self-sampling may reduce cultural and emotional barriers that have historically limited coverage.30 However, its success remains contingent on reliable pathways to ensure that women who test positive are promptly treated. This reaffirms that screening innovations cannot be evaluated independently of treatment capacity.Ultimately, the evidence suggests that the effectiveness of SAT programmes depends less on selecting the single best screening test or treatment modality and more on developing a coherent, contextually appropriate care pathway. Clinical performance, operational feasibility, patient acceptability and health system integration should be considered as inter-related components of cervical cancer prevention programme design.Conclusion The global inequity in cervical cancer burden reflects systemic failure, and the SAT approach represents a pragmatic, evidence-based response that prioritises feasibility and patient retention over diagnostic perfection. HPV testing, particularly through POC platforms and self-sampling, and portable TA devices together address the core operational barriers that have long undermined cervical cancer prevention in LMICs. Emerging trial evidence confirms that ablative treatment is non-inferior to LLETZ when eligibility criteria are observed, and its favourable safety and acceptability profile means that the risks of same-visit treatment are outweighed by the far greater danger of loss to follow-up in fragmented health systems. For WLHIV, standard protocols require adaptation, with closer surveillance, enhanced triage and integration within HIV care services. Ultimately, effective secondary prevention in LMICs will depend not on the pursuit of a diagnostically perfect programme, but on the implementation of resilient, contextually appropriate care pathways underpinned by political commitment, health system strengthening and sustainable financing.