Universal HPV access drives record uptake among overdue women while maintaining cancer detection rates.
Australia’s move to make HPV self-collection universally available through primary care has dramatically expanded cervical screening participation without reducing clinical performance, new research shows.
Women long overdue for screening, living remotely or facing socioeconomic disadvantage have been among the cohorts which have seen the biggest improvements in screening numbers.
In a retrospective cohort study conducted as part of quality assurance within the Australian National Cervical Screening Program, investigators analysed data from the National Cancer Screening Register spanning 1 December 2017 to 31 December 2023.
Self-collection was initially restricted to women aged 30 years and older who were at least two years overdue or had never screened when Australia transitioned to primary HPV testing in 2017. On 1 July 2022, eligibility was expanded to all women aged 25–74 years.
The study evaluated both uptake trends and histologically confirmed outcomes following colposcopy. Results have been published in The Lancet Public Health.
Co-author and Professor of Practice in the Cancer Elimination Centre and Sydney Medical School, the University of Sydney, Professor Deborah Bateson AM, told The Medical Republic there had been some early hesitation from clinicians but the data showed how quickly self-collection had been embraced.
“Initially they didn’t realise or didn’t know it was as accurate as clinician-collection, so there was hesitancy around it, and it wasn’t always being offered as a choice,” she said.
“I think now we’ve really turned the ship around, which is great. And so, clinicians, GPs, nurses – they’re all very well aware of it. And now, of course, the community is asking for it.
“So, I think that really has changed. This concept of, ‘no one ever looked forward to having a speculum examination’ – this negating that need for a speculum has been really the key change.”
Following the eligibility expansion, uptake of self-collection increased sharply, the researchers found.
Self-collected samples accounted for 1.2% of all valid HPV tests in the second quarter of 2022 and rose to 26.9% by the fourth quarter of 2023.
Uptake was not evenly distributed across the population; women more than 10 years overdue for screening had the highest uptake at 51.9%, compared with 31.4% among those overdue by two to five years.
Self-collection was chosen by 53.9% of women in very remote areas versus 23.8% in major cities, and by approximately 28–29% of women living in the most disadvantaged socioeconomic quintiles compared with 24.1% in the least disadvantaged.
Uptake was also highest among women aged 70–74 years (33.5%). In absolute terms, more under-screened and never-screened women used self-collection in the first six months after expansion than in the preceding four and a half years combined.
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Between December 2017 and June 2023, 4,926,713 women underwent a valid HPV test, with 484,622 (9.8%) testing positive.
In the first year after universal eligibility (1 July 2022 to 30 June 2023), 421,511 women were screened and 63,541 (15.1%) were HPV positive.
HPV positivity was higher in self-collected than clinician-collected samples (16.4% vs 14.8%; p<0.001), reflecting differences in baseline characteristics; women choosing self-collection were more likely to be older, under-screened, socioeconomically disadvantaged and living outside major cities.
To assess clinical performance, the investigators compared histological outcomes among women referred for colposcopy between 1 July 2022 and 30 June 2023.
For women with HPV-16/18, who are recommended for direct referral to colposcopy, 11,031 were included after exclusions.
Colposcopy attendance was similar between groups (87.5% for self-collected vs 87.7% for clinician-collected; p=0.79). Among women with HPV-16/18 detected on self-collected samples, 72.1% proceeded directly to colposcopy in accordance with guidelines, while 19.7% had cytology before their first colposcopy visit, contrary to recommendations.
Overall, 230 histologically confirmed high-grade lesions were detected among women with HPV-16/18 screened via self-collection. Although the crude detection rate of high-grade lesions was lower in self-collected than clinician-collected samples (11.2% vs 14.1%; p<0.001), this difference was not significant after adjustment for age, socioeconomic status, remoteness and screening history (adjusted odds ratio 0.96, 95% CI 0.81–1.13). Histological detection of cancer was also similar (adjusted OR 0.71, 95% CI 0.36–1.40).
Among women with oncogenic HPV types other than 16/18 who met cytology criteria for referral, detection of high-grade lesions was slightly lower in the self-collected group (50.8% vs 56.1%), but not statistically different after adjustment (adjusted OR 0.87, 95% CI 0.67–1.13).
Cancer detection did not differ significantly (adjusted OR 1.20, 95% CI 0.31–4.62).
Follow-up completeness emerged as a key implementation issue. Incomplete follow-up data were more common after self-collection (29.6%) than clinician collection (17.7%).
In women with HPV-16/18 detected on self-collected samples, failure to obtain liquid-based cytology at colposcopy – necessary to determine whether a second colposcopy was required – accounted for a substantial proportion of incomplete follow-up.
Attendance at second colposcopy visits was also lower than at first visits. Women with incomplete follow-up were more likely to be aged 25–39 years, under-screened or living in remote areas.
Despite these operational challenges, the adjusted analyses consistently demonstrated comparable histological detection of high-grade lesions and cancer between self-collected and clinician-collected pathways.
Professor Bateson said the findings reinforced evidence that clinically validated PCR-based HPV assays perform equivalently on self-collected and clinician-collected samples in routine practice when embedded within an organised program.
“It’s really out there now, which is fantastic,” she told TMR.
“It’s all about equity, and it has been a game changer for equity, because the greatest uptake is in the under-screened groups, older women, very remote areas, low socio-economic groups, and Aboriginal and Torres Strait Islander women.”
In addition to this were the capturing of women who had never been screened in any way.
“At the end of 2025, we can see that of those who have been never screened, almost 51% had chosen to have a self-collected test,” she said.
“And these are probably tests that would never have been done otherwise.”
The next important step was to ensure that primary care clinicians were aware of the importance of offering assistance with self-collection if needed.
This could be useful for people with disabilities, people with a history of sexual abuse or assault, and people screening for the first time, said Professor Bateson.
She said it was possible clinicians were not widely aware of the scope to offer assistance with self-collection without having to offer a full pelvic examination. She hopes raising this awareness will help capture even more people into the self-collection screening program.
“I work with a lot with people with disability, and they talk about the negative experiences, horrible experiences, sometimes with a speculum,” she said.
“It’s just providing this new option for people who’ve experienced sexual assault or child sexual abuse or have pelvic pain and also stigma and shame about having a pelvic examination. It’s really overcoming those barriers.”
Professor Bateson said the gains put Australia in a good position for its national goal to reach cervical cancer elimination by 2035.
“What we know is that overall, we hope that’s possible,” she told TMR.
“The most recent data that’s come out has shown a downward trend. The elimination target is fewer than four cases per 100,000 and in 2021 we were at 6.3 and 2020 I think it was 6.6 but the key thing is that this is different for different groups.
“We know that Aboriginal and Torres Strait Islander women have two to threefold higher rates. So, we’ve really got to look at that equity issue and make sure that we’re bringing everyone along on this and have targeted approaches to ensure that we do bring people into screening.”
