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Thomas C. Wright, Jr, MD; Lynette Denny, MMED, FCOG; Louise Kuhn, PhD; Amy Pollack, MD; Attila Lorincz, PhD

JAMA. 2000;283:81-86.

Context  More than half of the women diagnosed as having cervical cancer in the United States have not been screened within the last 3 years, despite many having had contact with the health care system. In many other regions of the world, there is only limited access to cervical cancer screening.

Objective  To determine whether testing of self-collected vaginal swabs for human papillomavirus (HPV) DNA can be used to screen for cervical disease in women aged 35 years and older.

Design  Cross-sectional observational study comparing Papanicolaou smears with HPV DNA testing of self-collected vaginal swabs.

Setting  Outpatient clinics in a periurban settlement outside of Cape Town, South Africa, between January 1998 and April 1999.

Participants  Screening was performed on 1415 previously unscreened black South African women aged 35 to 65 years.

Intervention  Women self-collected a vaginal swab for HPV testing in the clinic and were then screened using 4 different tests: Papanicolaou smear, direct visual inspection of the cervix after the application of 5% acetic acid, cervicography, and HPV DNA testing of a clinician-obtained cervical sample. Women with abnormal results on any of the screening tests were referred for colposcopy.

Main Outcome Measure  Biopsy-confirmed high-grade cervical squamous intraepithelial lesions or invasive cancer.

Results  High-grade squamous intraepithelial lesions were identified in 47 (3.4%) of 1365 women adequately assessed, and there were 9 cases of invasive cancer. Of women with high-grade disease, 66.1% (95% confidence interval [CI], 52.1%-77.8%) had high-risk HPV detected in self-collected vaginal samples, and 67.9% (95% CI, 53.9%-79.4%) had an abnormal Papanicolaou smear (P = .78). The false-positive rates for HPV DNA testing of self-collected vaginal samples and Papanicolaou smears were 17.1% (95% CI, 15.1%-19.3%) and 12.3% (95% CI, 10.5%-14.2%), respectively (P<.001). A high-risk type of HPV DNA was detected in 83.9% (95% CI, 71.2%-91.9%) of women with high-grade disease and 15.5% (95% CI, 13.6%-17.7%) of women with no evidence of cervical disease using a clinician-obtained cervical sample.

Conclusions  These results indicate that HPV testing of self-collected vaginal swabs is less specific than but as sensitive as Papanicolaou smears for detecting high-grade cervical disease in women aged 35 years and older, and HPV testing offers an important new way to increase screening in settings where cytology is not readily performed.

Author Affiliations: Department of Pathology, College of Physicians and Surgeons (Dr Wright) and Gertrude H. Sergievsky Center and Division of Epidemiology (Dr Kuhn), Columbia University and AVSC International (Dr Pollack), New York, NY; Department of Obstetrics and Gynecology, University of Cape Town, Cape Town, South Africa (Dr Denny); and Digene Corporation, Beltsville, Md (Dr Lorincz).

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