Background: Nasopharyngeal carcinoma (NPC) is a head and neck cancer more frequent among East Asian populations compared with Western populations. While much is known about human papillomavirus’s (HPV’s) role in oropharyngeal cancer (OPC), little is known about its prevalence and prognostic value in NPC. The aim of this study is to investigate the role of HPV in NPC treated with definitive radiotherapy at a single institution. Methods: A retrospective cohort analysis of patient’s medical records and HPV status treated for NPC in Rambam Health Care Campus (Rambam HCC). Immunohistochemical staining for p16 was used as a surrogate marker of HPV infection in the tumor cells. All specimens were stained and evaluated by pathologists at the referring center independently. Results: In total, 87 patients diagnosed with NPC were treated at Rambam HCC between 2005 and 2018. Seventy-four patients had accessible data on the disease’s clinical parameters and p16 status. In total, 10/74 (13.5%) had p16-positive staining in tumor cells; 75% were men and over 50% were smokers. The average age of diagnosis for the whole cohort was 48 years, being lower for p16-positive patients compared with p16-negative patients at 43 and 49 years old, respectively. A total of 84% of the patients had advanced disease of stage III and IV at presentation. Only 16% were diagnosed with stage I and II. Unlike the p16-negative group, the p16-positive group did not include any stage I or II disease. In univariate and multivariate analysis of overall survival rates, the age at diagnosis and the nodal spread status were the only statistically significant measures. P16 status was not found to be associated with survival. Conclusions: The HPV prevalence in NPC is nontrivial. p16-positive patients had significantly less nodal spread and tended to be younger. Both age and nodal status were significantly correlated with the survival, but P16 status was not prognostic. Further large-scale trials are needed to elucidate the role of HPV in NPC. Nasopharyngeal carcinoma (NPC) is an epithelial carcinoma of the head and neck region, arising mostly within the posterolateral pharyngeal recess. It is twice as common in men than in women, with over 130,000 new cases yearly worldwide. In the past decade, the incidence and mortality have steadily declined, perhaps due to changes in etiological factors, as well as better and earlier diagnostic and therapeutic modalities .Despite the histological similarity and anatomical proximity, it is distinctly different from other tumor subtypes originating from the head and neck mucosal lining, having different etiology, distribution, staging and treatment.Among various etiological factors reported, viral oncogenes have been strongly implicated in the pathogenesis of NPC, being most frequently associated with Epstein–Barr virus (EBV), indicated by histopathological examination and geographical distribution. It is more common in EBV endemic regions such as East and Southeast Asia, making up over 70% of the newly diagnosed cases worldwide, of which 95% are of the non-keratinizing subtype that is known to be strongly associated with EBV ,4.Recently, multiple studies have supported the diagnostic and prognostic value of anti-EBV antibodies and free viral DNA in plasma and showed correlation to tumor burden. Ling-Long Tang et al. reported a non-inferior 3-year failure-free survival for patients with low-risk NPC, defined as stage II/T3N0M0 without adverse features, including Epstein–Barr virus DNA <4000 copies/mL treated with radiotherapy alone compared with standard chemoradiation . FurtherAlmost all NPC cells demonstrate monoclonal EBV episomes in tumor cells. The proposed pathomechanism of carcinogenesis is through the expression of type II EBV latency gene products  facilitating global hyper-methylation, altering multiple cellular pathways and host microenvironments, thus promoting clonal expansion, proliferation and oncogenesis .Human papilloma virus (HPV) is a well-known causative factor for oropharyngeal carcinoma (OPC). Nowadays, it is found in over 70% and 50% of the newly diagnosed cases in the United States and the United Kingdom, respectively . RecentlHPV is a small 55 nm diameter non-enveloped, circular double-stranded deoxyribonucleic acid (DNA) oncogenic virus, best known to be a sexually transmitted disease (STD) having a strong tropism for host mucosal and cutaneous stratified squamous epithelium. It has been shown to cause genital warts, pre-cancerous lesions and cancers among different body sub-sites, mainly gynecological malignancies , anal cancer and head and neck cancers; it mostly affects sites harboring lymphoid tissue of the Waldeyer’s ring , occurring predominantly within the Oropharynx .Multiple HPV strains have been identified. They are divided into low-risk non-cancerous strains  causing indolent lesions, and high-risk aggressive strains causing cancers; 14 of these strains are the most prevalent , where 16 and 18 are responsible for over 70% of HPV-related cancers .HPV exerts its oncogenic effect mainly through the integration of the HPV genome into the host chromosome, subsequently allowing for the expression of the viral E6 and E7 genes so that their oncoproteins disrupt the tumor suppressor genes P53 and RB, respectively, resulting in dysregulated and selective growth advantage .Although HPV-positive oropharyngeal carcinoma (OPC) is strongly known to behave differently from HPV-negative OPC, the clinical behavior and prognostic value of HPV in NPC has been controversial, as trials have shown contradictory results ,16,17,18Traditionally, the treatment of locally advanced NPC has been definitive radiotherapy or chemoradiotherapy with neo-adjuvant or adjuvant chemotherapy depending on the disease stage at presentation, regardless of HPV and EBV status, even though the latter has been shown to be prognostic ,20,21,22This treatment approach has largely been shaped by large-scale trials from endemic regions. Nevertheless, it has been adopted by most centers even in non-endemic areas, mainly due to the lack of deep understanding of the differences in the disease behavior and response to treatment between endemic and non-endemic NPC. For instance, despite two previous pivotal trials ,21 in enAdditionally, the histological subtypes’ distribution differs, as non-endemic countries have a higher prevalence of keratinizing squamous cells carcinoma compared with non-endemic countries where the undifferentiated subtype with a better prognosis predominates. As we are eager to allow precision medicine for all, there is an ongoing need to deepen our understanding of the various etiological and biological factors associated with the disease.The aim of this study is to retrospectively investigate the prevalence, clinical outcomes and prognostic value of HPV among patients diagnosed with non-metastatic NPC treated with definitive radiotherapy or chemoradiotherapy at our institution.Our study received an institutional research ethics board approval. All patients who were newly diagnosed with nasopharyngeal carcinoma and treated with curative intent using external beam radiotherapy between the years 2005 and 2018 in Rambm Health Care Camps (the tertiary cancer center of north Israel) were included. All patients had clinical and imaging follow-up at our institution as stated by the NCCN guidelines dated for the same period. Patients with distant metastasis were excluded from the study as well as patients for whom tissue samples were unavailable for examination of the viral status.The viral etiology was confirmed using p16 immunohistochemistry staining (≥70% strong nuclear and cytoplasmic staining), a surrogate marker of prior HPV infection in the tumor tissue. The tissue samples’ evaluations were made by head and neck pathologists from 10 different institutes across Israel, each made by pathologists at the local institutes of the initial tissue sampling.Patients’ clinical characteristics, demographics, treatments and outcome data were retrieved from the local electrical medical records database. All tumors were staged using the AJCC TNM Classification eighth edition, which were based on the initial radiology reports at diagnosis. A multidisciplinary team comprising radiation oncologists, medical oncologists and an otorhinolaryngology surgeon treated our patients. Fifteen patients were treated with 3D conformal radiotherapy and the rest of the patients were treated with intensity-modulated radiotherapy (IMRT) with or without chemotherapy. Patients who had locally advanced diseased of T category 3 or 4 or having lymph node–positive NPC received concurrent chemoradiotherapy with additional induction chemotherapy. Patients with T1N0 were treated with radiotherapy alone and patients with T2N0 were managed with concurrent chemoradiotherapy without additional induction chemotherapy.The tumor volume receiving a radiation dose of 70 Gy and the electively treated volume irradiated to 56 Gy were contoured by senior head and neck radiation oncologist based on the Radiation Therapy Oncology Group (RTOG) contouring guidelines. The delineation and treatment plans were reviewed in weekly quality-assurance staff meetings.The treatment response was assessed initially 4 weeks after radiotherapy by radiation oncologist and otorhinolaryngology surgeon. Patients were followed every 3 months for two years, every 4 months for the third year and every 6 months for 2 more years, and annually thereafter. Disease recurrences were diagnosed by radiologic findings and confirmed histologically whenever the findings were unequivocal.The patients’ demographics and clinical characteristics, as well as disease-free survival (DFS), disease-specific survival (DSS) and overall survival (OS) were compared for the HPV-positive and HPV-negative patients.The follow-up time was assessed from the date of diagnosis until November 2019.p < 0.05 was considered to indicate statistical significance. Differences between p16-positive and p16-negative cohorts were evaluated by applying Fisher’s exact test for categorical variables.Five-year overall survival (OS), disease-specific survival (DSS) and disease-free survival (DFS) were calculated using the Kaplan–Meier method, and differences in survival rates were assessed using the log-rank test. OS was measured from the date of surgery to the date of death or the last follow-up. For DSS, patients who died from causes other than NPC were censored at the time of death. All variables that had prognostic potential were subjected to both univariate and multivariate analyses using the Cox proportional hazards regression model. Analyses were performed using IBM SPSS Statistics for Windows, version 24 . All statistics were two-sided. A value of p value 0.721), smoking status  and female-to-male ratio  were similar. On the contrary, patients who were p16-positive had statistically significantly  less nodal spread compared with those who were p16-negative  slides for p16 stain, which were positive for 10 (13.5%) of these individuals . The mednegative . Althougnegative .p value 0.002) and the N category  were predictors for overall survival, older age was also a predictor for disease-specific mortality  and advanced T category was associated with disease recurrence .The oncological outcomes for all patients are illustrated in p value 0.017) and the N category  were also predictors for overall survival, but older age was not a predictor for disease-specific mortality anymore . Advanced T category was still associated with disease recurrence, having a roughly five-fold relative risk . There was an over 3-fold increase in mortality for patients over 60 compared with those who were younger. The p16 status was not associated with OS, DSS or DFS either on univariate analyses or on multivariate analyses , the patient age  of our patients’ biopsy specimens stained positive for p16.HPV is strongly associated with head and neck cancer, particularly with OPC and, to a lesser extent, with oral cavity cancer and NPC. Though its significance is still debatable, its prevalence among NPCs varies widely from below 10% to over 50%, with white people and Caucasian people showing the most prominent associations ,10,11.There are approximately 14 high-risk HPV strains. While HPV-16 is the predominant type in OPC, occurring in over 95% of these cases, over 60% of HPV-positive NPC patients harbor other high-risk HPV types .Several detection methods for HPV exist. Although in situ hybridization (ISH) and polymerase chain reaction (PCR) are the most sensitive techniques, they are complicated, expensive and lack specificity for causal etiology . On the Moreover, p16 positivity might indicate that the virus is transcriptionally active, suggesting that the virus is a driving factor rather than being merely a bystander infection. This causal relationship assumption is further enhanced by the rare existence of EBV and HPV co-infection in the same tumor cells ,26 and tWhile EBV is recognized as the primary etiologic factor in