Prevention and screening

Cervical screening - HPV primary testing

NZ transitioned to HPV primary screening in September 2023, six years after Australia. The core programme architecture is now closely aligned across both countries. The remaining divergences are in stopping age, post-treatment surveillance timing, and the clinical management of an overdue cohort who have never experienced the new pathway.

Reviewed May 2026 NSU NZ 2023 NCSP Australia WHO 2021

Scope: routine cervical cancer screening in people with a cervix, aged 25-70 (NZ). Includes triage pathways and post-treatment surveillance. Excludes management of confirmed cervical cancer.

Where they agree

HPV primary testing is the preferred screening method over cytology alone; the shift is supported by large RCT evidence showing superior detection of CIN2+ compared with cytology⁴
Start screening at age 25 (NZ and AU); test every 5 years if HPV negative
HPV 16/18 genotyping on all positive HPV samples; direct colposcopy referral if HPV 16 or 18 detected regardless of cytology result
Self-collected vaginal samples are as accurate as clinician-collected cervical samples for HPV detection⁵
Immunocompromised people and those with HIV require more frequent surveillance and earlier commencement of screening
HPV vaccination does not replace screening; vaccinated people must continue to participate in the programme

Where they diverge

Stopping age: NZ stops at 70 if two consecutive negative HPV tests; AU continues to 74; WHO recommends 65
Post-treatment surveillance interval: NZ HPV test at 6 months after treatment for high-grade lesions; AU HPV test at 12 months
Self-collection availability: NZ offered universally to all eligible people from September 2023 launch; AU initially restricted to under-screened, expanded to all eligible in July 2022
WHO recommends screening from age 30 in general populations (25 in HIV-positive) - a divergence from both NZ and AU starting age of 25
The NZ programme is 6 years newer than Australia's HPV primary programme; patient education and clinician familiarity with the new pathway are still consolidating

