The traditional method to screen women for cervical cancer has been cytology (the Papanicolaou test, also known as the Pap smear or smear test). When cytology results are positive, the diagnosis is confirmed by colposcopy, and appropriate treatment is informed by biopsy of suspicious lesions for histological diagnosis. Introduction

# HPV mRNA technology and interpretation of test results
The focus of this edition of the updated guideline is the use of HPV mRNA tests (HPV E6/E7 messenger RNA detection) for HPV detection as an alternative method to HPV DNA tests for HPV detection. The virus infecting the basal cell layer of the cervical epithelium is comprised of a double-stranded DNA at its core and a protein coat (capsid). The DNA tests detect either the viral DNA through hybridization technique or a highly conserved region of the L1 capsid protein or of the E genes using polymerase chain reaction (PCR). Hence, HPV DNA tests detect the presence of the virus by detecting the viral DNA. The HPV mRNA tests detect transcripts of the viral E6 and E7 oncoproteins, which are responsible for HPV-mediated oncogenic transformation of epithelial cells.
Persistent infection from any of the high-risk types of HPV is essential for cervical oncogenesis.
The process of carcinogenesis starts with the virus particles entering the basal layer of the cervical epithelium and integration of their DNA with the host cellular DNA. As the carcinogenic process advances, the E6 and E7 oncoproteins are expressed, and these proteins are primarily responsible for neoplastic transformation. The E7 protein can bind and degrade retinoblastoma (pRb) tumour suppressor protein, which initiates uncontrolled activation of the cell cycle. The E6 protein degrades p53 (another tumour suppressor protein), inhibiting apoptosis (programmed cell death), and upregulating telomerase activity. Degradation of the key tumour suppression proteins leads to cell cycle deregulation and cellular immortalization, thus kickstarting the process of carcinogenesis. HPV mRNA testing is based on pooled detection of HPV E6/E7 mRNA from high-risk types of HPV.
The test is considered positive if HPV E6/E7 mRNA is above the detection threshold for any individual type or for multiple types. The Aptima TM mRNA assay does not separate out or give information on individual genotypes, such as HPV16/18/45. However, a separate assay is available that can be used to detect HPV16/18/45 among women testing positive on the pooled assay. It includes an internal control that monitors the presence of nucleic acid, and its processing and amplification. A result is considered negative when HPV mRNA in a sample is below the detection threshold and the internal control is positive. A result is considered positive when HPV mRNA in a sample is above the detection threshold, independent of the internal control result. Results are considered invalid when both HPV mRNA and the internal control are below the detection limit (10). Introduction

# Phased approach for development of updated recommendations and purpose of this guideline
Following the 2020 launch of the Global Strategy to accelerate the elimination of cervical cancer as a public health problem, a large panel of experts met to define the key areas of focus to increase access to screening and treatment to reach the 2030 targets. One of the agreed areas of focus was to update the existing 2013 WHO guidelines for screening and treatment of precancerous lesions for cervical cancer prevention (11), and to simplify the algorithms.
It was decided that WHO's updated cervical cancer screening and treatment guidance would be developed in four phases:

# Guideline objective:
To improve national strategies for screening and treatment to prevent cervical cancer in all women, including women living with HIV.
Updated recommendations on screening and treatment and the clinical algorithms for the most commonly used primary screening tests and triage strategies (HPV DNA tests, cytology and VIA) for both women in general (i.e. women who are presumed or confirmed to be HIV-negative) and those living with HIV. Phase 1 also addresses routine screening programmes, the ages at which to initiate and stop screening, and the frequency of screening.

# Phase 1
Evaluate the evidence and develop recommendations for the clinical algorithms using (a) HPV mRNA tests and (b) dual-stain cytology for the general population of women and for women living with HIV.

# Phase 2
Develop recommendations for the implementation of these screening and treatment strategies.

# Phase 3
Establish a consolidated "living guideline" for screening and treatment tests and algorithms (combining all the output from Phases 1-3), which will allow the recommendations to be updated as new evidence becomes available and is evaluated.