non-keratinizing NPC WHO type II and III, WHO type I keratinizing NPC lacks an association with EBV and is more linked to other etiological factors such as smoking and HPV. In a study of non-endemic NPC, all of the EBV-positive tumors were non-keratinizing type II and III NPC, while only two-thirds of the HPV+ NPC were as such, and two-thirds of the EBV/HPV-negative tumors were keratinizing type I NPC . Nearly The clinical presentation of HPV+ NPC seems to be different than HPV-negative NPC. Windon et al. have shown that in comparison to HPV + OPC and HPV − NPC, the HPV + non-OPC has uniqueness, a different presentation and perhaps a worse prognosis . Huang eIn contrast to its favorable prognostic value in OPC, HPV positivity remains controversial in non-OPC because even though several studies have suggested HPV to have a favorable impact on the prognosis of head and neck cancer despite sub-site, others have shown no survival benefit or even a detrimental effect among HPV-positive non-OPC patients ,16,17,18Unlike EBV + NPC, in which the predominant pattern of failure is distant metastasis, Stenmark et al. reported higher loco-regional recurrence rates among HPV + NPC . This obFurthermore, we found patients older than 60 years to have a three-fold relative risk of mortality. Nearly 80% of NPC cases occur in individuals aged 30–60 years. At our institution, 30% of NPC cases are in patients older than 60 years. A small amount of data has been published regarding the appropriate definition of elderly in NPC. Additionally, it is arguable whether the chronological age or the biological age has to be considered. Previous retrospective and prospective trials have chosen various age cutoffs where 60 was the lowest limit and a commonly used definition ,35. StudThe incidence of the HPV-related malignancies, particularly gynecological cancer, has declined dramatically after the introduction of the HPV vaccine, which is recommended at a young age to confer an effective prevention method against the sexually transmitted virus. Diana et al. found the vaccination to significantly lower the prevalence of oral HPV infection, with an estimated efficacy of 90%, but low vaccine coverage remains a major issue . Yet, thRecently, several novel vaccine-based therapies and cellular therapies have shown promise for the treatment of HPV-related head and neck malignancies. Some are being tested in combination with immune-checkpoint inhibitors, especially PD-1 inhibitors such as the biologic CUE-101 causing selective expansion of the HPV16 E711-20-specific population of cytotoxic CD8 + T cells . Thus, tAdditionally, the association between HPV and NPC raises concerns whether or not the nasopharynx has to be irradiated electively in HPV+ head and neck cancer of unknown primary. We believe this might be highly relevant for patients whose risk of having HPV+ NPC is non-negligible, particularly among non-endemic populations, Caucasian people, smokers and patients with nodal involvement patterns consistent with NPC, such as level V .Further large-scale studies are needed to validate whether p16 can serve as a good surrogate marker for HPV infection in NPC, or if advanced methods, such as PCR or ISH, should be performed. Equally, NPC should perhaps be categorized into viral etiological subgroups. The nature, clinical differences and molecular profiles of the EBV + HPV−, EBV − HPV−, EBV − HPV+ and the rarely-occurring EBV + HPV + NPC types should be investigated.In conclusion, HPV-positive NPC is assumed to be a distinct clinical entity different from other NPC or HPV-positive OPC. Its prognostic implication has to be studied while considering different confounding factors possibly affected by HPV status such as age, smoking status, histological type and disease stage.All of our patients were treated at a single medical facility, mostly receiving induction chemotherapy followed by chemoradiotherapy, and then followed for a relatively long follow-up period at our institution.Due to the nature of our study, there could be a bias, which applies to all retrospective studies.Additionally, our study lacked EBV status, HPV subtyping, standardized detection methods and centralized labs.


Human papillomavirus (HPV) is a group of alpha papillomaviruses that cause various illnesses, including cancer. There are more than 160 types of HPV, with many being “high-risk” types that have been clinically linked to cervical and other types of cancer. “Low-risk” types of HPV cause less severe conditions, such as genital warts. Over the past few decades, numerous studies have shed light on how HPV induces carcinogenesis. The HPV genome is a circular double-stranded DNA molecule that is approximately 8 kilobases in size. Replication of this genome is strictly regulated and requires two virus-encoded proteins, E1 and E2. E1 is a DNA helicase that is necessary for replisome assembly and replication of the HPV genome. On the other hand, E2 is responsible for initiating DNA replication and regulating the transcription of HPV-encoded genes, most importantly the E6 and E7 oncogenes. This article explores the genetic characteristics of high-risk HPV types, the roles of HPV-encoded proteins in HPV DNA replication, the regulation of transcription of E6 and E7 oncogenes, and the development of oncogenesis. Human papillomavirus (HPV) is one of the most common sexually transmitted infections, affecting millions worldwide annually. Human papillomaviruses belong to the papillomaviridae family of small, non-enveloped, double-stranded DNA viruses , which iThe HPVs have double-stranded circular DNA genomes ~8 kb) containing eight open reading frames (ORFs) that encode viral proteins . There i kb contaThe E2 protein can be considered the most pivotal protein in the HPV genome due to its role in the viral life cycle and oncogenesis. The HPV viral life cycle is tightly controlled by the E2 protein, which is also involved in transcriptional regulation, the expression of the E6 and E7 oncogenes, partitioning, and the maintenance of the viral genome, in addition to its role in the initiation of DNA replication . Papillomaviruses are ancient DNA viruses spanning ~400 million years and have been identified in humans, nonhuman primates, bovines, and other animals such as dolphins . HPVs haThere are five major known HPV genera: α , β (beta), γ (gamma), μ (mu), and υ (nu) . CarcinoThe IARC working groups have classified many of the HPV types into three categories, low-risk, high-risk, and probable high-risk , leavingYilmaz et al. discovered nucleotide variations in the E2 binding site consensus sequences (ACCGNNNNCGGT) of at least one of the three binding sites in all established high-risk HPV types  18]. Al. Al18]. As the Yilmaz classification of HPV types is based on the DNA sequence, any HPV type can be classified based on the consensus sequence mutation(s), without requiring clinical data on the potential to cause cancer, as shown in The HPV E2 protein is a DNA-binding protein with two conserved functional domains. The N-terminal has the transactivation domain, and the C-terminal has the DNA-binding domain. The two domains are connected by a flexible linker known as the “hinge region” A 18,19],1918,19]The transactivation domain is the largest, with approximately 200 amino acids, and is required for its replication, transactivation, and segregation functions B. The hiVarious papillomaviruses have shorter, truncated E2 proteins, known as isoforms. In the bovine papillomavirus, truncated E2 isoforms were observed and determined to be repressors of transcription and replication . In HPV,4)CGGT, where N denotes any nucleotide , sometimes referred to as the upstream regulatory region (URR). The LCR is the noncoding region of the HPV genome, and within it lie various binding sites, the origin of replication, and a few other cis elements. These four E2 binding sites (BS1–4) are highly conserved across papillomaviruses and are spatially arranged and characterized by the 12 bp palindromic sequence ACCG (Ncleotide  24]. . 4)CGGT,The DNA-binding domain located at the C-terminus of the E2 protein B recogniThe interaction between the HPV E2 protein and these binding sites is essential for E2 to regulate several functions in the genome. The E2 protein initiates DNA replication by binding to its sites, represses transcription of the oncogenes, and consequently halts oncogenesis. It’s been demonstrated that a single nucleotide variation in the consensus sequences can play a role in the fate of HPV-infected cells and help determine whether they will become a high or low risk for cancer. This interaction between the E2 protein and its binding sites plays an important role in the oncogenicity of high-risk HPVs. The E2 protein binds to all four binding sites but with different affinities . As demoBased on these binding studies, Yilmaz et al. have proposed a potential model for the E2 protein binding and activation at the low-risk and high-risk origins . AccordiThe replication and life cycle of HPV are initiated and controlled by epithelial cell differentiation . HPV entExposure of the basement membrane allows the L1 capsid protein of virions to bind to the heparin sulphate proteoglycans (HSPGs) present on the surface of the basal keratinocytes for initial attachment ,30. ThisThe initiation of DNA replication in HPV relies on the early E2 and E1 genes. The HPV viral genome begins to replicate immediately upon entry into epithelial cell . The iniAs the cell division cycle progresses, the episomal HPV DNA replicates along with the host cell chromosome. Viral genome DNA replication relies mostly on the host replication machinery. The initial replication that occurs is shown only to utilize E1 and E2 proteins, and studies have indicated that the function of E1 and E2 in promoting DNA replication is conserved across the papillomavirus family ,40,41. E. coli system. In E. coli, DnaA protein binds to specific binding sites in the origin of DNA replication, oriC and utilizes ATP to form a complex and recruit the DnaB helicase for initiation of DNA replication ,7776,77]Similarly, the HPV E7 protein degrades another tumor suppressor protein, the retinoblastoma protein (pRb). For cells to pass through the G1-S cell cycle boundary, pRb–E2F interaction is a necessary checkpoint. The E2F family of transcription factors remains bound to the pRb protein when cells are not ready to transition to the S-phase of the cell cycle. The E7 protein targets pRb for ubiquitination in HPV-infected cells, releasing the E2F transcription factors, which start transcribing the proteins required in the S-phase , which causes the cells to enter the S-phase prematurely C 80]..80].In addition to causing p53 and pRb degradation, the E6 and E7 proteins can target various host cellular factors and disrupt host signaling pathways. E6 targets other apoptosis-related proteins in addition to p53. These events involve interaction with the host protein Bcl-2 homologous antagonist/killer (BAK), which inhibits intrinsic apoptosis signaling. E6 combines with E6-AP to target BAK for degradation, similar to p53 ,81,82. FFurthermore, the HPV E5 protein has also been reported to play a role in oncogenesis. While HPV E5 has relatively limited transforming activity and, consequently, its role throughout the transformation process is not well understood ,87,88,89HPV is one of the oldest viruses in the world, allowing it to evolve into a large family of viruses. It is generally a silent virus that spreads its infection without major symptoms, potentially leading to various cancers in both men and women.Despite significant advancements in our understanding of the host pathways that HPV affects, new mechanisms are still being discovered. Therefore, it will be easier to create novel therapeutic drugs if we fully understand the cellular proteins and pathways that HPV disrupts during infection, particularly during carcinogenesis.The HPV E2 protein plays a significant role in controlling oncogenesis through two mechanisms: (i) regulating viral DNA replication and transcription via binding to its specific binding sites, and (ii) via transcriptionally repressing the E6/E7 oncogene expression, preventing oncogenesis. Therefore, the loss or attenuation of E2 function is pivotal for viral oncogenesis in HPV infection. The loss of expression of the E2 protein occurs due to insertional gene disruption during chromosomal integration of the virus. It can then lead to unregulated expression of the E6 and E7 oncogenes, a preamble to carcinogenesis.In summary, HPV is a virus that needs further study due to its silent nature and the lack of treatments or a cure. In addition, it is the causative agent of several anogenital cancers and, in recent years, has been linked to other mucosal cancers and head-and-neck cancers. The lack of treatment, combined with the high prevalence in the US and particularly in developing countries with less-than-ideal healthcare systems, calls for a broad-spectrum antiviral drug or vaccine against most high-risk strains of HPV.


