Efficient high-risk human papillomavirus screening through pooled testing: a simulation study based on real-world data in low- and middle-income countries

Background: The World Health Organization recommends high-risk human papillomavirus (hrHPV) testing as the primary method for cervical cancer screening. Combining samples in a pool can reduce the expense associated with large numbers of commercially available tests. This study simulated the potential test-saving impact of pooled hrHPV testing using real-world data from two low- and middle-income countries (LMICs). Methods: We simulated a two- and three-stage hrHPV pooling in Bangladesh (hrHPV prevalence 2.10%) and Uganda (hrHPV prevalence 22.52%) using real-world laboratory data. Measurements included the number of tests per stage, the total number of tests, and the percentage of tests saved. We performed sensitivity analysis to assess the impact of a 1.00% loss of sensitivity and specificity per additional sample in the pool on the false-negative rate (FNR). Results: In Bangladesh, the two-stage strategy (eight samples per pool) and the three-stage strategy saved 71.21% and 77.21% of tests, respectively, compared to testing individually. In Uganda, the two-stage strategy (three samples per pool) reduced the number of tests by 15.34% compared to testing individually. Assuming loss of sensitivity and specificity due to pooling, the FNR was higher (FNR = 0.012-0.134) when hrHPV prevalence was low under the two-stage strategy. Conclusions: Pooled hrHPV testing has the potential to reduce the number of tests used and enhance screening capacity in resource-limited settings. Notably, a lower prevalence of hrHPV allows for more efficient pooled testing. Despite the potential loss of sensitivity and specificity, pooled hrHPV testing could offer benefits for LMICs and warrant further verification.