# Phase 4 Introduction
The output of Phase 1 was a guideline that was published and launched in July 2021, presenting a large set of recommendations and good practice statements, with a primary focus on the use of HPV DNA tests. For the rationale for the development of the new edition of recommendations for screening and treatment to prevent cervical cancer, please refer to section 1.3 of that guideline (12).
Since the HPV mRNA test is in clinical use as a recognized option for HPV nucleic acid amplification testing (NAAT), the GDG prioritized evaluating the evidence on HPV mRNA testing to make recommendations for its use. The objective in this phase of the guideline update was therefore to develop recommendations for the use of HPV mRNA detection as a primary screening test for cervical cancer prevention -both in the general population of women and in women living with HIV. In addition to evidence gathered for this update process, this guideline is also supported by evidence compiled in the IARC handbooks of cancer prevention: cervical cancer screening, Vol. 18, which considers HPV mRNA as a NAAT that can be used for cervical cancer screening (13, 14).
The clinical flowcharts for the algorithms presented in this guideline include HPV mRNA-based screening strategies and follow-up testing at 12 months post-treatment (see Annex 4). In the near future, the recommendations in this guideline will be integrated with the recommendations recently published in WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention, second edition ( 12), along with the outputs of the upcoming phase on dual-stain cytology screening and the forthcoming recommendations on implementation of screening and treatment strategies, to develop a full consolidated version of this guidance.

# Previous and existing WHO recommendations for screening and treatment to prevent cervical cancer and definitions
In 2006, WHO published Comprehensive cervical cancer control: a guide to essential practice (C4GEP), which was updated in a second edition in 2014 (15), consolidating all the recommendations for screening and treatment to prevent and treat cervical cancer up to that year. The consolidated C4GEP included the WHO recommendations for HPV vaccination, treatment of cervical cancer and pre-cancer lesions, and palliative care, as well as the recommendations from the previous edition (2013) of this guideline: WHO guidelines for screening and treatment of precancerous lesions for cervical cancer prevention (11). In 2019, WHO published guidance on the use of thermal ablation for treatment of cervical pre-cancer lesions (16), and in 2020, WHO published guidance documents to support the introduction and scale-up of screening and treatment interventions, specifically relating to HPV testing and relevant medical devices (17).
In the updated second edition of the recommendations on screening and treatment for cervical cancer prevention, two populations of women are referred to: women living with HIV and the general population of women, which refers to women who are presumed or confirmed HIV-negative, but whose HIV status may be unknown. In addition, two approaches to screening and treatment are distinguished, the "screen-and-treat approach" and the "screen, triage and treat approach". Introduction
In a screen-and-treat approach, treatment is provided based on a positive primary screening test alone, without triage (i.e. no second screening test and no histopathological diagnosis).
- When the patient is eligible for ablative treatment, this should ideally be done immediately, at the same visit as the screening test (the single-visit approach). At some facilities, this is not feasible and a second visit is needed (the multiple-visit approach).
- Women who are not eligible for ablation can have excisional treatment on the same day if the clinic has the capacity for large-loop excision of the transformation zone (LLETZ). 4 If LLETZ is not available on-site, women need to be referred for the excisional treatment or for further evaluation.
In a screen, triage and treat approach, the triage test is done if the primary screening test is positive, and the decision to treat is made when both the primary test and the triage test are positive.
- A positive triage test can lead to colposcopy with biopsy and histopathological examination for diagnosis to determine the appropriate treatment. The implementation of colposcopy and biopsy can be challenging, however, so this guideline also considers triage strategies that are not dependent on the availability of colposcopy.
- When the primary screening test is positive, and the triage test is negative, women need appropriate follow-up evaluation at a specified date according to the recommendations.
The publication of the output of Phase 1 of the update of the recommendations for screening and treatment to prevent cervical cancer (in July 2021) presented 23 recommendations and 7 good

# Screening and treatment approaches
- In the "screen-and-treat approach", the decision to treat is based on a positive primary screening test only.
- In the "screen, triage and treat approach", the decision to treat is based on a positive primary screening test followed by a positive second test (a "triage" test), with or without histologically confirmed diagnosis.
practice statements (12). Those recommendations focused mainly on the use of HPV DNA testing as the primary screening test. Table 1.2 provides a summary of the recommendations.
The full set of recommendations is provided in the 2021 publication, WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention, second edition (12), and also in Annex 5 of this guideline.

# Target audience
This document is intended primarily for policy-makers, programme managers, programme officers and other professionals in the health sector who have responsibility for choosing strategies for cervical cancer prevention, at country, regional and district levels. Health-care professionals -such as doctors, nurses and community health workers working in reproductive health programmes, antenatal and postnatal services, family planning services, HIV/AIDS control programmes and in clinics that care for women at the district and primary health care levels -may also consult this document to understand how recommendations are developed and why it is vitally important to select and implement evidence-based strategies to prevent cervical cancer.
This document will also be informative in an adapted form for women, girls and their families in making decisions about cervical cancer screening and treatment.

