What is the procedure for performing the Human Papillomavirus (HPV) primary screening test?

HPV Primary Screening Test Procedure

HPV primary screening is performed by collecting a cervical specimen using a sampling device (such as a cytobrush or spatula) during a pelvic examination, which is then tested in a CLIA-certified laboratory using FDA-approved molecular assays that detect DNA from high-risk (oncogenic) HPV types. 1

Specimen Collection Technique

Collection Method

• The provider uses instruments designed to sample the cervical transformation zone, such as cytobrushes, which improve test accuracy. 1
• The specimen can be collected using either conventional methods (smeared onto a slide) or liquid-based collection systems. 1
• For liquid-based cytology systems, the sample can be collected at any time during the menstrual cycle, whereas conventional cytology should ideally be scheduled 10-20 days after the first day of menses. 1

Pre-Collection Considerations

• If mucopurulent discharge is present, it should be removed with a saline-soaked cotton swab before specimen collection, but testing should not be postponed. 1
• The sequence of specimen collection does not influence test results—vaginal specimens for STI testing are preferred, but endocervical specimens for STI testing can be collected first during the same pelvic examination. 1

Laboratory Testing

FDA-Approved Tests for Primary HPV Screening

Only two FDA-approved tests are currently available for primary HPV screening: 1

• cobas® HPV (approved 2014): Detects high-risk HPV types with specific genotyping for HPV 16 and 18 1
• Onclarity HPV (approved 2018): Provides extended genotyping for HPV types 16,18,45,31,51,52,33/58,35/39/68, and 56/59/66 1

Laboratory Requirements

• All HPV testing must be performed in CLIA-certified laboratories. 2
• Only FDA-cleared HPV assays should be used for their approved indications. 2
• HPV testing can be performed either as a separate test or by using material from the liquid-based cytology specimen. 1

Age-Specific Application

Appropriate Age Groups

• HPV primary screening should NOT be performed in women under 25 years of age due to high rates of transient HPV infection and viral clearance. 1, 2
• Women aged 25-29 years should have Pap testing alone every 3 years; HPV testing is not recommended for primary screening in this age group. 2
• HPV primary screening is appropriate for women aged 30-65 years, with testing every 5 years. 2

Self-Collection Option

Recent Developments

• Self-collected vaginal specimens for HPV testing are now acceptable (though clinician-collected cervical specimens remain preferred) for primary HPV screening of asymptomatic average-risk individuals. 3
• Self-collected specimens have sensitivity of 91.8% compared to 95.9% for provider-collected specimens, but lower specificity (51.6% vs. 57.5%). 4
• Repeat testing in 3 years is recommended following HPV-negative screens using self-collected vaginal specimens. 3

Quality Assurance Measures

Collection Standards

• Health care facilities that train providers on specimen collection and use simple quality assurance measures are more likely to obtain satisfactory test results. 1
• Professional and technical guidelines must be followed to assure adequate cervical cell sample collection and preparation. 1

Common Pitfalls to Avoid

• Do not use HPV testing as a screening test for STIs—it is specifically for cervical cancer screening only. 1, 2
• Do not perform HPV testing in women under 25 years, as this leads to unnecessary colposcopies due to transient infections. 1
• Ensure the laboratory has capacity for FDA-approved HPV testing, as availability may be location-dependent, particularly in smaller laboratories and lower-resource settings. 1
• Do not assume specimen adequacy—while most HPV assays lack internal adequacy standards (unlike cytology), proper collection technique using transformation zone sampling devices is critical. 1