Cervical cancer is the leading cause of cervical cancer and is one of the most significant cancer morbidity and mortality prevention issues for women worldwide—primarily caused by human papillomavirus (HPV) infection. Oncogenic HPV types, especially HPV16 and HPV18, can cause a HPV infection that progresses into progressive cervical epithelial abnormalities that ultimately can become invasive cervical cancer. While most HPV infections are short-lived and resolve spontaneously, some HPV infections with high-risk HPV types may lead to abnormalities of normal cell regulation and the development of cervical intraepithelial neoplasia (CIN) to infiltrating malignancy. The past few years have also seen significant molecular insights into the importance of HPV oncoproteins (E6 and E7) to disrupt normal tumor suppressor pathways to drive transformation to malignancy. [1,2]

Although prevention, screening and treatment of precancerous lesions are largely possible, cervical cancer is a major health problem worldwide. Based on estimates from GLOBOCAN 2022, there were an estimated 662,044 new cases of cervical cancer and 348,709 deaths from the disease in the world in 2022, making cervical cancer the fourth most common cause of cancer morbidity and mortality in women worldwide. It disproportionately affects low and middle income countries where low vaccination coverage, low screening coverage, and low levels of diagnostic services and access to treatment are responsible for high incidence and mortality rates. This imbalance underscores the fact that cervical cancer is not just a biological disease – as it is a symptom of inequity in health care and in society.

HPV infection is a natural history of infection, which can be asymptomatic and cleared up or become persistent in a subset of women. The key factor in the progression to cervical precancer and cancer is persistence of high-risk HPV infection. HPV16 and HPV18 are especially significant because they play a significant role in the cause of cervical cancer. Abnormal cell-cycle regulation, loss of apoptosis, genomic instability and progressive epithelial transformation are consequences of viral integration and the subsequent expression of E6 and E7 proteins which interfere with p53 and retinoblastoma-related pathways. Persistent infection with HPV does not necessarily lead to cancer, however, and host immunity, age, smoking, reproductive factors, co-infections and other behavioral and environmental factors may affect persistence and progression. [2,4]

Prophylactic HPV vaccination has presented an important opportunity for primary prevention. HPVs appear to be very effective in preventing infection with vaccine targeted oncogenic HPV types when administered prior to exposure to the virus. New studies suggest that the timing of vaccination is a significant factor determining vaccine effectiveness, with the most effectiveness typically seen when vaccines are administered prior to HPV exposure. Evidence from the present time also supports the general inclusion of HPV vaccination in cervical cancer screening and treatment programmes, especially in low- and middle-income countries where services are lacking for cervical cancer prevention. [6] However, there are limitations in the efficacy of vaccination to eradicate the need for cervical screening: there is no vaccine to prevent infection with all oncogenic HPV genotypes, and many women who are currently eligible for screening were not born in time for cervical vaccination to be offered to them in adolescence.

Vaccination is of special relevance for Pakistan, where awareness and uptake of HPV vaccination is still limited. A recent cross-sectional study conducted with adults in Pakistan showed that while many adults indicated willingness to be vaccinated against HPV, few had previously been vaccinated, thus there was significant mismatching between vaccine willingness and uptake. In the same way, research among women in Pakistan has found that they have little knowledge of cervical cancer, HPV vaccine, and screening. The results highlight the need to consider HPV related knowledge, vaccination status, screening and infection rates at local health care venues.

The major method of secondary prevention is the screening for cervical cancer in which women with HPV infection and cervical pre-cancer can be identified before the development of invasive cancer. Cervical cytology or Pap smear testing has been used in the past and screening strategies are moving toward primary HPV testing due to its higher sensitivity for clinically significant cervical precancer. The WHO has recommended HPV DNA testing as the first line screening method and the need to properly triage and treat HPV-positive women. Cervical screening coverage has also been shown to vary widely across the world, and in areas with only less organized screening programmes and poor healthcare coverage, there is typically a lower coverage rate. [10]

HPV self-sampling is another key advancement that could enhance screening uptake in women who face challenges to traditional clinician-based screening. Self-sample can alleviate the worry about privacy, discomfort, transportation, cost, and trained health care workers. Recent data has shown that HPV self-sampling is an effective strategy to increase screening uptake, especially in hard-to-reach and underscreened populations. Its potential has special significance in low-resource settings, but it will need validated HPV assays, reliable laboratory services, and effective communication of results and follow-up pathways for it to be successful.

The importance of HPV genotyping has also been growing in cervical cancer prevention as the risk of progression to cancer differs between the different high-risk HPV types. The presence of HPV16 or HPV18 may help differentiate women who are at relatively higher risk from those with other oncogenic HPV. The recently revised HPV 2026 WHO guideline includes recommendations for limited and extended genotyping approaches, as a means of risk stratification and molecular triage of HPV-positive women. This is a trend towards every woman with HPV being treated on a case-by-case basis contingent on her risk level based on the HPV genotype.