# Summary recommendation for the general population of women
Summary recommendation for women living with HIV WHO suggests using either of the following strategies for cervical cancer prevention among the general population of women:
 HPV DNA detection in a screen-and-treat approach starting at the age of 30 years with regular screening every 5 to 10 years.
 HPV DNA detection in a screen, triage and treat approach starting at the age of 30 years with regular screening every 5 to 10 years.

# WHO suggests using the following strategy for cervical cancer prevention among women living with HIV:
 HPV DNA detection in a screen, triage and treat approach starting at the age of 25 years with regular screening every 3 to 5 years. All individuals have the right to equality and non-discrimination in sexual and reproductive health care. In this guideline, we recognize that most of the available evidence on cervical cancer is based on study populations of cisgender women, and we also recognize that cisgender women, transgender men, non-binary, gender fluid and intersex individuals born with a female reproductive system require cervical cancer prevention services. However, to be concise and facilitate readability, we use the term "women" to refer to all gender diverse people at risk for cervical cancer. Sexual and reproductive health service providers and cervical cancer prevention services must consider the needs of -and provide equal care to -all individuals independently of gender identity or its expression.
This updated guideline has been developed in accordance with the methods described in the WHO handbook for guideline development, second edition (18). More detailed methods are described in the recent publication of the outputs of the first phase of the guideline update (12). Information in this section focuses on methods specific to this phase of the guideline update: HPV mRNA testing.

# Groups contributing to the guideline development process
Lists of all members of the Guideline Development Group (GDG), External Review Group (ERG), systematic review teams, modelling teams and other contributors are provided in Annex 1, with details of their expertise and affiliations. The WHO Secretariat consisted of staff from various relevant WHO departments, and staff from the International Agency for Research on Cancer (IARC). The Steering Group of the WHO Secretariat led the coordination of the development of this guideline. Members of the Secretariat who were not part of the Steering Group were kept informed of the guideline development process and participated in the discussions, in particular during meetings of the various teams.
For the evaluation of the evidence and formulation of recommendations relating to HPV mRNA testing, the GDG comprised 53 members (35 women, 18 men), from across all six WHO regions, including representatives from civil society organizations and women's groups, and women living with HIV. The members brought varied expertise on cervical screening and treatment. Two members acted as co-chairs and moderated the GDG meetings. An External Review Group (ERG) was also established to provide peer review for the guideline document. Its 18 members, none of whom was also a member of the GDG, had expertise in research, policy development, programme implementation and clinical care. Once the GDG had agreed on the recommendations, the ERG reviewed the full draft of the guideline and provided feedback.
Multiple teams prepared evidence relevant to HPV mRNA testing (see details in Annex 2).
- Two teams conducted evidence reviews relevant to HPV mRNA testing -one on test accuracy of HPV mRNA versus HPV DNA detection for CIN2+ and CIN3+, and one on longitudinal evidence for the use of HPV mRNA tests.
- One team developed the mathematical model relevant to HPV mRNA testing in the general population of women.
- One team ran a survey of the GDG members about the feasibility concerns relating to the priority screening algorithms (including but not limited to those involving HPV mRNA testing).

# Methods for development of recommendations on HPV mRNA testing
- One team surveyed women about their values and preferences (relating to HPV testing in general, covering both HPV DNA and HPV mRNA).
- Two teams conducted a systematic review of qualitative literature on values, preferences, acceptability and feasibility, and a review of reviews on acceptability, feasibility, resources and equity for the use of different screening tests.
A guideline methodologist with experience of using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach (19) coordinated the presentation of evidence and decision-making processes that facilitated the development of the recommendations, as stipulated in the WHO handbook for guideline development, second edition (18).

# Declarations and management of conflicts of interest
Each invited GDG member completed a written declaration of interest (DOI) form (including those who had previously completed them prior to participation in the first phase of the guideline update). The DOIs were reviewed by two members of the WHO Secretariat and no conflicts of interest were identified (Annex 3). At the beginning of every GDG meeting, members were asked to declare any potential new conflicts of interest.
Each GDG member also signed a confidentiality agreement at the beginning of the guideline development process, and the WHO Secretariat restated at the start of each GDG meeting that all discussions and draft recommendations were to remain confidential until publication.