The purpose of this paper is to provide evidence-based guidance on the management of a positive human papilloma virus (HPV) test and to provide guidance around screening and HPV testing for specific patient populations. The guideline was developed by a working group in collaboration with the Gynecologic Oncology Society of Canada (GOC), Society of Colposcopists of Canada (SCC), and the Canadian Partnership Against Cancer. The literature informing these guidelines was obtained through a systematic review of relevant literature by a multi-step search process led by an information specialist. The literature was reviewed up to July 2021 with manual searches of relevant national guidelines and more recent publications. The quality of the evidence and strength of recommendations were developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The intended users of this guideline include primary care providers, gynecologists, colposcopists, screening programs, and healthcare facilities. The implementation of the recommendations will ensure an optimum implementation of HPV testing with a focus on the management of positive results. Recommendations for appropriate care for underserved and marginalized groups are made. In 2020, the World Health Organization (WHO) announced a global strategy towards the elimination of cervical cancer as a public health priority by reducing the incidence of cervical cancer to less than 4 per 100,000 . The priThe introduction of cytologic screening programs has decreased the incidence of cervical cancer. However, cytologic screening programs have failed to eliminate cervical cancer due to issues that include test limitation and sub-optimal coverage of screening activities. Randomized controlled trials (RCTs) have demonstrated that cervical cancer screening with HPV testing offers higher protection against cervical precancer and cancer compared to cytology-based screening ,5,6,7,8.In this context, a guideline was commissioned by the Canadian Partnership Against Canada in collaboration with the Gynecologic Oncology Society of Canada (GOC) and the Society of Canadian Colposcopists (SCC) to provide an evidence-based approach to the management of a positive HPV test. Guidance was also sought for caring for specific populations, such as those who are immunocompromised and those who face challenges in accessing and receiving quality care after a positive screening test result, such as LGBTQ2S+, First Nations, Inuit, Metis, newcomers, and immigrants to Canada. We were also asked to review the evidence surrounding HPV self-sampling in the general population and in non-/under-attenders and regular attenders.The group does not endorse any one HPV test over another. Any Health Canada-approved HPV test or device for cervical screening should be used for testing according to their regulatory approval. Recommendations provided in this document are not meant to supersede local guidelines or existing provincial or territory population-based cervical screening programs or clinical judgment.The committee was recruited to represent interested gynecologists and pathologists from many Canadian provinces. Initial meetings were held in the fall of 2020 and a series of objectives was developed.The literature informing these guidelines was located using a multi-step search process led by an information specialist. An initial search for existing clinical practice guidelines related to HPV testing for cervical screening was designed in Ovid MEDLINE All and performed on 7 June 2021. A modified version of the guidelines filter developed by Canadian Agency for Drugs and Technology in Health (CADTH) for Ovid MEDLINE was used . The seaA second search targeting evidence related to HPV testing for cervical screening in specific contexts and populations was designed in Ovid MEDLINE All and executed on 10 November 2021. The contexts of interest included triaging a positive HPV test, self-sampling in the general population, and self-sampling in non-attenders. Specific searches were also performed to summarize the existing literature on HPV testing in populations of interest, including the Indigenous, LGBTQ+, immunocompromised, immigrants, newcomers to Canada, and those living in rural settings. A modified version of the LGBT search filter from Lee et al. was used to develop the LGBTQ+ portion of the search . A publiA third search targeting evidence related to managing a positive HPV test after a hysterectomy was designed in Ovid MEDLINE All and executed on 7 February 2022. A publication date limit from 2018–present was applied to the search. No publication type, study design, or language limits were applied. The search is reported in full in For each specific theme searched, the results were imported to Covidence for deduplication and screening. Members of the working group screened titles and abstracts for relevant papers, which were then obtained for full text review.Our working group set cut off risk of ≥5% of CIN3+ to be referred to colposcopy and used this to guide referral algorithms to colposcopy after a positive HPV test. During the working group meetings, the committee was asked to generate and propose algorithms for self-sampling and referral to colposcopy, understanding that there is still no FDA or Health Canada approved test for self-sampling. This is still under evaluation in Canada.Recommendations were developed and graded based on the quality of evidence available using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework Recommendations:HPV tests providing partial genotyping information are preferred. Reflex liquid-based cytology should be performed on all HPV-positive samples. Persons testing positive for HPV 16 or 18 should be referred for colposcopy, regardless of reflex testing result. Persons testing positive for other HR types should be referred to colposcopy if their cytology shows AGC, ASC-H, HSIL, or cancer. Persons testing positive for other high types with normal, ASCUS, or LSIL cytology should not be referred to colposcopy but retested (HPV and reflex cytology) at 12 and 24 months. If, at 24 months, there is persistent HR–HPV positivity, regardless of cytology, they should be referred to colposcopy. There is currently insufficient evidence to support the use of p16 and DNA methylation as triage tools following a positive HPV test. The Pap test has been an effective screening strategy. It is responsible for reductions of up to 70% of cervical cancers where quality screening programs have been implemented. However, the low sensitivity and interpretive nature of the test are significant limitations. When compared in the Canadian context, Mayrand et al. showed that the sensitivity of HPV testing and Pap testing to detect CIN2+ was 94.6% and 55.4%, respectively, with a specificity for HPV of 94.1% and 96.8% for Pap testing . AbnormaThe evidence from these trials has shown that HPV testing alone would be more sensitive but also would cause many individuals to be referred to colposcopy unnecessarily. Hence, there is a need for an appropriate triage test. The ideal triage test post-HPV testing would allow for full automation and avoid tests that have inherent subjectivity.We are proposing a management strategy following a positive HPV test after evaluating the existing literature on triage tools to best identify CIN2+ using a general cut-off of >5% risk of CIN3+. There is no universally accepted level of risk established . It is rTriage by cytology utilizes the high sensitivity of HPV testing combined with the specificity of cytology. It also has the advantage of being performed on the same sample as the HPV test if liquid-based cytology (LBC) is conducted. The HPV Focal trial performed in BC evaluated a protocol with HPV testing followed by reflex LBC testing for those who tested positive for HPV compared to liquid-based cytology alone. If the LBC was abnormal (≥ASCUS), a referral was made to colposcopy. The control arm was managed similarly to the standard of care using reflex HPV testing and conventional criteria for referrals to colposcopy. Testing was done at 0, 24, and 48 months. The use of HPV primary testing resulted in significantly fewer CIN3+ and CIN2+ cases at 48 months. For CIN3+, the risk reduction was 0.42 (95% CI 0.25–0.69). For CIN2+, it was 0.47 (95% CI 0.34–0.67). However, this benefit came with a marked increase in referrals to colposcopy in the first round of screening in the HPV arm. By the 48-month mark, there was less colposcopy in this arm, with the overall rate being similar . In the Persistent HPV infection is a necessary cause of cervical cancer. There are more than 100 known types of HPV. Currently, 13 high-risk genotypes have been identified as carcinogenic . Among tThis approach has been recommended by the WHO where genotyping information is available and by many national screening programs . This alp16 is a cellular protein that is upregulated in transforming HPV infections, the test is done on cytology (or histology) slides and requires subjective assessment. This has been combined with Ki-67 staining. With a cellular proliferation marker, a positive test has at least one cell stained for both. This test is highly reproducible and, in the future, may be automated . This isMethylation of host genes and viruses has been identified as a potential marker of productive infection and clinically relevant cervical lesions. Increased host DNA levels of methylation are observed as cervical epithelium progresses into a transforming CIN2/3 lesion and on to cancer. Methylation assays are available commercially and can be performed on cervical tissue, LBC samples, self-collected cervico-vaginal cells, and urine. The testing can be automated and is highly reproducible. As a testing modality, it has promise as a triage tool for HR–HPV other positive, HPV 16/18 negative results and self-collected specimens .In summary, we recommend that HPV testing with genotyping and reflex cytology is used to triage an abnormal HPV test with a threshold for referral to colposcopy when the risk of CIN3+ is over 5%. The management algorithm for clinician collected specimens is shown in Recommendations:Self-sampling may be mailed to identify non-attenders to cervical screening programs, as this has been shown in many studies to increase the uptake of screening. Self-sampling, coupled with face-to-face interactions, was even more effective with community health workers, nurses, or health outreach workers conducting home visits. The availability of HPV tests has led to much interest in self-sampling with most evidence being available for under-screened populations. A systematic review by Nishimura and colleagues, consisting of 72 articles and published from 2002 to 2018, has summarized the values and preferences surrounding self-sampling and sampling settings for cervical cancer screening . OverallScarinci et al. published a study with the following aims: evaluate adherence to cervical cancer screening using a patient-centered approach that provided a choice of self-sampling at home for HPV testing or standard-of-care screening at the local health department (“Choice”) versus only standard-of-care screening at the local health department (‘SCS”) among under-screened African American women . “Choicen = 46) were never screened, and one-third (n = 69) were under-screened. Nine women were HPV 16/18 positive, and eight had completed all follow-ups by the conclusion of the study. A further 30 women tested positive for a high-risk type other than HPV 16/18 (HPV other), of which 14 had completed follow-up at the conclusion of the study. Satisfaction with the HPV self-sampling kit, the process of self-sampling and the service model, was high . However, many women had difficulty understanding their official HPV results and needed health care provider assistance.In another study, Aboriginal women aged 25–69 years of age were recruited from eight rural and remote communities in New South Wales, Australia, to participate in HPV self-sampling via a community-based service model . In totaThe option to conduct at-home self-sampling proves to be both acceptable and attractive amongst non-attenders in these studies. The reasons cited in one study for foregoing screening included feeling uncomfortable or embarrassed to be tested by a male clinician, a lack of time to attend screening, concerns of potential pain, assumptions of low risk of HPV, and fear of a