Comparison

Domain	NZ - NSU 2023	AU - NCSP	International - WHO 2021
Screening method	HPV primary testing since September 2023. Replaced cytology-based programme (the "smear test"). All samples tested for HPV first; liquid-based cytology (LBC) used only as a triage tool for non-16/18 HPV-positive results, not as the primary test.Funded	HPV primary testing since December 2017. Well-established programme; infrastructure and clinician familiarity are mature. LBC used as triage for other HPV-positive results, same pathway as NZ.Fully subsidised	WHO 2021 recommends HPV primary testing as the preferred method globally, replacing the "screen and treat" cytology approach. Acknowledges that in lower-resource settings, visual inspection with acetic acid (VIA) remains a pragmatic alternative where HPV testing infrastructure is unavailable.
Eligible population and starting age	All people with a cervix aged 25-70, regardless of sexual history, vaccination status, or whether sexually active. This includes transgender men and non-binary people with a cervix. Starting at 25 represents a change from the previous programme (which started at 20). Evidence supports this: HPV infection before 25 rarely leads to persistent high-grade dysplasia.	All people with a cervix aged 25-74. Includes the same populations (transgender men, non-binary people). Entry into the programme at 25 is well established. Previous cytology-based programme started at 18-20; the shift to 25 was part of the 2017 transition to HPV primary testing.	WHO recommends starting at 30 years in the general population (HIV-negative). Start at 25 years for people living with HIV. The younger starting age in NZ and AU reflects programme decisions based on population epidemiology and resource capacity rather than disagreement with the WHO evidence base.
Screening interval and stopping age	Interval: every 5 years if HPV negative. Stop at 70 years if the person has had two consecutive negative HPV test results (ie negative at age 65 and negative at age 70). If last screen was at or before age 65 and was negative, one further test at 70 before exit. People who have never been screened or who are overdue should be offered a screen at any age up to 70.	Interval: every 5 years if HPV negative. Stop at 74 years if the most recent test (within the last 5 years) was HPV negative. This is 4 years later than NZ. People aged 70-74 who are overdue are actively invited to participate. Exit from the programme occurs after a negative test at or after age 70.	WHO recommends every 5-10 years depending on resource setting and test used (HPV or VIA). Stop at 65 years with two prior negative HPV tests (or three negative cytology results within 10 years). The earlier stopping age reflects that CIN progression after 65 is uncommon in adequately screened women, and overdiagnosis risk rises.
Sample collection options	Two options, clinician's choice in consultation with the person: 1. Clinician-collected: cervical sample taken with a brush, placed in LBC medium. Can be collected by any trained clinician (doctor, nurse, nurse practitioner, midwife). 2. Self-collected: vaginal swab collected by the person, using a flocked swab inserted into the vagina (does not require a speculum). Tested for HPV only (no cytology on self-collected samples).	Same two options. Self-collection was initially restricted to people who were overdue for screening or had never been screened. From July 2022 it was extended to all eligible people, aligning with the NZ approach. The same technical note applies: self-collected vaginal samples are tested for HPV only. If HPV positive, a clinician-collected sample is required for reflex cytology (or direct colposcopy referral for HPV 16/18).	WHO strongly endorses self-collection as a strategy to reach underscreened and never-screened populations, particularly in lower-resource settings. Meta-analysis confirms HPV detection accuracy on vaginal self-collected samples is equivalent to clinician-collected cervical samples.⁵ WHO does not prescribe the method of collection, deferring to national programme implementation.
Self-collection as an equity strategy	NZ made self-collection available to all eligible people from programme launch in September 2023. This is not a second-class option restricted to overdue patients - it is an equally valid first-choice for anyone who prefers it. Offering self-collection proactively (rather than waiting until someone is overdue) is a deliberate equity strategy targeting the participation gap among Maori and Pacific women, who have historically lower screening rates and higher cervical cancer incidence and mortality.	Now available to all eligible people following the 2022 expansion. The Australian programme rolled out self-collection more gradually. The evidence for self-collection as an equity tool is well established in the Australian context, particularly for Aboriginal and Torres Strait Islander women and those in rural and remote settings.Expanded 2022	WHO identifies self-collection as a critical enabler for achieving 70% population screening coverage by 2030 (a target within the WHO 90-70-90 strategy for cervical cancer elimination). Systematic review evidence confirms self-collection increases participation among never-screened and underscreened populations.⁵
Triage pathway - HPV 16/18 positive	Refer directly to colposcopy, regardless of reflex cytology result. HPV 16 or 18 carries a high enough risk of CIN2+ (approximately 25-35% within 5 years) that cytology triage is not used in this group. This applies whether the sample was clinician-collected or self-collected. If self-collected and HPV 16/18 positive, a clinician-collected sample is not required before colposcopy referral.	Same pathway. Direct colposcopy referral for all HPV 16/18-positive results. This has been the Australian approach since 2017 and is a well-established clinical norm. No cytology triage step before referral for this group.	WHO endorses immediate treatment or colposcopy for HPV 16/18-positive results as part of a screen, triage, treat approach. In settings where colposcopy is unavailable, WHO supports immediate ablative treatment (thermal ablation or cryotherapy) for eligible lesions without colposcopy.
Triage pathway - other high-risk HPV positive (non-16/18)	Reflex liquid-based cytology (LBC) is performed on the same clinician-collected sample (co-testing). The cytology result then determines next steps: Normal LBC: repeat HPV test in 12 months. Low-grade cytology (LSIL): repeat HPV + LBC in 12 months. High-grade cytology (HSIL or worse): refer to colposcopy. If self-collected and non-16/18 HPV positive: clinician-collected sample required for reflex LBC.	Same reflex LBC pathway and the same cytology-based decision tree. No meaningful difference from NZ in this triage arm. Return intervals at 12 months for normal or low-grade cytology have been standard since the 2017 programme launch.	WHO recommends a triage step for non-16/18 high-risk HPV results using either cytology (where available) or a visual triage method (VIA). The principle - that not all HPV-positive results require immediate colposcopy - is consistent with NZ and AU approaches.
Post-treatment surveillance (test of cure)	After treatment for high-grade cervical intraepithelial neoplasia (CIN2 or CIN3, including CGIN): HPV test at 6 months post-treatment (clinician-collected sample with reflex LBC). If HPV negative at 6 months: repeat HPV test at 24 months, then return to 5-yearly routine screening if negative. If HPV positive at 6 months: manage as per triage pathway (genotype-directed).	HPV test (with reflex LBC) at 12 months post-treatment. This is the major practical difference from NZ in post-treatment management. If HPV negative at 12 months: annual HPV test for a further 2 years, then return to 5-yearly routine screening if all negative. The AU surveillance pathway after a negative test-of-cure is slightly more protracted than NZ's.	WHO recommends HPV testing at 6 months after treatment, aligning with the NZ approach. If negative: test at 12 months, then return to 5-yearly screening. WHO's post-treatment pathway reflects the evidence that persistent HPV detection at 6 months is a strong predictor of treatment failure and residual/recurrent CIN.
Special populations	Immunocompromised / HIV: commence screening when sexually active (regardless of age). Annual HPV testing for 2 years; if both negative, 3-yearly until age 70. If HIV-positive and CD4 count below 200 cells/microlitre, manage with gynaecology input. Post-hysterectomy: if complete hysterectomy with no previous high-grade CIN or cervical cancer: no further screening required. If previous CIN2+ or cervical cancer: vault LBC at 6 and 18 months post-surgery, then 5-yearly to age 70. DES exposure in utero: annual vault LBC regardless of HPV results. Refer to gynaecology if not already under surveillance.	Similar special population pathways. Immunocompromised: annual co-test (HPV + LBC) for first 2 years; then 3-yearly if negative. Post-hysterectomy: same logic as NZ (no vault testing if no prior high-grade dysplasia or cancer). DES exposure: annual cytology.	WHO emphasises that immunocompromised people, including those with HIV, require more frequent screening and should be a priority for programme outreach. WHO does not provide specific post-hysterectomy or DES guidance in the 2021 document, deferring to national implementation.
Colposcopy referral thresholds	Refer to colposcopy if: HPV 16/18 positive (any cytology), or other HPV positive with HSIL or worse on LBC, or persistent non-16/18 HPV positive at 12-month follow-up with any cytological abnormality, or any HPV-positive result after treatment. Colposcopy is free for all eligible people referred through the programme. Ensure referral includes the HPV result, genotype, and LBC result on the referral letter.	Same referral thresholds. Colposcopy is subsidised through the public health system. NCSP manages a national colposcopy register; all colposcopies performed on programme participants should be registered.	WHO recommends colposcopy as the standard triage and diagnostic step in adequately resourced settings. In settings where colposcopy is not available, WHO supports screen-and-treat strategies using ablative therapy (thermal ablation, cryotherapy) for eligible lesions without histological confirmation.