# Scoping review and appraisal of the existing recommendations
The questions for HPV mRNA are based on the scoping review and the prioritization of research questions and algorithms for screening and treatment that was performed by GDG members in 2019 at the start of the process of updating the WHO recommendations on this topic. The key questions relating to HPV mRNA tests (see Table 2.1) followed a similar format to those assessed for the recently published outputs of the first phase of the guideline update, referring to both the general population of women and women living with HIV.

# Priority algorithms
Since screening and treatment can be done using different primary screening and triage tests, there are numerous possible combinations or algorithms. In December 2019, GDG members were surveyed to prioritize the screening and/or triage tests and the treatments that should be evaluated. Following this prioritization exercise, a subgroup of GDG members met to review the results from the survey and to agree on the algorithms to be prioritized. They reached a consensus to address seven priority algorithms in the first phase of the guideline update (see Annex 4 in that guideline, and to address the following four algorithms relevant to HPV mRNA testing for this phase of the guideline, as presented in Table 2.2. For detailed algorithms (clinical flowcharts) based on the recommendation in this guideline, see Annex 4.

# Table 2.2. The four algorithms considered
1 HPV mRNA as the primary screening test, followed by treatment Screen, triage and treat approaches:
HPV mRNA as the primary screening test, followed by VIA triage, followed by treatment 3 HPV mRNA as the primary screening test, followed by colposcopy triage, followed by treatment 4 HPV mRNA as the primary screening test, followed by cytology triage, followed by colposcopy and treatment PICO 3 Should women be followed up at 5 or 10 years after a negative or positive HPV mRNA result?
The GDG agreed that the outcomes previously identified for the 2013 first edition of this guideline (11) and for the 2021 guideline which presented the output of the first phase of the guideline update continue to be the most relevant outcomes for the new PICO questions; they are listed in Table 2.3. Adverse events were defined as outcomes that were a direct consequence of pre-cancer treatment and were grouped as one category, with the exception of preterm birth, which was considered a critical outcome.

# Syntheses of evidence
Evidence was synthesized for each PICO question according to the methods in the WHO handbook for guideline development (18), and the Cochrane handbook for systematic reviews of interventions (20). The literature review performed for the development of the IARC handbook of cancer prevention: cervical cancer screening, Vol. 18 (13) was also part of the evidence synthesized for the development of this guideline -details of this review and its methods have been published (14).
A systematic review of the relative diagnostic accuracy of HPV mRNA tests compared with HPV DNA tests for detecting CIN2+ and CIN3+ was also performed and published (21). The literature search was conducted from 1994 up to August 2020 in PubMed/MEDLINE, Embase and Scopus, and the references of included studies were also searched for additional sources of evidence. A random effects meta-analysis of the relative clinical sensitivity and specificity of HPV mRNA tests compared with HPV DNA tests was conducted. Further details about the methods are provided in that publication.
The certainty of the evidence from the systematic reviews, modelling and surveys was assessed using the GRADE methodology. The four levels of certainty of evidence are summarized in Table 2.4.

# Mathematical modelling
We used the Policy1-Cervix platform (developed by the Daffodil Centre, a joint venture between the University of Sydney and Cancer Council NSW, Australia), an extensively validated dynamic model of HPV transmission, vaccination, type-specific natural history, cancer survival, screening, diagnosis and treatment (22)(23)(24)(25)(26)(27)(28)(29)(30), to predict outcomes in women across all 78 low-and middle-income countries. The Policy1-Cervix model was one of three models used by the Cervical Cancer Elimination Modelling Consortium (CCEMC) to evaluate the impact of cervical cancer prevention interventions in 78 low-and middle-income countries (22,23). For the baseline analysis, we assumed that 70% of women attended screening at each routine screening event and 90% of women complied with follow-up. Outcomes were assessed over the lifetime of birth cohorts eligible for screening in 2030 onwards and included cervical cancer incidence and mortality, pre-cancer treatments, additional preterm deliveries as a result of pre-cancer treatment and cost-effectiveness.
A range of sensitivity analyses were considered, including a range of test performance assumptions for HPV mRNA tests. For the mRNA analysis, a specific validation exercise was performed to demonstrate that the Policy1-Cervix model predictions matched the available longitudinal information on the performance of HPV mRNA technology for cervical screening. Detailed methods for the mathematical modelling are presented in Supplementary material 13a, in Web annex A: syntheses of evidence (31).

