Title : Barriers limiting access to follow-up care after HPV screening for cervical cancer

Background: HPV-based cervical cancer screening, including HPV self-sampling, is being rapidly scaled worldwide to expand early detection of high-risk infections. However, the effectiveness of screening depends on timely diagnostic follow-up and treatment after a positive result. In many settings, follow-up systems remain fragmented or inaccessible, raising concerns that expanded screening may not translate into equitable cancer prevention. While barriers to HPV vaccination and screening uptake are well documented, less is known about the distinct emotional, practical, and structural challenges individuals face after receiving an HPV-positive result.

Methods: We conducted a systematic review following PRISMA 2020 guidelines (PROSPERO registration: CRD420251062691). We searched Medline, Embase, Scopus, and Web of Science for studies published between January 1, 2015 and May 28, 2025 that examined barriers to follow-up care after a positive HPV screening result. Quantitative, qualitative, and mixed-methods studies conducted globally among individuals with a cervix were eligible. Data were extracted on study characteristics, geographic setting, research team composition, and reported barriers. Methodological quality was assessed using the Mixed Methods Appraisal Tool. A narrative synthesis was conducted to identify and organize recurring barriers thematically.

Results: Fifteen studies from 12 global locations across Africa, Europe, North America, and South America met inclusion criteria. Barriers to follow-up occurred across multiple levels and were grouped into five domains: health system, knowledge and communication, psychological and emotional, social and relational, and structural and logistical barriers. Common challenges included delayed care, weak patient tracking systems, limited understanding of HPV results, fear and stigma, lack of partner or community support, transportation difficulties, financial constraints, and complex referral pathways. Local context strongly shaped how individuals interpreted results and navigated care. A notable strength of the literature was that all studies were conducted by local or locally partnered research teams, enhancing contextual validity.

Conclusion: As HPV self-sampling and HPV-based screening expand globally, identifying barriers to follow-up should not undermine screening efforts but instead guide targeted, system-level improvements. All individuals deserve timely knowledge of their health status, alongside accessible pathways to diagnostic evaluation and treatment. This review is the first to systematically synthesize global evidence on barriers to follow-up after an HPV-positive result and highlights the critical factors that must be addressed to ensure expanded screening translates into equitable and effective cervical cancer prevention.

Dr. Jessica Beetch is a Postdoctoral Fellow in the T32 Cancer Disparities Program at the University of Minnesota. Her research focuses on addressing viral exposure disparities related to cancer outcomes. She holds an MPH and a PhD in Epidemiology from the University of Oklahoma Health Sciences.