positive result . Most ofOffering self-sampling among non-attenders increases screening uptake  ,56,57,58Interestingly, among the non-attenders that participated in the studies, colposcopy follow-up attendance was consistently high. This aligns with previous studies that have reported high follow-up attendance among non-attenders. Therefore, evidence suggests that adherence to follow-ups following a positive self-sampling result is generally very good.Once again, there is a high level of evidence to support the use of self-sampling for cervical screening. Self-sampling has the distinct possibility to improve participation for that subset of the population that does not attend cervical screening. Recommendations:Self-sampling could be offered to Canadian individuals with a cervix. Individuals should be informed that in case of a positive HPV test, they would require an appointment with a health care provider to undergo a pelvic speculum exam to obtain a Pap test or may be referred for colposcopy assessment if HR-HPV 16/18 positive. Most of the evaluation of self-sampling to date has been in under-screened populations who may have different risk/prevalence profiles, impacting the performance of the test as a screening tool. However, there is undeniable interest for this option to be available in the general population.A 2019 CADTH report concluded that self-sampled HPV tests had similar accuracy to clinician-collected samples to detect CIN2+ particularly when PCR-based HPV testing was conducted . UpdatedFor individuals with an adequate screening history, self-sampling provides a convenient screening method that is less intrusive, more comfortable, and less embarrassing. Self-collected sampling for HPV testing has the potential to address many of the reported challenges to screening participation, including access to a health care provider, dependence on clinic hours, and transportation. Sampling kits can be mailed to individuals who request them or could be provided in health care providers’ office or other venues such as pharmacies. The exact mode of offering self-collected sampling will need to be tailored to specific jurisdictional and screening program resources. In addition, if self-collected sampling is offered as a mail-out test, programmatic involvement may be necessary, particularly for those without access to a primary health care provider.An early meta-analysis by Petignat et al. compared self-sampling to provider sampling methods . EighteeIn summary, there is good evidence to demonstrate that self-sampling for HR–HPV for cervical cancer screening in the general population is not only acceptable but preferred in most cases.Several HPV self-sampling devices and detection methods are available. Most studies report utilization of flocked swabs sent dry or in liquid medium. Generally, a self-sampling HPV test collected by vaginal swab must be low in price and offer appropriate sampling performance as well as high acceptability . The useIn the general population, there is a need to have a second triage step other than HPV genotyping. In the absence of a molecular test, a cytology sample requiring a visit to a health care provider has to be obtained. This approach has been implemented in some jurisdictions ,71. FiguAustralia renewed its National Screening Program in 2017 with the introduction of five yearly HPV tests. Initially, they also introduced the option of self-collection for those who had never been screened, or those who were over 4 years since the last Pap test. However, effective mid-2022 after a review of the acceptability and efficacy, a decision was made to offer all screen-eligible people the choice of self-collected or clinician-collected cervical samples. They chose to use a health care provider to mediate this ,71. In cRecommendations:Individuals with immunocompromised status and a positive HR–HPV test should go directly to a colposcopy, regardless of HR–HPV genotype and cytology. Management, once in colposcopy, should follow the same guidelines as the immunocompetent population. .Individuals who are immunocompromised have increased rates of cervical cancer, with most of the evidence being in the HIV-positive and solid organ transplant population. Individuals living with HIV have higher HPV acquisition , lower HPV clearance , and higher incidence of cervical cancer  than that of the general population (Liu 2018). This also holds true for other immunosuppressed individuals ,74. ThisRecommendations:It is recommended that primary-care providers include a process of asking patients for their identifiers, including gender at birth and their current gender to aid in the identification of patients in need of ongoing cervical screening . HPV self-collected samples should be offered to patients who, despite a respectful and patient-centered environment, are unable to undergo provider-collected cervical samples, or simply prefer self-sampling. All individuals with a cervix who have ever been sexually active should undergo routine cervical screening regardless of their gender or the gender of their sexual partners. Referring providers and colposcopists must be respectful of gender identity and create an environment that is safe and for all individuals with a cervix regardless of gender identity or sexual orientation. Evidence suggests that cervical cancer screening rates in the LGBTQ2S+ community are suboptimal. The implementation of primary HPV testing with an option for self-collected sampling may be more acceptable and lead to increased uptake of cervical screening.Transgender men  have a cervix unless they have undergone gender-affirming surgery in the form of hysterectomy. If the cervix is present, transgender men require cervical screening, as per provincial guidelines. However, studies find that rates of cervical screening in this population are less than in cisgender women. In one study, 37% of transgender men report having never received a pelvic examination or cervical Pap smear in their lifetime, compared to 5% of cisgender bisexual women reporting never having been examined. In addition, 10% reported never having had a cervical Pap smear . In anotUnmet needs for information also affect women who have sex with women. In one study, 28% of sexual minority patients perceived that cervical cancer screening was unnecessary . CompareMany transgender patients find the experience of cervical screening to be highly distressing. They feel vulnerable having to remove their clothes, especially if there is more than one provider in the room. While some patients prefer having a chaperone in the room, others might find this upsetting ,92. SpecThe use of HPV testing as a primary screen for transgender patients may have value in patient preference and increase diagnostic value since atrophy and the use of androgens can falsely increase the findings of inadequate samples or high-grade dysplasia from cervical Pap testing ,95,96. IThe performance characteristics of self-collected HPV cervical swabs versus provider-collected cervical swabs were assessed in a study of 131 transgender male patients who underwent both tests, randomized to which test was performed first. Compared to provider-collected cervical swabs as the gold standard, self-collected swabs demonstrated a sensitivity of 71% and a specificity of 98.2%. Over 90% of the study participants preferred the self-collected sample .Many health care professionals have acknowledged a lack of education and some discomfort in providing primary care to patients in the LGBTQ2S+ community. For instance, 80% of health care providers surveyed received no instruction in the care of transgender patients, and only one-third of providers indicated they were comfortable caring for transgender patients . TransgeIt is important to identify all patients who have a cervix, including transgender men and non-binary people . In one survey of transgender patients, only 8% had undergone hysterectomy. Meanwhile, of the remaining 92% of patients, only 27% reported a pap smear in the past year compared to 43% of cisgender patients . Based oRecommendations:It is recommended that primary-care providers and colposcopists increase their understanding and knowledge of their local First Nations, Inuit, and/or Métis communities to work towards building relationships, knowledge translation, and understanding. It is recommended that colposcopy providers increase cultural safety and trauma awareness training to all persons working in the facility. It is recommended that colposcopists champion alternate approaches, including, but not limited to, the creation of a space and workflow that avoid re-traumatization as well as recognize local Indigenous cultures and land, addresses fears of abuse and coercion honestly, supports the patient both in the appointment and at home, and offers Cultural Support and advocacy as needed. A study conducted in 2017 by the First Nations Health Authority (FNHA) and BC Cancer Agency found that the incidence of cervical cancer is significantly higher amongst First Nations women than non-First Nations women . This stHigher rates of cervical cancer amongst First Nations individuals reflect the barriers they face to access the necessary preventative screenings and cancer treatment throughout Canada. Barriers may include access due to geographically available screening sites, or a lack of culturally safe cervical screening services.Cervical cancer screening and treatment have the potential to be retraumatizing for First Nations, Inuit, and Metis peoples and communities who have experienced and/or who may have painful memories, deep-rooted fear, and distrust of medical personnel (particularly those wearing PPE) associated with historical and personal past experiences: residential schools, Indian hospitals, provincial sterilization acts/legislation, medical experimentation, coerced temporary or permanent sterilization, sexual abuse, physical abuse, a devaluation of long-held traditional and holistic medical beliefs that further widened the gap between individuals eligible for cervical screening and their providers. Embedding cultural safety and humility into all health care services and planning is vital in mitigating these negative impacts and creating a safe health care environment where First Nations, Inuit, and Metis are eligible for cervical screening, and their families feel respected.FNHA conducted a self-collection and acceptability pilot project for cervix screening in British Columbia. Prior to embarking on this project, Pap screening and follow-up were already in place and linked to the provincial data registry. The project showed that HPV self-collection swabs were both a feasible and preferred option for First Nations individuals, and that the utilization of self-collection swabs will support greater rates of cancer screening for First Nations individuals. Self-collected swabs were especially beneficial for trauma survivors who risk re-traumatization during a pelvic exam, particularly, with a provider unknown to them (unpublished). Of note, while First Nations community members were eager to take part in self-screening, they expressed a high level of discomfort when they were asked to attend a colposcopy appointment for follow-up after identification of an abnormal result. In more than one instance, there was refusal. Trials in Ontario and Quebec have shown similar findings regarding preference for self-screening ,106,107.The proven systemic anti-Indigenous racism in the health care system, along with the ongoing impact of colonialism, has presented First Nations, Inuit, and Métis community members with many reasons to feel fear or discomfort when asked to attend a colposcopy appointment. Clients may not feel comfortable with a second or unknown provider that they have not met in advance, particularly if they have heard negative stories from friends or families about colposcopy offices being unsafe. Many First Nations individuals may not trust gynecology appointments due to fear of sterilization and the risk of being re-traumatized by their past experiences. Until 1973, BC had a law requiring the forced or coerced sterilization of certain people, of which Indigenous people were disproportionately targeted. Even after the repeal of this provincial law, Indian hospitals continued to sterilize Indigenous women without their consent. Canada’s Standing Senate Committee on Human Rights released a