The Pakistan context further reinforces the importance of locally-produced evidence. Recent studies have revealed significant gaps in cervical cancer knowledge, screening uptake and HPV vaccination awareness among women in Pakistan. These deficiencies likely have a role in the delayed presentation and missed opportunities for prevention. Local hospital based studies can help in determining the prevalence of high-risk HPV infection, distribution of HPV genotypes, prevalence of cervical cytology abnormalities, vaccination status, and inadequate screening factors. These results can guide health care providers to creating targeted education and screening interventions for particular groups of people.

The WHO global cervical cancer elimination strategy is based on the principle that elimination would need to be driven by simultaneous progress in vaccination, screening and treatment. The 90-70-90 goals are for 90% of girls to be fully vaccinated with HPV vaccine by age 15 years, 70% of women who are screened by high-performance screening between ages 35 and 45 years, and 90% of women with cervical disease to seek appropriate treatment. To reach these goals, it is not enough to have good technologies; other factors include the raising of public awareness, making healthcare services accessible to everyone, solid referral networks and follow-up care.

In this context, the present cross sectional observational study was conducted at Molvi Ameer Shah Women and Children Hospital, Peshawar to find out the prevalence of HPV in women who were attending the hospital and its association with certain demographic and clinical factors, past cervical cancer screening, HPV vaccination status, awareness, distribution of HPV genotypes and cervical cytological abnormalities. The aim of the study is to provide local evidence from a hospital-based population, which will help to develop better understanding of HPV-associated cervical cancer risk and better development of HPV vaccination, screening and prevention programs in the local context.

This was a cross sectional observational study conducted at Molvi Ameer Shah Women and Children Hospital, Peshawar from 01st September 2025 to 30th February 2026. During the study period, a total of 80 women who attended the gynecology outpatient department and cervical cancer screening services were enrolled. The sampling technique which was used was consecutive sampling. In the study, eligible women for cervical cancer screening, women with relevant gynecological complaints and women at risk for HPV infection were included. Women with a previous diagnosis of cervical cancer, women who had had a total hysterectomy with no further cervical surgery and women who refused to participate were excluded. Demographic data and clinical details were obtained with a structured questionnaire after informed consent was obtained. The variables were: age, marital status, place of residence, educational level, parity, age at marriage, age at first pregnancy, number of sexual partners, smoking and tobacco exposure, history of sexually transmitted infections, previous cervical screening, HPV vaccination status and gynecological symptoms. Data was also collected on previous pap smears and HPV testing, and HPV and cervical cancer awareness. The screening for cervical cancer was done using the diagnostic facilities available at the study hospital. Samples were taken of the cervix by experienced health care workers following standard sampling procedures, and hosted HPV testing and/or cervical cytology was conducted per available lab procedure. Samples were tested for the presence of HPV, and if HPV testing was available, samples were tested for high-risk HPV infection and genotype-specific results were recorded. Cervical cytology results were classified by the reporting system used, and women with abnormal screening results were referred for the appropriate gynecological assessment and management. WHO guidelines are currently recommending HPV DNA testing as a primary screening method of choice and support the use of HPV genotyping and triage depending on the level of healthcare infrastructure and follow-up capacity available. The main outcome of the study was the prevalence of high-risk HPV infection among the women enrolled. Other outcomes measured were HPV genotype distribution, abnormal cervical cytology results, prior cervical cancer screening, HPV vaccination status, awareness of HPV and cervical cancer and relationships between HPV positivity and selected demographic, reproductive, behavioral, and clinical risk factors. The data were entered into a statistical software package and analyzed using descriptive and inferential statistics. Categorical variables were reported as counts and percentages and continuous variables were reported using mean and standard deviation or median and interquartile range. The HPV status and categorical risk factors were compared by using the chi-square test or Fisher's exact test, as appropriate. A p-value of < 0.05 was statistically significant. Ethical issues were adhered to in the study. All participants signed informed written consent. The identities of participants were protected by anonymizing identifiers (study ID #) and data were only used for research. Women who had an abnormal screening test were appropriately counselled and referred for further diagnostic assessment and management.

A total of 80 women were included in the study conducted at Molvi Ameer Shah Women and Children Hospital, Peshawar, from September 2025 to February 2026. Participants' mean age was 38.6 ± 9.7 years, most of whom were in the 31–40 year age group (33.8%). The majority of respondents were multiparous (72.5%) and married (96.3%). 27.5% of women had previously received screening for cervical cancer and 10.0% had previously received HPV vaccination. 31.3% of the respondents were aware of HPV as a cause of cervical cancer. Descriptive data for the study population are shown in Table 1.