# Values and preferences
The results from the systematic review performed for the first phase of the guideline update that addressed, among other considerations, the values and preferences of end-users, health-care providers and other stakeholders were also used to address these considerations in this phase.
The results of the literature review were compiled by study design and methodology, location and population, and presented to the GDG. The evidence was assessed using the GRADE-CERQual approach (Confidence in the Evidence from Reviews of Qualitative Research) 5 and confidence in the evidence was rated from very low to high in the summary of findings. This information was presented in evidence tables and in the evidence-to-decision (EtD) framework to inform the development of the recommendations by the GDG (see Web annex: EtD framework for mRNA testing for HPV), and the findings are also presented in Supplementary material 10, in Web annex A: syntheses of evidence (31).
For primary data, we also used the results of the voluntary and anonymous survey distributed via SurveyMonkey during the first phase of the guideline update. The survey was open to all women and girls aged 15 years and older, regardless of their prior cervical cancer screening or treatment status. The survey received approval from the WHO Ethics Review Committee and was run in English and French from 22 June to 18 September 2020. Awareness of the survey had been raised among a wide range of civil society groups through a webinar. The survey was also promoted through the Union for International Cancer Control and the WHO advisory group of women living with HIV, and shared through WHO regional focal points for Cervical Cancer Elimination Initiative.
The responses from the 561 respondents, including their qualitative responses to open-ended questions, were analysed. The detailed methods and results are available in Supplementary material 9, in Web annex A: syntheses of evidence (31).
Both the systematic review and the survey considered screening tests and HPV tests, but did not differentiate between HPV DNA and HPV mRNA tests as both are NAATs and the process from the client's perspective is similar. We therefore used this evidence to inform judgements for the recommendations for HPV mRNA testing.

# Feasibility, acceptability, resources and equity considerations
Due to the paucity of data related to these considerations for HPV mRNA testing, evidence for HPV DNA testing was used to inform judgements, as both tests are NAATs. This evidence came from (i) a survey of the GDG members and (ii) a review of reviews.
The survey of GDG members was administered via SurveyMonkey to assess the implementation feasibility considerations for all of the priority algorithms. The survey was developed using the context and implementation of complex interventions (CICI) framework (32). Each GDG member was asked about their level of concern about each algorithm being able to sustainably meet the large-scale goal of cervical cancer elimination. The following components of cervical cancer screening and management service delivery were queried separately according to the priority algorithm: demand generation, access to screening and the follow-up management of positives, workforce training, infrastructure development and maintenance, development and maintenance of the screening registry, and cost and integration with other priority health services. The considerations of the GDG members were assessed for the following eight stakeholder groups: health authorities at the national level, health authorities at the regional level, professional societies, providers at both the hospital and primary care levels, community health workers, clients (screened women) and the community. The detailed methods and results of the survey are provided in Supplementary material 11, in Web annex A: syntheses of evidence (31).
A review of systematic reviews of the acceptability, feasibility, resources and equity considerations for the use of different screening tests included systematic reviews published since 2010 that synthesized results from studies with quantitative or qualitative design. Further information about the methods and findings are provided in Supplementary material 12, in Web annex A: syntheses of evidence (31).

# Development of the recommendations
All the GDG meetings that focused on formulation of recommendations were held virtually. Tables to facilitate decision-making for recommendations -evidence-to-decision (EtD) tables -were produced by the guideline methodologist for each recommendation and circulated to the GDG members before each meeting. These tables included a summary of the evidence (benefits and harms), relevant values and preferences information, and other issues, including use of resources and cost, feasibility, equity and acceptability.
During the meeting, the EtD tables and evidence were discussed with the GDG. Following the meeting, the methodologist, systematic reviewers, modellers and WHO Steering Group assessed the GDG input and used it to write the recommendations.
Agreement on the recommendations was made by consensus during the GDG meetings, and the final written recommendations were then approved electronically. The responses solicited via email were either to approve, approve "with the following remarks" or not approve. The GDG had agreed that, if consensus could not be reached, a majority vote of 51% would have been accepted to make recommendations -yet the group did reach a consensus on all the recommendations.
Strong recommendations (worded as "WHO recommends") were made when all the desirable consequences of the intervention clearly outweighed the undesirable consequences in most settings.
Conditional recommendations (worded as "WHO suggests") were made when the desirable consequences of the intervention probably outweighed the undesirable consequences in most settings Table 2.5 describes how strong and conditional recommendations should be interpreted.
For information on important considerations for the recommendations, please refer to Chapter 3 of the published guideline which delivered the outputs of the first phase of the guideline update (12).