NZ clinical context

NSU 2023 programme and population-specific considerations

The September 2023 transition: what changed

NZ's move to HPV primary testing in September 2023 brought three fundamental changes that need active communication with patients:

It is no longer called a smear test. The term "cervical screen" or "HPV test" is preferred. The old "smear" framing referred to the Pap smear cytology method, which is no longer the primary test. Using "smear test" with patients now creates confusion about what the test does.
The test is now every 5 years, not 3. Many patients and some GPs still carry the old 3-year cytology interval in their heads. A longer interval is appropriate with HPV primary testing because a negative HPV result confers greater reassurance than a negative cytology result.
Self-collection is available to anyone who wants it. It is not a fallback for difficult examinations or non-compliant patients - it is an equally valid option for anyone. Offering it proactively at every recall opportunity will make a material difference to participation rates, particularly for Maori and Pacific women.

Many women who were mid-interval on the old cytology programme will have been transitioned at their next due date. By 2026, the majority of newly presenting screenees should be on the new pathway, but expect to see older women who have been on extended intervals from good cytology results and who may not have received updated education.

Maori and Pacific women: the participation gap and its consequences

Cervical cancer is not an evenly distributed disease in NZ. Maori women are approximately 2.5 times more likely to be diagnosed with cervical cancer and around 3 times more likely to die from it compared with non-Maori non-Pacific women.⁷ Pacific women have similarly elevated rates. The major driver is not differential HPV biology - it is lower screening participation, later-stage diagnosis, and inequitable access to follow-up and treatment after abnormal results.