report in June 2021 on the forced and coerced sterilizations of persons in Canada, in which they acknowledge that this practice is “not confined to the past but clearly is continuing today” and that “[its] prevalence is underreported and underestimated” . CliniciBox 1DEFINITIONSCultural humility is a process of self-reflection to understand personal and systemic biases and to develop and maintain respectful processes and relationships based on mutual trust. Cultural humility involves humbly acknowledging oneself as a learner when it comes to understanding another’s experience. .Cultural safety is an outcome based on respectful engagement that recognizes and strives to address power imbalances inherent in the healthcare system. It results in an environment free of racism and discrimination, where people feel safe when receiving health care. .Cultural Competence is defined as a set of values, behaviors, attitudes, and practices within a system, organization, program, or among individuals, which enables them to work effectively cross-culturally. Further, it refers to the ability to honor and respect the beliefs, language, interpersonal styles, and behaviors of individuals and families receiving services, as well as staff who are providing such services.Trauma-Informed Care (TIC) is about recognizing the link between trauma and mental illness, substance use, barriers to access, physical ailments, and more. TIC involves making sure that people feel safe and are not re-traumatized by their care.Sex is the classification of a person as male or female and is assigned at birth, usually based on external anatomy. It is a combination of bodily characteristics including chromosomes, hormones, internal and external reproductive organs, and secondary sex characteristics.Gender Identity is a person’s internal, deeply held sense of their gender. It is most commonly boy/man or girl/woman. However, some individuals are non-binary and/or genderqueer.Gender Expression is the external manifestation of gender. It is expressed through name, pronouns, clothing, haircut, behaviour, voice, and/or body characteristics.Cisgender is used to describe individuals who are not transgender. From Latin, cis on the same side.Transgender is people whose gender identity differs from the sex they were assigned at birth.Gender dysphoria is a sense of unease that a person may have because of a mismatch between their biological sex and their gender identity.Sexual Orientation is a person’s enduring physical, romantic, and/or emotional attraction to another person. Commonly “straight”, “lesbian”, “gay”, “bisexual”, or “queer.”Sexual minority is a group whose sexual identity, orientation, or practices differ from the majority of the surrounding society. Primarily used to refer to lesbian, gay, bisexual, or non-heterosexual individuals, it can also refer to transgender, non-binary, or intersex individuals.Box 2Practice Cultural Humility:-Practice humility; know your own beliefs and honour the beliefs and practices of your clients. Treat others how you would like to be treated.-Reflect on your own assumptions and positions of power within the health care system.-Do not offer opinion, but only the best medical evidence. Ensure informed choice is maintained free of bias and coercion. Consult and share unbiased evidence-based resources, i.e., 1800 Sex Sense, Options for Sexual Health, SOGC.-Listen to what the client wants, fears, and is worrying about.Acknowledge, Respect Culture and History:-Recognize that First Nations, Inuit, and Métis communities have strategies of caring for individuals from preconception to elderhood that have been passed down orally through the generations.-Seek to draw from oral tradition by using stories to demonstrate cultural practices, beliefs, and values as evidence of healthy and protective ways of being. (Ref: Smylie).-Learn and incorporate culture, ceremony, and traditions into care. Ensuring this education and work is done in collaboration with the community you serve.Facilitate Whole Person Care:-Work to facilitate timely access to appropriate supports for mental health and wellness, including cultural and/or traditional supports at home when possible and consider virtual care when not possible.-Facilitate support services.-Talk about ways to support cultural connections.-Maintain awareness and compassion regarding possible trauma/intergenerational trauma.-Be flexible to the needs of the community.Reduce Barriers for Rural and Remote communities:-Ensure guidelines are culturally safe, applicable to rural and remote locations, clearly communicated, and include flow charts of actions.-Start conversations with families early to ensure there are contingency plans in place to provide a continuum of care/support for mothers and infants particularly if travelling for care.-Be aware of the complexities of leaving/returning to communities.Box 3Do not have the patient undress before seeing them.Build trust by calling the patient by name or meeting them in advance of appointment, allowing time to answer questions, and explain specific details of the procedure. Ideally, the person calling the patient is the person performing the examination and/or is going to be in the room during the examination .Consider utilization of an Indigenous liaison to be involved in communication and care.Allow a support person to attend the appointment.Acknowledge and respect concerns the patient may have regarding coerced sterilization and having an honest conversation about fertility risks.Provide clear next steps following the assessment/procedure ensuring community resources, and ensure supports are in place at home and known to the patient.Create a culturally safe and welcoming environment by using artwork by local First Nations artists to represent the community throughout the office.Post land acknowledgements in the office/clinic.Ensure all members of the team are introduced and roles defined, and the purpose of each room/piece of equipment is explained.Recommendations:For individuals living in rural and remote areas of Canada, HPV self-sampling techniques facilitated by mail programs or obtained from local health facilities should be strongly considered to overcome geographical barriers to cervix screening. Care pathways to obtain pap specimens and colposcopy should be in place. HPV self-sampling should be considered among immigrants and newcomers to Canadian populations as an acceptable alternative to provider-collected cervical screening where cultural barriers may inhibit provider-based screening uptake. Cervical screening in immigrant populations has not been well-studied. While there are several studies evaluating cervical screening in different ethnic populations, these studies typically include a single ethnic group in a single geographic area, limiting the ability to generalize to the Canadian immigrant and newcomer populations.In general, immigrant populations are more likely to have never been screened compared to their non-immigrant populations ,110. VerSeveral studies have examined the role for HPV self-sampling among immigrant populations ,119,120.Recommendation:HPV vault testing is not recommended for individuals who have undergone hysterectomy for benign diseases with no prior history of abnormal pap smears. Patients with LSIL on hysterectomy specimen should have an HPV test at 6–12 months; if negative, they require no further follow-up. Patients with a previous history of treated HSIL (CIN2/3) who had a negative HPV test thereafter and have a subsequent hysterectomy for benign indications and have no cervical pathology do not need any follow-up. Patients with a previous history of treated HSIL (CIN2/3) who have had no HPV-based test following treatment, have a subsequent hysterectomy for benign indications, and have no cervical pathology should have an HPV test at 12 months; if negative, they require no further follow-up. Patients who have a hysterectomy for HSIL (CIN2/3) and have residual cervical pathology (LSIL/HSIL) should have an HPV test at 12 months; if negative, they require no further follow-up. Patients who undergo a hysterectomy for AIS should have three consecutive annual HPV tests, followed by HPV testing every 3 years. Patients who have a history of AIS and have been discharged from colposcopy and undergo a hysterectomy for another reason should have HPV testing every 3 years. Patients who undergo HPV testing post-hysterectomy should have reflex cytology if positive HR–HPV is detected. Referrals to colposcopy should be made for results with HR–HPV 16/18 and any cytology showing HSIL/ASC-H. Patients with cervical carcinoma on hysterectomy specimens are not covered by this guideline and should be followed according to gynecologic oncologist recommendation. Vaginal screening is not recommended for individuals who have undergone hysterectomy for benign disease with no prior history of abnormal pap smears. The risk of developing vaginal HSIL post-hysterectomy for benign indications is extremely low, approximately 0.1–0.3%. Hence, screening for dysplasia in these patients is not recommended ,123,124.However, Vaginal HSIL can be seen in 7% of patients after hysterectomy for HSIL with most of the dysplasia being detected in the first 2–4 years post-hysterectomy. For this reason, these patients warrant some form of surveillance ,125. TheThere is no data to guide a similar approach to those treated for AIS with a hysterectomy. The consensus is to recommend three consecutive annual HPV tests followed by HPV testing every 3 years ,128.Those who have vaginal testing with a HR–HPV positive should have reflex cytology. Those with HR HPV 16/18 and/or reflex cytology with HSIL or ASC-H cytology should trigger an immediate referral for vaginal colposcopy ,124,129.The working group notes that the existing literature is limited. More data is needed in this patient population to understand how best to evaluate patients post-hysterectomy. Guidelines should be updated with new data when available.Recommendation:Screening and colposcopy algorithms should be the same, irrespective of HPV vaccination status. HPV vaccination was introduced in many Canadian provinces from 2008–2009. Donker et al. from British Columbia recently evaluated the effect of vaccination on CIN2+ lesions. They demonstrated a 62% (95% CI 54–68%) and 65% (58–71) reduction in CIN2 and CIN3, respectively, in the vaccinated population . The UK Grimes et al. performed a decision analysis model to evaluate different cervical cancer screening modalities and vaccination rates on CIN2+ detection . LBC-basGiven the paucity of clinical data and the lack of rigorous vaccination registries, it is recommended at this time that individuals who have received HPV vaccination should adhere to cervical cancer screening protocols that are being used for non-vaccinated individuals.Recommendations:Individuals with HR HPV16/18 with any cytology results should be seen within 6 weeks of referral Individuals with an HR–HPV “other” positive test and HSIL/ASC-H/AGC should be seen in colposcopy within 6 weeks of referral. .Individuals with an HR–HPV “other” positive test meeting criteria for referral should be seen in colposcopy within 12 weeks of referral. .Individuals with an HR–HPV positive test and cytology that is suggested of carcinoma should be seen in colposcopy as soon as possible, ideally within 2 weeks of referral. .Abnormal cervical screening tests and referral to colposcopy lead to significant anxiety for individuals . EstabliThe recommendations in this manuscript are meant to supplement jurisdictional guidelines and not meant to replace cervical screening programs that are in place at a provincial or territorial level. We strongly support centralized programmatic-based management using consensus-based algorithms. Centralized registries to access results of previous cervical screening test are also critical for clinicians to manage patients appropriately and adhere to local guidelines. As part of the joint commission to create these guidelines, a plan is in place to implement web-based tools and applications to facilitate triaging of abnormal test results for clinicians and when to refer to colposcopy. In future, further HPV genotyping and molecular tests may help to better triage a positive HPV test to reduce unnecessary referrals to colposcopy. A highly vaccinated population will also require less frequent cervical screening.