# Management of the external peer review
The draft guideline document was circulated to the External Review Group (ERG) for comment. The WHO Secretariat prepared a summary table with all ERG responses and sorted the comments by topic or section. The WHO Secretariat then reviewed the comments, which were minor wording changes, without any implications for the substance of the recommendations themselves, and the guideline document was finalized.

# For individuals
Most individuals in this situation would want the recommended course of action, and only a small proportion would not.
Formal decision aids are not likely to be needed to help individuals make decisions consistent with their values and preferences.
The majority of individuals in this situation would want the suggested course of action, but some may not.

# For health-care providers
Most individuals should receive the recommended course of action.
Adherence to this recommendation (when it aligns with national guidelines) could be used as a quality criterion or performance indicator.
Clinicians should recognize that different choices may be appropriate for different individuals and that clinicians must help each individual arrive at a management decision consistent with the individual's values and preferences.
Decision aids may be useful to help individuals make decisions consistent with their values and preferences.

# For policymakers
The recommendation can be adopted as policy in most situations.
Policy-making will require discussion and involvement of various stakeholders.

# Recommendations on HPV mRNA testing
In this present publication, only recommendations for the use of HPV mRNA testing are presented. For other recommendations, please refer to the July 2021 publication of the WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention, second edition (12), or to Annex 5 of this guideline.
In the general population of women, HPV DNA is the recommended primary screening test, but HPV mRNA detection may also be used.
When providing HPV mRNA testing, WHO suggests:
- providing it with or without triage;
- using samples taken by the health-care provider; and
- 5-year screening intervals.

# This is a conditional recommendation, based on low-certainty evidence.
- HPV DNA is the recommended screening test. Choosing the alternative option of HPV mRNA testing implies having the capacity to provide follow-up screening at 5-year intervals.
Note: No recommendation was made for using HPV mRNA in women living with HIV because evidence on the outcomes of using HPV mRNA detection applicable to this population was not identified.
For the detailed algorithms (clinical flowcharts) based on this recommendation, see Annex 4.
WHO suggests that HPV mRNA detection using samples taken by the health-care provider may be used as a primary screening test, either with or without triage, to prevent cervical cancer in the general population of women with regular screening every 5 years. Important considerations for the recommendations
Despite the similar cross-sectional sensitivity and specificity of HPV mRNA testing compared with HPV DNA testing, a conditional recommendation was made for the use of HPV mRNA as a primary screening test because the longitudinal evidence on HPV mRNA test performance is uncertain. Modelling data suggest that there may be similar reductions in cervical cancer cases and deaths when using HPV mRNA testing with or without triage compared with HPV DNA testing with or without triage. In addition, there may be fewer treatments for pre-cancerous lesions when using HPV mRNA testing. However, the evidence from the mathematical model is uncertain, as the predicted reductions in cases and deaths when using HPV mRNA testing overlap with the uncertainty intervals for those with HPV DNA testing, and the model validation was performed against limited longitudinal data. Some longitudinal data with follow-up of more than five years and a model trial validation exercise (based on follow-up at 4-7 years) suggest that the incidence of CIN3+ may be higher in women who were negative for HPV mRNA compared with those who were negative for HPV DNA. There also do not appear to be other reasons related to feasibility or resources in favour of selecting HPV mRNA testing rather than HPV DNA testing.
The evidence available did not include women living with HIV, and data from the general population of women was not applicable to that population. Therefore, no recommendation was made for women living with HIV.

