Human papillomavirus (HPV) DNA testing is reshaping cervical cancer screening worldwide.
For decades, cervical cytology (Papanicolaou test) has been the cornerstone of screening programs, contributing substantially to reductions in cervical cancer incidence and mortality. Advances in molecular diagnostics, however, have demonstrated that high-risk HPV DNA testing is more sensitive than cytology for detecting cervical precancer, allowing earlier identification of women at risk while safely extending screening intervals.
Brazil has recently joined this global transition. The Ministry of Health incorporated HPV DNA testing as the primary screening method within the Brazilian Unified Health System (SUS), while the supplementary healthcare system has also adopted molecular testing following recommendations from national medical societies. This shift represents one of the most important changes in cervical cancer prevention in recent decades, moving from a cytology-based opportunistic strategy toward an organized, risk-based screening program.
Why is cervical cancer still a major health problem in Brazil?
Despite being one of the most preventable malignancies, cervical cancer continues to represent an important public health challenge.
According to the Brazilian National Cancer Institute (INCA), approximately 19,000 new cervical cancer cases are expected annually, making cervical cancer the third most frequent cancer among Brazilian women, excluding non-melanoma skin cancer. More than 7,000 Brazilian women die from the disease each year, with the greatest burden occurring in regions where access to screening and healthcare remains limited. Persistent infection with high-risk HPV is responsible for virtually all cervical cancers, making effective screening one of the most powerful cancer prevention strategies available.
Although Brazil has maintained a nationwide cytology program for decades, screening has historically been opportunistic rather than organized. Many women undergo unnecessary annual Pap smears, whereas others—particularly those living in socially vulnerable areas—remain unscreened. This imbalance contributes to persistent inequalities in cervical cancer outcomes.
Why is HPV DNA testing replacing the Pap smear as the primary screening test?
The traditional Pap smear detects cellular abnormalities after HPV infection has produced cytological changes. In contrast, HPV DNA testing detects the presence of high-risk viral infection before morphological abnormalities become evident.
Large randomized clinical trials and long-term follow-up studies have consistently demonstrated that HPV-based screening has higher sensitivity for detecting CIN2+ and CIN3+ lesions than cytology alone. Earlier identification of women at increased risk allows appropriate triage, colposcopy when indicated, and timely treatment of precancerous lesions, reducing the future incidence of invasive cervical cancer.
An equally important advantage is the high negative predictive value of HPV DNA testing. Women with a negative high-risk HPV test have an extremely low probability of developing significant cervical disease over the following years. Because of this high level of reassurance, international guidelines support extending the screening interval to five years after a negative HPV test in average-risk women.
This longer interval does not mean less screening. Instead, it reflects a more accurate test that safely reduces unnecessary examinations while maintaining or even improving protection against cervical cancer.
What changes with the new Brazilian screening strategy?
The incorporation of HPV DNA testing changes both the screening test and the overall screening philosophy.
Under the new Brazilian recommendations, women aged 25 to 64 years undergo primary HPV DNA testing rather than cytology. Women with negative results repeat screening every five years, while those with positive tests undergo risk stratification based on HPV genotype and reflex cytology to determine the need for colposcopy or surveillance.
The supplementary healthcare sector has already incorporated molecular HPV testing following recommendations from Brazilian specialty societies, allowing many women access to this strategy through private health insurance.
Within SUS, however, implementation remains gradual. Incorporating a new technology into a continental healthcare system involves much more than purchasing laboratory tests. It requires reorganizing laboratory networks, establishing referral pathways, training healthcare professionals, implementing quality assurance programs, adapting information systems, and educating both clinicians and patients regarding the new screening intervals.
These implementation challenges explain why cytology continues to coexist with HPV DNA testing during the transition period.
Can HPV DNA testing contribute to cervical cancer elimination?
Evidence from countries that adopted HPV-based screening demonstrates substantial improvements in cervical cancer prevention.
When combined with high HPV vaccination coverage and appropriate treatment of precursor lesions, HPV DNA testing can strengthen the screening pillar of the World Health Organization’s strategy for eliminating cervical cancer as a public health problem.
Its greatest strength lies not only in detecting more precursor lesions but also in identifying women at extremely low risk. A negative HPV test provides sufficient reassurance to safely postpone the next screening examination for five years, reducing unnecessary procedures while maintaining excellent protection against cervical cancer.
For Brazil, this transition represents an opportunity to improve screening quality, expand coverage, reduce regional disparities, and allocate healthcare resources more efficiently. Achieving these goals, however, will depend on successful nationwide implementation, equitable access to molecular testing, timely diagnostic follow-up after positive results, and sustained public confidence in a screening strategy that intentionally recommends less frequent—but more effective—testing.
Written by Dr. Marianne Potengy, MD
Surgical Oncologist | Brazil Hub, OncoDaily
FAQ
Is the Pap smear no longer recommended?
No. Cytology continues to play an important role, particularly as a triage test after a positive HPV DNA result and during the transition to the new screening model.
Why can screening be repeated every five years after a negative HPV test?
Because HPV DNA testing has a very high negative predictive value. Women with a negative test have an extremely low risk of developing significant cervical disease over the following years, making a five-year interval safe for average-risk individuals.
Who should undergo primary HPV DNA screening?
Current Brazilian recommendations apply to individuals with a cervix aged 25 to 64 years who have initiated sexual activity and are considered at average risk.
Will HPV DNA testing replace the Pap smear immediately throughout Brazil?
No. Implementation within SUS is gradual and depends on laboratory infrastructure, professional training, healthcare organization, and regional capacity. During this transition, both screening strategies may coexist.
Does HPV vaccination eliminate the need for screening?
No. Vaccinated individuals should continue participating in cervical cancer screening because current vaccines do not protect against all oncogenic HPV types, and screening remains essential for early detection.