The significance of these differences is still unclear, as a correlate of protection has not been identified. Few studies have focused on demonstrating vaccine efficacy in PLH, with variable results depending on the age at vaccination and baseline seropositivity. Although waning humoral immunity for HPV seems to be more rapid in this population, there is evidence that suggests that seropositivity lasts at least 2–4 years following vaccination. Further research is needed to determine the differences between vaccine formulations and the impact of administrating additional doses on durability of immune protection.People living with HIV (PLH) experience higher rates of HPV infection as well as an increased risk of HPV-related disease, including malignancies. Although they are considered a high-priority group for HPV vaccination, there are limited data regarding the long-term immunogenicity and efficacy of HPV vaccines in this population. Seroconversion rates and geometric mean titers elicited by vaccination are lower in PLH compared to immunocompetent participants, especially in individuals with CD4 counts below 200 cells/mm Human papillomavirus (HPV) is a common sexually transmitted infection that is associated with cervical cancer as well as other anogenital and oropharyngeal malignancies ,2,3. ThrThese vaccines have proven to be effective in the general population, with a decrease in the prevalence of infections with HPV types included in the vaccine formulations as well as in the incidence of genital warts and HPV-associated cancers and pre-malignant conditions following vaccination campaigns ,10,11,12Higher rates of HPV infection are reported in people living with HIV (PLH), as well as a more frequent carriage of multiple HPV types ,15,16. TPLH are also at increased risk of suffering HPV-related disease, including malignancies. Current evidence suggests the more rapid progression of precancerous lesions and higher rates of HPV persistence in this population ,21,22,23As a result of the increased prevalence of HPV infection and disease discussed above, PLH are considered a high-priority group for HPV vaccination ,25. Howe3 [HIV infection is associated with altered cellular and humoral responses to vaccines, even in individuals on ART with an undetectable viral load (VL) and CD4 counts that exceed 500 cells/mm3 . The dur3 . Recent 3 ,16,32.In this review, we aim to provide a summary of current knowledge regarding HPV vaccine efficacy (VE) and immunogenicity in PLH, focusing on immune response durability and possible strategies to improve it.All guidelines emphasize the importance of HPV vaccination in PLH and agree on maintaining the three-dose schedule in this population .Centers for Disease Control and Prevention (CDC) guidelines recommend giving a series of three intramuscular HPV vaccine injections to all PLH (men and women) up to the age of 26 that have not already been vaccinated at the target age for immunization (11–12 years old). Additionally, the guidelines suggest that some adults aged 27–45 might still benefit from vaccination and are eligible to receive the vaccine after discussion with their medical provider . 3 who might benefit from deferring vaccination until they are established on ART.The updated European AIDS Clinical Society (EACS) guidelines published in 2022 recommend the administration of three doses of HPV vaccine between the ages of 9 and 45, using the nonavalent vaccine if it is available . SimilarThe updated World Health Organization (WHO) recommendations, published in December 2022, include an alternative single-dose schedule as an off-label option that can be used in immunocompetent girls and boys aged 9–20 years ,35,36. HPublications regarding HPV vaccination in PLH reported that the bivalent, quadrivalent and nonavalent vaccines were safe and tolerable for this population compared to the results in studies including immunocompetent participants ,42,43. THPV vaccines result in a robust and durable neutralizing antibody response, with higher titers than natural infection. Peak antibody titers reported in the clinical trials of mostly immunocompetent individuals are observed 4 weeks after first vaccination. Seropositivity rates and geometric mean titers (GMTs) remain high for at least 12 years following the receipt of a multidose schedule of 2vHPV and 4vHPV and for 7 years after the most recently approved nonavalent formulation ,46,47,48Both 2vHPV and 4vHPV demonstrated cross-protection against HPV types not included in the vaccine .In studies evaluating these vaccines in PLH, almost all HPV seronegative participants seroconverted to HPV types included in the vaccines and were still seropositive 28 weeks after initial vaccination. Data from two meta-analyses also show that GMTs are lower for HPV-18 compared to HPV-16, both initially and during follow-up ,42. The When comparing immunogenicity in PLH and immunocompetent participants, current data show slightly lower seroconversion rates and GMT titers in PLH . DiffereA prospective cohort of perinatally HIV-infected youth showed seroconversion rates of 83%, 84%, 90% and 62% for HPV-6, HPV-11, HPV-16 and HPV-18 after the receipt of quadrivalent vaccine, which were significantly lower than the rates in perinatally exposed but uninfected participants . GMTs weThe significance of these lower antibody titers is yet to be determined, as a correlate of protection has not been identified, whilst antibody levels needed to achieve protection against HPV acquisition and disease are still unknown ,41,53,54A publication looking at sera from 75 PLH and 147 immunocompetent men who received 3 doses of quadrivalent vaccine reported that antibody avidity was significantly lower for HPV-16 and HPV-18 one month after the third vaccine dose in PLH . However3 and detectable VL have lower seropositivity rates and GMTs compared to the well-controlled PLH, as seen in other vaccine platforms [Most studies conclude that PLH with CD4 counts below 200 cells/mmlatforms ,57,58. Hlatforms . In anotlatforms . FurtherThe long-term durability of the immune response in PLH has not been sufficiently studied. Although seropositivity rates and antibody titers decline over time, there is evidence that suggests that seropositivity lasts at least 2–4 years . Table 3A recent publication with data on the 4-year follow-up of 176 children living with HIV (CLH) aged 9–14 in Kenya after the receipt of the quadrivalent vaccine reported that the rate of seropositivity at 48 months was 83% for HPV-6, 80% for HPV-11; 90% for HPV-16; and 77% for HPV-18 . A plateLikewise, a 4–5 year follow-up of CLH after the receipt of 3 doses of 4vHPV in another study reported that seropositivity levels measured with a line-immunoassay (LIA) were 86%, 71%, 100% and 71% for HPV types 6, 11, 16 and 18, respectively, experiencing a slightly higher reduction than in the one reported in similar studies in healthy children . GMTs alA phase 2 open-label study evaluating the response to the quadrivalent HPV vaccine in young WLH evidenced that GMTs declined significantly for all four vaccine-types, but remained higher than those induced by natural infection, consistent with the studies in healthy women .Several studies reporting results based on a competitive luminex immunoassay (cLIA) suggest that waning humoral immunity might be more rapid for HPV-18 compared to other types ,27,53. HEinstein et al. reported the differences in antibody titers between 2vHPV and 4vHPV in immunocompetent women aged 18–45 which were seronegative and DNA-negative at baseline ,66. At 6There are limited data comparing different vaccine formulations regarding long-term immunogenicity in PLH. An RCT reporting results from 91 PLH found no significant differences in HPV-16 antibody titers, but HPV-18 titers were higher in the 2vHPV compared to the 4vHPV group, with a GMT ratio at 12 months of 4.15  . In thisRegarding cellular immunity, a study including CLH who received three or four doses of quadrivalent HPV vaccine reported no significant differences between treatment groups and demonstrated that B- and T-cell responses can be detected 5 years after vaccination . HPV-speMore information regarding long-term immunogenicity in PLH is required to determine vaccine durability and its association with VE, as there are no data on seropositivity rates and GMTs beyond 4–5 years following vaccination. Antigen re-exposure by the administration of additional doses triggers an anamnestic response in vaccinated individuals, as shown in studies including PLH as well as in immunocompetent individuals ,69,70,71As a result of the wide availability of ART, the life expectancy of PLH has significantly increased in developed countries, evidenced by the fact that more than half of PLH in the US are over 50 years old . The comThere is evidence that VE against HPV vaccine-type infection as well as cervical, vaginal and vulvar neoplasia in women and anogenital neoplasia in men, remains high 10 years after vaccination in immunocompetent individuals ,73. Howe3 and 69% of the participants had undetectable VL. The incidence rate (IR) of newly acquired persistent vaccine-type HPV was 2.3 per 100 PY  in the intention to treat (ITT) group, more than half of which are due to HPV-18, and 1.0 per 100 PY  in the per-protocol efficacy (PPE) population. No cases of vaccine-type HPV-associated cervical intraepithelial neoplasia (CIN) of grade two or higher developed in women with normal baseline cytology and the IR for anogenital warts was 2.3 per 100 PY  in the ITT group. When compared with reported rates of infection and disease in other studies, WLH seem to be at higher risk for vaccine failure, but rates of persistent HPV infection are lower than in unvaccinated WLH, suggesting an important benefit from vaccination. McClymont et al. reported results from a Canadian cohort of WLH aged 9–65 years old . A totalA prospective cohort study comparing the immunogenicity and VE of the quadrivalent vaccine in perinatally HIV-infected and exposed-uninfected youth revealed an IR of 15.0  and 2.9  per 100 PY of abnormal cervical cytology in sexually active HIV-positive and -negative participants, respectively . p = 0.98), external anogenital lesions  or in the acquisition of vaccine-type HPV after 48 months. However, the vaccine offered protection against the acquisition of genotype 6 during the first year of follow-up .An RCT in PLH aged 27 or older analyzing VE for the prevention of persistent or newly acquired anal infections as well as high-grade squamous intraepithelial lesions (HSIL) had to be stopped early due to futility . A totalSeveral strategies to optimize HPV vaccine response and improve the durability of protection have been analyzed in previous publications .Salmonella minnesota’s bacterial wall and adsorbed onto aluminum hydroxide [Superior immunogenicity has been reported with the use of 2vHPV, a Toll-like receptor (TLR)-adjuvanted vaccine, compared to 4vHPV, an alum-adjuvanted vaccine, especially when considering memory B-cell responses to HPV-18 ,56. 2vHPydroxide . This adydroxide ,78. Thisydroxide ,80,81. Aydroxide .9vHPV has a higher antigen content than the quadrivalent vaccine and its administration resulted in slightly higher GMTs in the general population for HPV-18 . It remaThe impact of administrating a fourth dose of the quadrivalent vaccine at 72 weeks after last vaccination was studied in CLH . This inAnother strategy to improve the durability of protection might be delaying vaccination until immune reconstitution has been achieved, as most studies report enhanced immunogenicity after ART initiation, with optimized CD4 counts and undetectable VL ,53,57,58Although PLH are considered a high-priority group for HPV vaccination, there are only modest data regarding long-term immunogenicity and efficacy in this population. Studies that address the durability of immune response and its potential impact on VE should be considered research priorities, as there is currently insufficient information on both cellular and humoral responses beyond 2 years after vaccination. Further data are necessary to understand the influence of CD4/CD8 counts and HIV VL on vaccine response, especially in individuals who have experienced immune reconstitution as a result of ART. Studies focusing on HIV-positive transgender individuals as well as persons who inject drugs are also needed to understand the impact of vaccination in these populations. RCTs comparing VEs between different vaccine formulations and schedules in PLH are essential to dictate future recommendations. Optimized vaccination strategies, in combination with improved screening and treatment procedures, can potentially reduce the burden of HPV disease in PLH.


