Evidence-based recommendations on using HPV DNA genotyping levels (extended, limited, no genotyping) for cervical cancer screening strategies tailored to programme follow-up capacity.
What this guideline saysGMJ summary
This guideline provides recommendations for using HPV DNA tests with different levels of genotyping (extended, limited, or no genotyping) as part of cervical cancer screening programmes. It stratifies 12 carcinogenic HPV types into four risk groups (1a: HPV16; 1b: HPV18/45; 1c: HPV31/33/35/52/58; 1d: HPV39/51/56/59) based on cervical cancer attributable fraction, enabling risk-stratified management of screen-positive women.
The recommendations differ according to programme follow-up capacity. In settings with high follow-up capacity (≥60% attendance at all care continuum steps), WHO suggests using extended or limited genotyping over treating all HPV-positive women or triaging all. The preferred strategy treats women positive for groups 1a, 1b and 1c and triages group 1d. In low follow-up capacity settings (<60% at any step), WHO suggests treating all women positive for groups 1a, 1b, 1c (and 1d) to minimize losses to follow-up, accepting some overtreatment to prevent progression to cancer.
All strategies assume adequate ablative treatment capacity is in place before screening begins. Women should be visually assessed for eligibility for ablative treatment; those ineligible receive LLETZ. When triage is used, VIA or colposcopic impression is preferred over cytology. These conditional recommendations are based on low-certainty evidence from systematic reviews of cumulative CIN2+/CIN3+ risk and mathematical modelling, as no longitudinal trials of genotyping strategies exist yet.
Key pointsfor clinicians
- HPV DNA testing remains the recommended primary screening test; these recommendations apply to using different genotyping levels within HPV DNA testing strategies
- Carcinogenic HPV types are classified into four risk groups: 1a (HPV16), 1b (HPV18, 45), 1c (HPV31, 33, 35, 52, 58), 1d (HPV39, 51, 56, 59), based on cervical cancer attributable fractions of 62.4%, 20.1%, 14.5% and 2.1% respectively
- In high follow-up capacity settings (≥60% attendance at ALL steps), use extended or limited genotyping: treat women positive for groups 1a, 1b and 1c; triage group 1d with VIA, colposcopy or cytology
- In low follow-up capacity settings (<60% at ANY step), treat all women positive for any carcinogenic HPV types (groups 1a, 1b, 1c, 1d) or at minimum groups 1a, 1b, 1c to prevent loss to follow-up of pre-cancerous lesions
- Regular screening should start at age 30, prioritizing ages 30–49 years, with intervals of 5–10 years for HPV DNA testing
- Before any treatment, visually assess eligibility for ablative treatment (with or without colposcope after acetic acid); women ineligible for ablation receive LLETZ
- When triaging HPV-positive women, use VIA or colposcopic impression rather than cytology or dual-stain cytology
- Programmes must establish adequate ablative treatment capacity before initiating screening; follow-up capacity should be assessed using indicators showing percentage completion at triage, treatment and follow-up visits
Classification of 12 carcinogenic HPV types into WHO TPP risk groupsextracted from the guideline
| HPV subgroup | HPV types | % prevalence in cervical cancer | % prevalence in normal cytology | Odds ratio | % Attributable fraction |
|---|---|---|---|---|---|
| Group 1a | HPV16 | 55.8 | 2.6 | 47.6 | 62.4 |
| Group 1b | HPV18, 45 | 14.3, 4.8 | 1.0, 0.6 | 15.7, 8.3 | 15.3, 4.8 |
| Group 1c | HPV31, 33, 35, 52, 58 | 3.5, 4.0, 1.6, 3.2, 4.0 | 1.0, 0.6, 0.4, 1.0, 0.8 | 3.7, 7.1, 3.9, 3.3, 5.1 | 2.9, 3.9, 1.4, 2.6, 3.7 |
| Group 1d | HPV39, 51, 56, 59 | 1.3, 1.0, 0.8, 1.2 | 0.6, 0.9, 0.6, 0.4 | 2.0, 1.2, 1.3, 2.9 | 0.8, 0.2, 0.2, 0.9 |
What changed in this edition
- New recommendations on the use of HPV DNA genotyping levels (extended, limited, no genotyping) not previously addressed in the 2021 second edition
- Introduction of WHO Target Product Profile classification stratifying 12 carcinogenic HPV types into four risk groups (1a, 1b, 1c, 1d) based on cervical cancer attributable fraction
- Stratification of recommendations by programme follow-up capacity (high ≥60% vs low <60%) with different preferred strategies for each