# Summary of the evidence
The GDG considered evidence from cross-sectional and longitudinal studies, and from mathematical modelling of long-term outcomes. Well designed and implemented cross-sectional studies consistently found that compared with HPV DNA testing, the sensitivity of HPV mRNA is likely slightly lower and the specificity slightly higher at baseline: relative sensitivity and specificity for CIN2+ are 0.97 (95% CI: 0.95-1.00) and 1.03 (95% CI: 1.02-1.05), respectively, and for CIN3+ are 0.98 (95% CI: 0.95-1.02) and 1.03 (95% CI: 1.01-1.06), respectively (based on moderate-certainty evidence) (21). Few studies measured the longitudinal performance and performance over repeat rounds of screening with HPV mRNA tests. Some of the available long-term data suggest that women who test negative for HPV mRNA may have a higher subsequent incidence of CIN3+ than those who test negative for HPV DNA, especially when using longer screening intervals (5+ years), but the data are sparse and the findings are also inconsistent across studies (low-certainty evidence) (see Web annex: EtD framework for mRNA testing for HPV).
The model used data extracted from the cross-sectional studies in the systematic review on sensitivity and specificity and was validated against the available longitudinal evidence. The findings -based on low-certainty evidence -suggest that when comparing the long-term effects of repeated rounds of HPV mRNA testing with HPV DNA testing, when implemented programmatically at 5-year screening intervals, there may be up to 8-12% higher relative cervical cancer incidence and 6-8% higher cervical cancer mortality for those screened with HPV mRNA compared with HPV DNA tests. However, after considering uncertainties in observed HPV mRNA test performance in a sensitivity analysis, the predicted reductions in cases and deaths with HPV mRNA testing overlap with the ranges of uncertainty for HPV DNA testing (for detailed results, see Web annex: EtD framework for mRNA testing for HPV). The modelling evidence also suggests that the number of treatments for pre-cancer lesions may be lower than with HPV DNA testing strategies (27-33% fewer pre-cancer treatments), leading to lower costs (6-10% lower), although there are also uncertainties in these predictions, which are contingent on the available data.
When compared with VIA or cytology screening, HPV mRNA screening may result in greater reductions in cervical cancer incidence and mortality. There is very low-certainty evidence comparing samples taken by health-care providers with self-collected samples for HPV mRNA testing. Available data suggest that HPV mRNA testing performs worse with self-collected samples, and therefore the recommendation suggests samples taken by health-care providers (see Web annex: EtD framework for mRNA testing for HPV).
None of the studies reviewed contained information specifically for women living with HIV, and a separate analysis could not be performed. The GDG agreed that the agreed recommendation presented here does not apply to women living with HIV.
The GDG also considered whether there are advantages to using HPV mRNA testing over HPV DNA testing, and could not identify any advantages related to feasibility, acceptability, equity or resources, since implementation of HPV mRNA is similar to HPV DNA testing. The findings of the survey on values and preferences performed for the first phase of the guideline update were considered when formulating this recommendation. However, because collection of samples by health-care providers rather than self-sampling is suggested for HPV mRNA testing, the feasibility and acceptability of HPV mRNA testing may be different. The AptimaTM mRNA assay is the only HPV mRNA test that has been widely assessed to date. The prices of both HPV mRNA and HPV DNA testing are generally in the same range in high-income countries and both have similar equipment and training needs.
For both the general population of women and women living with HIV, although cross-sectional data were available for the general population of women, and were used to inform the evidence on HPV mRNA tests presented in this guideline, the GDG noted that more longitudinal data on the impact of HPV mRNA tests in screening programmes are needed. This includes follow-up and assessment of outcomes beyond five years in women who have been screened using HPV mRNA testing. More studies are also needed on the test outcomes, with comparison between self-sampling and provider-collected samples, because it is important for programmes to provide more options for screening and treatment. In addition, there is an urgent need for different assays to be validated, using each of the specific transport media.
There is currently a complete absence of data on the use of HPV mRNA tests among women living with HIV. With the need for more frequent screening in women living with HIV due to higher rates of recurrence of cervical pre-cancer lesions, screening tests with higher specificity like HPV mRNA tests could have the additional benefits of decreasing the number of cervical cancer treatments needed in a screen-and-treat approach and lowering costs. Therefore, trials comparing the screen-and-treat approach with the screen, triage and treat approach using HPV mRNA testing for primary screening are important to further understanding of these dynamics and of HPV mRNA test performance among women living with HIV -particularly in low-and middle-income settings where diagnostic and treatment capacities may be different from high-income settings.
Comparative longitudinal studies comparing HPV mRNA and HPV DNA screening tests are needed, particularly those that will enable calculation of test performance (sensitivity, specificity, positive predictive value, negative predictive value) against a reference standard of histological confirmation. Furthermore, longitudinal studies that assess outcomes among women living with HIV over longer periods of time, including with different screening intervals and collection techniques, will be important to ascertain the long-term benefits and risks of different screening tests and strategies.