Dermatologic interventions in both the pre- and post-vaccination periods were analyzed with zero-inflated Poisson regression and a proportional intensity model for repeated events with consideration of the clinically relevant cofactors. The hazard ratio for major dermatologic interventions was 0.27  between pre- and post-Gardasil-9® intervention. Gardasil-9® vaccination showed good efficacy in reducing major dermatologic interventions even after correction of relevant cofactors and national COVID-19 caseloads during the observational period. Alpha-HPV vaccination may potentially cause a significant decrease in dermatologic interventions and overall mortality as well as healthcare costs in immunosuppressed patients with high skin tumor burden.cSCC (cutaneous squamous cell carcinoma) and its precursors are a major cause of morbidity, especially in immunosuppressed patients, and are frequently associated with human papillomavirus (HPV) infections. The purpose of this study is to investigate the therapeutic potential of alpha-HPV vaccination for immunosuppressed patients with established cSCC and its precursors. In this retrospective study, all patients who received Gardasil-9 Skin warts and especially non-melanoma skin cancer (NMSC) are a major cause of morbidity in patients under chronic immunosuppressive treatment, such as patients after solid organ transplantation (SOT) ,2. The iBeta-HPV infection in keratinized skin appears to play a predisposing role in the genesis of NMSC and has been significantly clustered in cSCCs of immunosuppressed transplant recipients. The carcinogenic effect is seen as a combination of beta-HPV infection with ultraviolet (UV) light ,10.®, Gardasil®, and Gardasil-9®) on the market are designed to prevent α-HPV-related diseases and provide highly effective protection specific to oral and anogenital mucosal HPV subtypes  to 0.1/year [IQR: 0.0–0.1] (p < 0.01) with a positive response in similar 68.4% of patients (26/38). Similarly, overall visits declined from 1.3 to 0.4/year (p < 0.01), while visits without any interventions remained stable , see Visits with major dermatological interventions declined after vaccination from a mean of 0.7/year [IQR: 0.0–0.8] to 0.2/year [IQR: 0.0–0.2] (p < 0.001) between pre- and post-Gardasil-9®. Gardasil-9® intervention remained effective in reducing major dermatological interventions after correction for relevant co-factors  and even after correction for national COVID-case load . A relevant proportion of patients received their vaccination schedule during or in the early phase of the COVID-19 pandemic  and heavy pre-vaccination treatment burden  were associated with an increased odds ratio for treatment response.  with vaccination response  as dependent and previous interventional burden, age at vaccination, number of immunosuppressive drugs, and treatment indication (TPL vs. non-TPL) as independent factors. Indeed, TPL patients . Furthermore, no detailed analysis of HPV infection (type), no histopathological data, and no data on vaccine-specific HPV antibody measurements before and after vaccination are available.The question remains whether a possible seroconversion with mostly low titers against non-genital skin HPV types really has clinical relevance. A possible explanation could be a mixed infection of different HPV types. Thus, sometimes genital, mostly high-risk alpha-HPVs are found in cSCC besides beta-HPVs ,22,23. T® vaccination in respect of major surgical intervention. The study population comprised a typical cohort of IS patients in a tertiary dermatology clinic and a repeated and well-documented treatment log for vaccination and dermatology interventions.To our knowledge, this is among the largest cohort of dermatology patients at risk for recurrent keratotic skin lesions investigating the effect of Gardasil-9Furthermore, attempts are being made to develop vaccinations against beta-HPV infections. To date, no anti-beta HPV vaccine is on the market. The large heterogeneity of HPV types in cutaneous keratotic lesions makes the development of efficient anti-beta HPV vaccines difficult . Further® vaccination. Our data show that with the administration of such a vaccination, the skin tumor burden in these patients can be significantly decreased. This could reduce invasive procedures, overall mortality, and healthcare costs. Our data may pave the way for further prospective and randomized controlled trials, which are needed to prove the effect of alpha-HPV in cutaneous HPV infection.In summary, the association between beta-HPV and cSCC development and the increasing burden of cSCC development, especially in immunocompromised patients, highlights the need for efficient immunization against HPV-related skin cancer. Although the direct effect of alpha-HPV vaccination on cutaneous HPV infection has not been proven, our study demonstrated a significant decrease in dermatologic procedures in immunosuppressed patients after administration of the Gardasil-9


N = 3724) completed a web-based survey in the summer of 2022. Oversampling ensured that half of the sample were underscreened for cervical cancer (>3 years since previous screening or never screened). The participants completed validated scales of cervical cancer, HPV, and HPV test knowledge and HPV test and self-sampling attitudes and beliefs. Between-group differences (underscreened vs. adequately screened) were calculated for scales and items using independent sample t-tests or chi-square tests. The underscreened participants (n = 1871) demonstrated significantly lower knowledge of cervical cancer, HPV, and the HPV test. The adequately screened participants (n = 1853) scored higher on the Confidence and Worries subscales of the HPV Test Attitudes and Beliefs Scale. The underscreened participants scored higher on the Personal Barriers and Social Norms subscales. The underscreened participants also endorsed greater Autonomy conferred by self-sampling. Our findings suggest important differential patterns of knowledge, attitudes, and beliefs between the underscreened and adequately screened Canadians. These findings highlight the need to develop targeted communication strategies and promote patient-centered, tailored approaches in cervical screening programs.As Canadian provinces and territories prepare to transition to HPV-based primary screening for cervical cancer, failure to identify and address potential barriers to screening could hinder program implementation. We examined screening-eligible Canadians’ attitudes towards and knowledge of cervical screening. A nationally representative sample of screening-eligible Canadians ( For decades, cytology-based  screening in Canada has resulted in a significant decline in cervical cancer rates. However, there remains an estimated 1450 diagnoses (estimated age-standardized incidence rate in 2022: 7.5 ) and 380 deaths from cervical cancer in Canada annually  has shown that transitioning to HPV testing as the primary screening method without adequate and anticipatory population-wide preparation can result in confusion, misinformation, and mistrust ,13. SimiThe current study was conducted as part of a multi-phase project aimed at understanding Canadian women’s preparedness for the transition from cytology to HPV test-based primary screening to prevent cervical cancer. The present study objectives were: (1) to describe HPV, the HPV test, and cervical cancer knowledge and attitudes regarding HPV testing and self-sampling in adequately and underscreened women and (2) to estimate differences in knowledge and attitudes and beliefs between the two groups .A detailed description of the study methodology can be found elsewhere . In brieThe participants provided information regarding sociodemographics, relevant health behaviours, and cervical screening in either English or French. At various points during the survey, the participants were shown informative statements which provided minimal and neutral information to orient them towards the items that followed. For example, before completing items related to self-sampling, the participants were informed about the availability of and procedures to conduct self-sampling with an accompanying infographic demonstrating the procedure, since this screening option is currently unknown to most Canadians. These informative statements are available in the published protocol .adequately screened , and thtrue”, “false”, or “I don’t know”. The response option of “I don’t know” was included to counteract errors due to random responses or guessing, and such responses were categorized as incorrect for the analyses. The Cronbach’s α values for the present study were as follows: CCKS (α = 0.78); HTKS (α = 0.73); HPV General Knowledge Scale (α = 0.90).The participants completed three scales measuring knowledge of cervical screening-related topics. The Cervical Cancer Knowledge Scale (CCKS) and HPV Testing Knowledge Scale (HTKS) were developed by our team and each contain eight items . HPV knoPersonal Barriers , Social Norms , Confidence , and Worries . The HSABs contains two factors: Concerns  and Autonomy . The participants responded to the attitudes and beliefs items on a seven-point Likert scale from “strongly disagree” to “strongly agree”.The participants completed the HPV Testing Attitudes and Beliefs Scale (HTABS) and HPV Self-Sampling Attitudes and Beliefs Scale (HSABS) as developed and validated by our team . The HTAFor each knowledge item, the proportion of participants who correctly answered the item was calculated. Total knowledge scale scores were calculated as the total number of correct responses across all relevant items. For the attitudes and beliefs scales, mean scores for each item and subscale  were calculated.t-tests to evaluate between-group differences and calculated the effect size (Cohen’s d). Bonferroni corrections were used to adjust significance levels for multiple comparisons according to the number of items within a given scale or subscale. We used the benchmarks defined by Cohen [Chi-square tests of independence were used to examine differences on individual knowledge items between adequately screened and underscreened participants, and for significant differences, we calculated the effect size (Cohen’s h). For continuous data , we used independent sample by Cohen  to interby Cohen  and R 4.by Cohen  statistiIn total, 4082 participants completed the survey. After data cleaning methods were applied , 3724 oM) score for the full sample for the CCKS was 4.72 out of a possible 8 (standard deviation (SD) = 2.26). Adequately screened participants  had significantly higher scores than underscreened participants , t(3722) = 6.870, p < 0.001, d = 0.23. Adequately screened participants had significantly higher correct responses on seven of the eight items of the CCKS (see true) versus all other items. This item and the item “A woman is at lower risk for developing cervical cancer if she smokes”  significantly exceeded knowledge of the remaining six items, among which knowledge levels were largely indistinct . Adequately screened participants  had significantly higher mean scores than underscreened participants , t(3722) = 5.421, p < 0.001, d = 0.18. Regarding item-level