Table 1. Sociodemographic and Clinical Characteristics of Participants (n=80)

High-risk HPV infection was detected in 18 of the 80 participants, giving an overall prevalence of 22.5%. HPV positivity was highest among women aged 41–50 years (30.4%), followed by those aged 31–40 years (22.2%). HPV positivity was more frequent among women with three or more children, those without previous cervical screening, and those who reported low awareness of HPV. Among HPV-positive women, HPV16 was the most frequently identified genotype, followed by HPV18 and other high-risk HPV types.

Table 2. HPV Infection and Cervical Screening Findings

Abnormal cervical cytology was identified in 14 participants (17.5%). Abnormal cytological findings were considerably more common among HPV-positive women than HPV-negative women. Among the 18 HPV-positive participants, 8 (44.4%) had an abnormal cytology result compared with 6 (9.7%) of the 62 HPV-negative participants. This difference was statistically significant (χ²=11.36, p=0.001).

Table 3. Association Between HPV Positivity and Selected Risk Factors

A statistically significant association was observed between HPV positivity and absence of previous cervical screening (p=0.04) and between HPV positivity and low HPV awareness (p=0.03). Higher parity showed a tendency toward increased HPV positivity, although this association did not reach statistical significance (p=0.08). No statistically significant association was observed between age group and HPV infection (p=0.68). None of the eight vaccinated women tested positive for high-risk HPV; however, the small number of vaccinated participants limited meaningful statistical comparison.

There were 18 women with high-risk HPV (22.5%) and 62 were HPV-negative (77.5%) out of 80 women who were screened. HPV16 was the most common genotype-specific infection, and the other high-risk HPV types were the most common category among the HPV-positive participants. The vast majority of participants (81.3%) had negative cytology. A low grade abnormality (ASC-US and LSIL) was found in 15.1% of participants, and a high grade abnormality (HSIL) was found in 2.5%. Overall, the results showed that there was a strong association between high-risk HPV infection and abnormal cervical cytology, reinforcing the value of HPV testing and subsequent appropriate management of women at risk.

In the present cross-sectional study, 80 women were studied in Molvi Ameer Shah Women and Children Hospital, Peshawar and the prevalence of high risk HPV was found to be 22.5%. This discovery suggests that HPV infection rates are high among women who attended the study setting and highlights the need to augment cervical cancer prevention programs. The infection with HPV is the known cause of nearly all cases of cervical cancer, and infection with the high-risk genotypes (particularly HPV16 and HPV18) that persist in the cervix for a prolonged time are the most likely to lead to cervical precancer and invasive cancer. The predominance of HPV16 in HPV-positive subjects was observed and it is known to play an important role in cervical cancer. [16,17]

A small proportion of the women in this study (10%) reported previous HPV vaccination, reflecting low levels of vaccine uptake in this population. Due to the limited number of participants who were vaccinated, it is not possible to draw firm conclusions about vaccine effectiveness, but no woman was found to have a high risk HPV infection who had been vaccinated. Population-based data have shown that HPV vaccination programmes have resulted in significant decreases in HPV infection and HPV-related cervical precancer. The findings underscore the need to scale up adolescent HPV vaccine programmes in Pakistan, alongside community engagement to raise awareness and break down perceptions, vaccine uptake, availability, and cost.

One of the findings was that previous cervical cancer screening was very low with 27.5% of the participants having had a routine screening exam before. Women with no prior screening had a significantly higher proportion of being HPV positive compared to those who had previously had screening (27.6% vs. 9.1%; p=0.04). The discovery indicates that low participation in screening could play a role in the delayed detection of high-risk HPV and cervical pre-cancerous cells. The high sensitivity of HPV-based screening for clinically significant cervical precancer and the recommendations of WHO to proceed with HPV-based screening based on the availability of healthcare systems in place are preferred. [19]

The study also found that there was a significant correlation between HPV positivity and low awareness of HPV. Almost one-third of respondents had poor knowledge of HPV and HPV infection occurred significantly more frequently in participants with low knowledge (29.1%) than in participants with adequate knowledge (8.0%) (p=0.03). Limited knowledge, as revealed in the study of cervical cancer prevention, can have a detrimental effect on screening uptake and preventive health-seeking behavior. Educating the community on the issues of HPV transmission, HPV vaccination, cervical cancer risk, and cervical cancer screening services could therefore help to advance early detection and better prevention practices.

