Transitioning to HPV-based cervical cancer screening in four low- and middle-income countries: policy and implementation pathways from a scoping review.

INTRODUCTION Cervical cancer remains a leading cause of preventable mortality in low- and middle-income countries despite effective screening technologies. Although the World Health Organization recommends primary human papillomavirus (HPV) testing, adoption and implementation remain uneven. This review examined how cervical cancer screening policies evolved and how HPV-based screening was introduced in Cambodia, Ethiopia, Mozambique and Uganda.

Methods

A scoping review of peer-reviewed and grey literature published between 2006 and 2025 was conducted. Data were analysed using the health policy analysis triangle and synthesised comparatively across countries. A causal loop diagram was developed to explore interactions between policy development and implementation.

Results

All four countries incorporated HPV testing into national policy frameworks, but implementation remained limited and visual inspection with acetic acid continued to predominate. Three policy-implementation pathways emerged: policy-led (Cambodia and Mozambique), pilot-driven (Ethiopia) and partner-driven (Uganda). Pilot programmes generated local evidence and, in some settings, informed subsequent policy development or scale-up. Implementation was constrained by health system limitations, fragmented coordination and reliance on external actors. POLICY SUMMARY The transition to HPV-based screening is shaped by context-specific interactions between policy, evidence, stakeholders and health system capacity. Sustainable scale-up requires integrating pilot-generated evidence into national decision-making and implementation planning, strengthening national governance, coordination and resource mobilisation, and investing in implementation readiness across laboratory and diagnostic capacity, workforce, supply chains, information systems and referral and treatment pathways. External partnerships can facilitate this transition when aligned with national priorities and designed to strengthen sustainable national capacity.