differences, adequately screened participants had significantly higher correct responses on six of the eight items of the HTKS  and “The HPV test sample can be collected by the woman herself using a specialized HPV self-sampling kit”. Adequately screened participants had significantly higher knowledge of the item pertaining to the difference between HPV and Pap test results versus the item about the availability of self-sampling, but this difference was not observed for the underscreened participants. More detailed results are available in The mean score for the full sample for the HTKS was 4.32 out of a possible 8 . Adequately screened participants  had significantly higher scores than underscreened participants , t(3722) = 6.265, p < 0.001, d = 0.21. Adequately screened participants had significantly higher correct responses on twelve of the twenty-three items of the HPV Knowledge Scale  participants had significantly higher mean scores on the Personal Barriers subscale of the HTABS compared to the adequately screened participants , t(3722) = 18.530, p < 0.001, d = 0.61, and had significantly higher scores across all seven items, suggesting that participants in this group have greater and more multifaceted perceived barriers to screening. In the item-level differences, among the adequately screened participants, the highest agreement was observed for the item “the HPV test would be painful”, whereas the underscreened participants demonstrated similarly high agreement between this item and “I would be embarrassed to show my genitals to a healthcare professional during the HPV test”. One item had distinctly lower agreement versus all others in both groups, “healthcare professionals doing the HPV test would be rude to me”.The underscreened  had significantly higher mean scores on the Social Norms subscale compared to the adequately screened participants , although the effect was very small, t(3722) = 3.935, p < 0.001, d = 0.13. The underscreened participants also had significantly higher scores on three of the four items of this subscale. The item “my partner’s opinion about getting the HPV test would be important to me” had distinctly higher agreement in both groups versus the other social norm items, with no significant difference observed between the groups. A similar item pertaining to one’s family had higher agreement than two items relating to the importance of the opinion of friends and social media in HPV test decision-making.The underscreened participants  had significantly higher scores on the Confidence subscale compared to the underscreened participants , t(3722) = 7.787, p < 0.001, d = 0.26) and across five of the six items, which could indicate greater general trust in HPV testing. Agreement was relatively high on this subscale, with scores on all items exceeding the item-level scores on all other HTABs subscales. The item “if the HPV test showed I had HPV, it is important to follow up on it” had distinctly higher agreement in both groups versus all other items. Contrastingly, an item pertaining to the importance of public health agencies’ recommendations for HPV testing had significantly lower agreement in both groups than any other item.The adequately screened participants  had significantly higher scores than the underscreened participants on the Worries subscale , although the effect was very small, t(3722) = 4.392, p < 0.001, d = 0.14. This could reflect greater concerns about increased screening intervals and ages in this group, which the items in this subscale examined. However, the effect size was very small. The adequately screened participants had higher scores on two of the three items on this subscale. The participants in both groups expressed distinctly high agreement for the item “I would be worried about starting screening with the HPV test at 30 years old instead of 21 years old” versus the two remaining items, between which no difference in agreement was observed.The adequately screened participants  = 1.707, p = 0.088. However, significant differences were observed across three of the four items in this subscale  had significantly higher mean scores than the adequately screened participants  on the Autonomy subscale, t(3722) = 11.883, p < 0.001, d = 0.39 and across all three items. Item-level analysis indicated that agreement was similarly high in both groups between two items pertaining to agreement that self-sampling confers greater bodily control and would save travelling time and distinctly higher than the item “I would be more comfortable doing the swab by myself using HPV self-sampling than having an HPV test done by a healthcare professional”.The underscreened participants  but was significantly higher in adequately screened (81.6%) versus underscreened (74.7%) women. Consistent with this, the results from the HPV Testing Knowledge Scale confirmed that most participants (75.8%) understood that an HPV-positive test result indicated an increased cervical cancer risk. However, knowledge of the high lifetime incidence of HPV and the likelihood of sequalae following infection was low, suggesting that, while participants understood HPV’s relationship with cervical cancer, they were less knowledgeable about the probability of becoming infected or developing HPV-related diseases. Importantly, knowledge of HPV causing genital warts and oral, anal and penile cancers was also low and similar to the results observed by Thompson et al. , in whicConfidence subscale of the HTABS were higher than for all other subscales, showing the importance of this dimension, independent of screening status. This is consistent with findings suggesting that women’s perceptions of HPV testing are not only related to the perceived performance of the test itself but also to participants’ understanding of the rationale for using it  [Worries subscale of the HTABS, which contains items pertaining to increased screening ages and intervals, support this observation. Like those individuals who supported the petition in Australia to not shift to HPV testing, adequately screened Canadians might be more likely to be worried about going through testing with the HPV test less often than every 3 years considering that, unlike the underscreened participants, it would alter the screening regimen to which they are already accustomed. Within the Worries subscale, the participants in both groups were most concerned about the age of initial screening being adjusted to 30 rather than 25, confirming findings from a recent nationwide survey showing low preference for screening initiation at age 30 [Scores on the  cancer) ,31,32. I cancer)  found tht age 30 . Considet age 30 , public Personal Barriers subscale emphasize the importance of addressing psychological  and practical  barriers and screening-discordant beliefs . Such concerns have been highlighted in previous reviews, both of cervical screening generally [The consistent between-group differences on the enerally ,36,37,38enerally , and areenerally . By creaenerally  and low enerally  as barrienerally  and Nothenerally , which ienerally  and increnerally .Social Norms subscale of the HTABS in the underscreened participants could suggest the importance of designing interventions to promote screening-positive social norms within populations with low levels of screening. For example, a study by Knops-Dullens et al. [Higher scores on the s et al.  in the Ns et al. . Howevers et al. . An exams et al.  demonstrA systematic review and meta-analysis by Virtanen et al.  examininConcerns subscale of the HSABS indicate a unique pattern of attitudes between adequately screened and underscreened participants. The underscreened participants typically had higher scores on items measuring harm  resulting from self-sampling, whereas adequately screened participants demonstrated greater concern about conducting sampling incorrectly . These results suggest contrasting barriers to self-sampling participation between these groups and support the need to reassure those who have more limited experience with screening about the safety of self-sampling. These results align with a recently published Canadian study showing that adequately screened Canadians typically have a low preference for self-sampling compared to alternative screening methods [Item-level differences on the  methods . Scores  methods ,48,52. A methods . Attenti methods ,54.This Canada-wide investigation of knowledge, attitudes, and beliefs towards HPV-based cervical screening is critically important given imminent changes to screening programs in multiple jurisdictions. The use of a large sample of underscreened and adequately screened women enabled accurate between-group comparisons to produce findings which can inform targeted communication and education strategies. However, the use of self-reported screening status could limit the applicability of our findings, given difficulties recalling past screenings. Future studies should consider using screening registries to identify screening histories. The use of validated scales, which were previously tested among Canadian women for the purpose of addressing implementation challenges for HPV-based screening , ensure The shift to HPV-based cervical screening in Canada provides an important opportunity to continue to reduce the burden of cervical cancer and reduce disparities in screening, diagnosis, and treatment. Our results support concerns from other countries’ experiences that progress cannot be made without adequate consultation and communication with the screening-eligible population. By conducting a population-wide and large web-based survey, this study illuminates the knowledge and attitudes about cervical screening that may be implicated in the acceptance and uptake of HPV-based screening in Canada. Our findings also indicate that successful screening programs should avoid a “one-size-fits-all” approach, both in their communication strategies and program design. For underscreened women, providing targeted education about HPV, testing, and cervical cancer, and addressing barriers to screening (including concerns about embarrassment and HPV-related stigma) will be critical. Including self-sampling in organized cervical screening programs could increase screening uptake in this group and communications should emphasize the personal choice (autonomy) and the comfort that this method provides. For adequately screened women, there is a need to address worries about increased screening intervals and later ages of initiation associated with HPV testing.Successful implementation of primary HPV-based cervical screening, which will progress Canada’s goals for cervical cancer elimination, will require buy-in at all levels. Screening-eligible Canadians are key stakeholders in cervical screening and provincial governments, federal agencies, and organizations involved in cancer recommendations, care, and prevention, should continually consider their knowledge, attitudes and beliefs as changes are implemented. By investigating Canadians’ current perceptions of HPV-based cervical screening, this study provides a timely investigation which can aid in aligning public health strategies to address population-level knowledge gaps and attitudinal barriers.