In a primary care consult, this means:

Check the cervical screening register status of every Maori and Pacific woman aged 25-70 at every relevant encounter, not just at dedicated screening appointments.
Offer self-collection proactively - do not wait for a patient to ask. The evidence suggests that offering self-collection increases uptake among previously unscreened women.
For women who have a colposcopy referral, actively support attendance: the drop-off rate between referral and attendance is a known failure point, and it disproportionately affects Maori and Pacific women.
Ensure abnormal results are communicated clearly and that the patient understands what the next step is - not just that "something was found."

HPV vaccination and screening: they are not substitutes

NZ introduced the school-based HPV vaccination programme in 2008 (girls) and expanded to boys in 2017. The vaccine (Gardasil 9) protects against HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58 - covering approximately 90% of cervical cancer-causing HPV types. However:

Vaccinated people must continue to participate in cervical screening. The vaccine does not cover all oncogenic HPV types, and people vaccinated as teenagers may have had prior HPV exposure.
Many women currently being screened were too old to receive the vaccine, or received an older vaccine formulation with narrower coverage.
Do not use a history of HPV vaccination as a reason to defer or deprioritise screening. Make this explicit with patients who believe vaccination makes screening unnecessary.

Who is eligible: inclusive language in practice

The NZ programme is for all people with a cervix aged 25-70. This includes transgender men and non-binary people who have a cervix. In practice, some transgender men are incorrectly excluded from recall systems because their gender marker has been updated to "male" in the enrolment database without a corresponding note about cervical screening eligibility. Check cervical screening status at any encounter where it is clinically appropriate, regardless of how the patient's gender is recorded. Ask rather than assume.

Bottom line for NZ practice

What this means in the consulting room

Every eligible person aged 25-70 with a cervix should be offered a cervical screen every 5 years. Check the screening register at opportunistic encounters - do not wait for a dedicated screening appointment. The old 3-year interval no longer applies.
Offer self-collection to every patient as a genuine first-choice option, not a fallback. A vaginal swab taken privately, without a speculum, is as accurate as a clinician-collected cervical sample for HPV detection. Removing the barrier of the speculum examination is likely to be the single most effective thing a primary care clinician can do to improve participation among previously unscreened women.
If HPV 16 or 18 is detected, refer to colposcopy regardless of the cytology result. Do not wait for cytology to come back abnormal before referring - the genotype alone is sufficient.
After treatment for high-grade CIN, the NZ test-of-cure HPV test is at 6 months, not 12. This is a meaningful difference from Australian guidance. Make sure this is communicated clearly at the time of treatment and documented in the plan.
For Maori and Pacific women, treat every relevant consult as a potential screening opportunity. Check the register. Offer self-collection. Follow up abnormal results actively. The participation and outcome gaps are real and addressable at the primary care level.

Sources

National Screening Unit. The National Cervical Screening Programme guidelines. Wellington: Ministry of Health; 2023. Available from: nsu.govt.nz
Australian Government Department of Health. National Cervical Screening Programme: guidelines for the management of screen-detected abnormalities, screening in specific populations and investigation of abnormal vaginal bleeding. Canberra: Cancer Australia; 2022. Available from: cancerscreening.gov.au
World Health Organization. WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention. 2nd ed. Geneva: WHO; 2021.
Ronco G, Dillner J, Elfstrom KM, et al. Efficacy of HPV-based screening for prevention of invasive cervical cancer: follow-up of four European randomised controlled trials. Lancet. 2014;383(9916):524-32.
Arbyn M, Verdoodt F, Snijders PJ, et al. Accuracy of human papillomavirus testing on self-collected versus clinician-collected samples: a meta-analysis. Lancet Oncol. 2014;15(2):172-83.
Kyrgiou M, Athanasiou A, Paraskevaidi M, et al. Adverse obstetric outcomes after local treatment for cervical preinvasive and early invasive disease according to cone depth: systematic review and meta-analysis. BMJ. 2016;354:i3633.
Ministry of Health. Cancer: new registrations and deaths 2020. Wellington: Ministry of Health; 2023.