Self-sampling of HPV may be a useful approach to enhance screening uptake rates in populations with suboptimal screening rates. Systematic reviews have demonstrated that HPV self-sampling can significantly improve participation, especially among women who are not screened or would have difficulty attending health care facilities. Also, diagnostic evidence shows that validated HPV molecular assays on self-collected samples can yield clinically relevant results equal to clinician-collected samples. Self-sampling was not assessed in the current study but is highly relevant in places like Peshawar where cultural issues, lack of knowledge, transportation problems, and fear of pelvic examination, may diminish the uptake of traditional screening initiatives.

Abnormal cervical cytology was found in 17.5% of the participants, and the prevalence of abnormal cytological findings in HPV positive women was significantly higher than that of HPV negative women (44.4% vs. 9.7%, p=0.001). That this was a statistically significant association further supports the biological and clinical linkage between HPV persistence and a cervical epithelial abnormality. HPV testing can identify women at higher risk, and cytological assessment and other triage techniques can help distinguish those women with HPV who should undergo further diagnostic testing. Special attention should be paid to appropriate follow-up of women with an HPV test positive result, as it can significantly impact the success of cervical cancer screening and prevention programmes if not followed. [22]

Increasing clinical relevance of HPV genotyping. HPV16 positive samples were the most common in this case study, followed by HPV18 positive samples and other high risk HPV types. Genotype-specific risk assessment may be valuable to help identify women who need more immediate assessment and those who have a lower risk who may benefit from appropriate surveillance. Limited and extended HPV DNA typing are recognised as methods for enhancing risk stratification of HPV-positive women in the updated WHO guidelines. The use of advanced molecular technology is not the only criterion for using it for implementation however, other factors such as capacity of local laboratories, availability of colposcopy, treatment services and patient follow-up shall be considered.

However, higher parity was also more common among those with HPV-positive status, but this was not statistically significant (p=0.08). Therefore, this finding should be taken with a grain of salt. Likewise, age was not found to be significantly related to the HPV positivity (p=0.68). A lack of significance could be due to the limited sample size and the cross-sectional design of the study. However, larger multicenter studies with larger populations would be needed to clarify the independent role for demographic and reproductive factors in HPV infection in this context.

This study has important implications for cervical cancer prevention in Pakistan. An effective strategy should include HPV vaccination, low-cost HPV screening, mass education, proper triage and timely treatment of HPV-induced pre-cancerous lesions. The WHO framework for elimination stresses high vaccination coverage, screening coverage and treatment of women with cervical disease. In low-resource contexts, interventions that are simple, inexpensive and scalable, and can be integrated into current maternal and reproductive health care services need to be prioritized.

There were some limitations in this study. The sample size was small and the participants were selected from a single hospital and hence the results cannot be generalized to the larger population of females in Peshawar or Pakistan. The cross-sectional design also does not allow for the determination of any temporal or causal relationships between HPV infection and putative risk factors. Additionally, few women were vaccinated, so the association between vaccination and HPV positivity could not be assessed. These limitations do not detract from the value of these local data on HPV infection, screening, HPV vaccination uptake, awareness and cervical cytological abnormalities, and highlights the need for HPV prevention and screening services to be strengthened.

In the present cross sectional study of women (n=80), at Molvi Ameer Shah Women & Children Hospital Peshawar, Pakistan, the prevalence of high-risk HPV was 22.5%, with HPV16 as the most common genotype observed. Poor HPV awareness and no prior cervical screening were significant factors associated with high risk HPV infection, and women with HPV infection were significantly more likely to be found to have abnormal cervical cytology. Low HPV vaccine uptake and cervical cancer screening uptake reflect significant gaps in preventive health care. The results reinforce the necessity of a comprehensive cervical cancer prevention policy that integrates HPV vaccination, availability of HPV-based screening, risk-based assessment, follow-up of cervical abnormalities and timely management.

Recommendations

HPVs vaccines should be promoted in children through adolescent vaccination schemes, community education and increased access to low cost vaccination services. Use of HPV based cervical cancer screening should be extended, especially to women who have never been screened, and HPV self-sampling should be utilized where appropriate to enhance participation in screening. Referral and follow-up systems should be effective at healthcare facilities for women who are HPV positive and women who have abnormal cytology, with timely referral to colposcopy and treatment, if appropriate. HPV transmission, HPV vaccination, risk factors for cervical cancer, and the advantages of early screening should all be subjects of public education programs. HPV genotyping and HPV risk-based triage should be integrated into screening services if available in labs. Additionally, larger multi-center studies of different populations are suggested to assess the prevalence and genotype distribution of HPV infections and estimate local risk factors for cervical cancer.

Disclaimer:
Nothing to declare.

Acknowledgement:
The author thank the department medical staffs for their help and support. They keep patient record properly and managed the data carefully which helped in completing this research.