# Research gaps and further considerations for HPV mRNA testing

# Guideline dissemination and impact
This recommendation will be integrated into a full consolidated version of WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention, second edition, along with the outputs of the next phases of the guideline update, in the near future.
In brief, the outputs of each phase and the final consolidated second edition will be disseminated using WHO's worldwide network to make sure that the guideline reaches health-care providers and programme managers so that the most recent evidence is integrated and accessible for clinical decision-making to prevent cervical cancer. The full dissemination strategy was approved for the second edition and includes dissemination on the WHO website and in the next edition of HRP News, and printed copies will be disseminated upon request to health ministries, WHO country and regional offices, WHO collaborating centres on cervical cancer, and other cervical cancer collaborators and partners. Policy briefs and an app will also be produced. The guideline will be translated into the six WHO official languages.
Dissemination plans also include partners involved in the implementation and roll-out of cervical cancer screening and treatment programmes. These include other United Nations agencies, the United States President's Emergency Fund for AIDS Relief (PEPFAR), the Global Fund and Unitaid.
WHO headquarters will work with WHO regional offices and country offices to ensure that countries will be supported in the adoption, implementation and monitoring of the guideline. For this purpose, regional workshops and webinars in different languages will be organized to present, discuss and plan guideline adaptation and implementation, as well as to update current national guidelines.
In addition, impact of the fully updated and consolidated second edition will be measured by developing and disseminating surveys for both health workers and clients, as was done during the guideline development on the topic of values and preferences. This will be done a year after release to assess any changes in country policies and national guidelines. This will also assess the reach of the guideline and ultimately its impact in changing practice.
Over the next year, WHO's Comprehensive cervical cancer control: a guide to essential practice, which was last published in 2014 (15), will be revised to provide an up-to-date and global consolidation of all recommendations to prevent cervical cancer.

# Dissemination and updating of the guideline

# Guideline update
Evidence for the sensitivity and specificity of the different tests addressed in the full updated guideline (including in this present guidance, focusing on HPV mRNA testing) and evidence on the impact of these tests on important outcomes is accumulating, and syntheses of this evidence are needed. These syntheses will be used in a continual process to develop new recommendations -as part of the "living guidelines" approach -in the final phase of the guideline update (33).
The GDG will continue to work with the WHO Secretariat in an ad hoc manner, so that the research gaps identified during the process can be addressed. The GDG anticipates that as data and experience with new screening tests and modalities advance, new recommendations will be needed through a living guideline process that is able to rapidly respond and evolve. 1. HPV mRNA as the primary screening test, followed by treatment Screen, triage and treat approaches:
- HPV mRNA as the primary screening test, followed by VIA triage, followed by treatment 3. HPV mRNA as the primary screening test, followed by colposcopy triage, followed by treatment 4. HPV mRNA as the primary screening test, followed by cytology triage, followed by colposcopy and treatment

# Screening and treatment approaches
- In the "screen-and-treat approach", the decision to treat is based on a positive primary screening test only.
- In the "screen, triage and treat approach", the decision to treat is based on a positive primary screening test followed by a positive second test (a "triage" test), with or without histologically confirmed diagnosis. Rows shaded in pink indicate that the recommendation or good practice statement is identical for both the general population of women (left column) and women living with HIV (right column). In other rows, the wording of the recommendations differs for each population. In existing programmes with cytology or VIA as the primary screening test, rescreening with the same test should be continued until HPV DNA testing is operational among both the general population of women and women living with HIV.
Good practice statement 34. As programmes introduce HPV DNA testing, use this test at the woman's next routine screening date regardless of the test that was used at prior screening.
In existing programmes with cytology or VIA as the primary screening test, rescreening with the same test should be continued until HPV DNA testing is operational among both the general population of women and women living with HIV.

# Good practice statement
HPV: human papillomavirus; VIA: visual inspection with acetic acid.
Rows shaded in pink indicate that the recommendation or good practice statement is identical for both the general population of women (left column) and women living with HIV (right column). In other rows, the wording of the recommendations differs for each population.

# For both the general population and women living with HIV

# Strength of recommendation and certainty of evidence
- Once a decision to treat a woman is made -whether from the general population of women or women living with HIV -it is good practice to treat as soon as possible within six months to reduce the risk of loss to follow-up. However, in women who are pregnant, good practice includes deferral until after pregnancy.
In circumstances when treatment is not provided within this time frame, it is good practice to re-evaluate the woman before treatment.

# Summary recommendation for the general population of women
WHO suggests using either of the following strategies for cervical cancer prevention among the general population of women:
- HPV DNA detection in a screen-and-treat approach starting at the age of 30 years with regular screening every 5 to 10 years.
- HPV DNA detection in a screen, triage and treat approach starting at the age of 30 years with regular screening every 5 to 10 years.

# Summary recommendation for women living with HIV
WHO suggests using the following strategy for cervical cancer prevention among women living with HIV:
- HPV DNA detection in a screen, triage and treat approach starting at the age of 25 years with regular screening every 3 to 5 years.