- Explicit threshold of 60% attendance at all care continuum steps to define high vs low follow-up capacity
- In high follow-up settings, extended/limited genotyping now preferred over treating all HPV-positive women or triaging all
- In low follow-up settings, treating all cHPV-positive women (or at minimum groups 1a, 1b, 1c) now preferred over strategies requiring additional triage visits
ApplicabilityGeorgia and the region
Georgia and neighbouring countries in the South Caucasus and Eastern Europe face substantial cervical cancer burden and are working toward the WHO 90-70-90 elimination targets. Implementation of these recommendations requires national programmes to first assess their follow-up and treatment capacity using routine programme indicators (percentage of screen-positive women attending triage/treatment, percentage attending 12-month and 24-month follow-up visits). Programmes with well-established linkage systems achieving ≥60% completion at all steps may benefit from extended or limited genotyping to reduce overtreatment while maintaining cancer prevention benefits. Programmes struggling with retention or just establishing screening infrastructure should prioritize immediate treatment of all or most HPV-positive women to prevent losses to follow-up of women with pre-cancerous lesions. Critical prerequisites include ensuring adequate supply of ablative treatment equipment (cryotherapy or thermal ablation) and LLETZ capacity, training providers on visual assessment for treatment eligibility, and establishing quality assurance for whichever HPV test is procured. The choice between genotyping levels should align with laboratory capacity, HPV test availability and validation status, and realistic assessment of the health system’s ability to ensure women complete multi-visit care pathways.
Questions this guideline answers
What is the difference between extended, limited and no genotyping?
No genotyping provides only a positive/negative result for carcinogenic HPV. Limited genotyping separately identifies HPV16/18 (±45) and pools other carcinogenic types. Extended genotyping separately identifies groups 1a and 1b and further divides other types into groups 1c and 1d. Full genotyping (individual identification of all 12 types) is not recommended as it adds unnecessary complexity.
How do I determine if my programme has high or low follow-up capacity?
Calculate the percentage of screen-positive women who attend the next visit (triage or treatment), percentage of triage-negative women attending 2-year follow-up, and percentage of treated women attending 1-year post-treatment follow-up. If all three percentages are ≥60%, you have high follow-up capacity. If any single percentage is <60%, or data are unavailable, consider your programme as having low follow-up capacity.
Can I use extended genotyping results as just a positive/negative result?
Yes. While extended and limited genotyping tests provide differentiated results for carcinogenic HPV type groups, the results can be pooled and used as a simple positive/negative result, functioning the same as a no-genotyping test. This approach is actually preferred in low follow-up capacity settings where all HPV-positive women should be treated.
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- Issuer
- World Health Organization
- Type
- Guideline
- Edition
- 2026
- Replaces
- WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention, second edition, 2021 (supplemented, not replaced)
- Status
- Current
- Published
- 2026-05-12
- Languages
- English
- Scope
- Screening strategies using HPV DNA tests with different genotyping levels for cervical cancer prevention in the general population of women aged 30 years and above
- Audience
- Policy-makers, programme managers, programme officers, health professionals responsible for choosing evidence-based cervical cancer prevention strategies
- Pages
- 69
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978-92-4-012174-4
- Evidence
- GRADE-rated systematic review of cumulative CIN2+/CIN3+ risk by HPV type group and mathematical modelling of screening strategies across 78 low- and middle-income countries; conditional recommendations based on low-certainty evidence
- Next review
- 1–3 years as data and experience with screening tests and modalities advance
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