There are three types of HPV vaccines, bivalent, quadrivalent and nine-valent, all of which have been proven to have good efficacy, longer-lasting protective effectiveness and benefits (10, 11). Bivalent HPV vaccine could significantly reduce the incidence of cervical intraepithelial neoplasia(CIN) grade 3 and cervical cancer (12). The relative reduction in the incidence of cervical cancer and CIN3 at age 12-13 was 87% and 97%, respectively. The incidence of invasive cancer can be greatly reduced by quadrivalent HPV vaccination, with vaccination before age 17 decreasing the incidence of invasive cancers to 0.12 (per 100,000 population). 1 dose of quadrivalent HPV vaccine in 10 years provides comparable protection efficacy against HPV16 and HPV18 with two and three doses of vaccination (13). The 9-valent vaccine has been shown to be equivalent to the quadrivalent in preventing the four types of HPV infections, as well as preventing five other types of HPV infections (14). In addition, HPV vaccination not only reduces the incidence of HPV16 and HPV18 infections, precancerous lesions and cervical cancer but also decreases the occurrence of genital warts and HPV-related tumors (15, 16).

HPV vaccination is influenced by a number of factors, and vaccination rates are limited on the global average. Only 55% of countries committing to eliminating cervical cancer have introduced HPV vaccination, and the HPV vaccination rate (calculated by world population)in 2019 was approximately 15% (17). HPV vaccination is impacted by trust in the vaccine, availability, price, etc (18). For example, the crisis of confidence in the HPV vaccine in Japan has led to very low vaccination rate (19). The HPV vaccination rate for adolescents in the United States in 2020 was 58.6%, with those below the poverty line having a higher rate than those above the poverty line (20). And this was associated with greater access to the childhood HPV vaccination program for those below the poverty line. Due to external funding support (21), Free HPV vaccination can be widely implemented in Rwanda with vaccination rates exceeding 90% (22).

Currently, the common screening methods are HPV testing, cytology screening and visual inspection with acetic acid and lugol iodine(VIA/VILI). Studies related to cervical cancer screening have focused the effectiveness of different screening techniques and triage strategies for HPV positive results (23, 24). Screening techniques that are often compared are HPV testing and cytology screening.

Cytological screening has been proven over decades to be effective in decreasing the incidence and mortality rate of cervical cancer (25–27). The advantages of this screening method are the relatively high specificity of the results due to diagnosis by professional pathologists and the relatively low price. Because of dependence on pathologists, cytology screening is not suitable for application and promotion in areas with insufficient health resources (28).

HPV testing has been shown to have good sensitivity and positive predictive value (29, 30), which is the first recommended method by WHO in the latest screening guidelines (31). Compared to cytology screening, HPV testing can provide 60-70% higher protective rate against invasive cervical cancer (32). An randomized controlled study showed that HPV testing was superior to cytological screening and VIA/VILI for detection of CIN2+ and CIN3+ (33). Another study in China with a population of approximately 1.16 million also confirmed that HPV testing was superior to cytology screening in detecting CIN2+ (34). Combined HPV testing and cytology screening provides better results than testing with either modality alone; however, the increased sensitivity compared to HPV testing alone is not obvious (35). HPV testing with HPV16/18 genotyping plus cytology triage can significantly improve CIN2+ detection rates by 34-36% in women aged 35-54 years compared to cytology screening (36).

In addition to screening technology, the willingness to utilize screening services also directly affects the effectiveness of cervical cancer prevention and control. Women’s health awareness, cognitive level, access to services, screening quality, follow-up management, and adequacy of funding for screening programs all influence the utilization of screening services (37). There are some differences in the factors influencing the utilization of cervical cancer screening services between developed and developing countries. In high-income countries, there are relatively few cases of non screening due to lack of access to screening, mainly due to lack of knowledge and health awareness (38). In contrast, women in most low- and middle-income countries (LMICs) have low levels of education, awareness, and access to screening. Utilization of screening services in many areas is affected by local sociocultural factors (39). These reasons contribute to regional disparities in cervical screening coverage, particularly low screening coverage in LMICs (40, 41).

Cervical cancer screening services have been transformed from nonexistent to available, but coverage remains limited. China’s cervical cancer prevention and control measures were conducted in 2009 and named the “two cancers” screening program, including breast cancer and cervical cancer. In addition, screening services have been integrated into basic public health services since 2019. Screening is free for all women aged 35-64 years, but due to factors such as insufficient funding and a large population to be screened, the state currently adopts the practice of providing a certain number of free screening services to rural women each year. Based on the official data from 2009 to 2020, the nationwide cumulative number of people screened for cervical cancer is approximately 130 million, while the number of people to be screened is much greater than that. The coverage of the current screening population is approximately 25.7%, and there is a huge gap in comparison to the requirement of over 70% coverage (50) ( Table 2 ). One study showed lower coverage rates in rural areas than in urban areas (55).

Table 2 Current status of cervical cancer prevention in China and the WHO targets

The affordability and accessibility of screening services are key factors impacting screening utilization by Chinese women (56), which further affects the coverage rate. Through a large-scale institutional survey, Li found that the capacity of LBC testing and pathology service provision in rural China is less than half of that in urban areas, with the most significant differences in pathology services (57). More importantly, according to the technology and efficiency of current screening, some may not be able to access one screening service for their lifetime. In addition, state financial assistance is far from sufficient to cover the cost of the program (58). Therefore, this will affect the quality of services provided by primary health facilities, which will also further affect women’s expectations and utilization of screening services. In terms of personal factors, income, health insurance, and health knowledge can also influence an individual’s utilization of services (59).

Domestic HPV vaccine production, development and vaccination are actively promoted, but coverage remains very low. There are three types of HPV vaccines: bivalent, quadrivalent and nine-valent, which became available in mainland China in 2016, 2017 and 2018, respectively, and all three vaccines are imported and self-funded (60). The bivalent domestic HPV vaccine became available in 2019 and is self-funded, and there are some high valent vaccines in clinical trials. HPV vaccination is not yet included in the National Immunization Program (NIP), which significantly affects the HPV vaccine coverage rate (61). The first city in China to carry out free HPV vaccination was Erdos, where the work started in August 2020 (62). Currently, more than a dozen cities are conducting HPV vaccination pilots. Most people need to make an appointment in advance and wait 3-6 months for vaccination services. It is often more difficult to make an appointment for the 9-valent HPV vaccine. The current HPV vaccination rate in girls aged 9-14 years in China is less than 5%, in contrast to the WHO vaccine coverage goal of over 90% (50) ( Table 2 ).

The main factors influencing HPV vaccination are awareness of the vaccine, the price of the vaccine, and the availability of the vaccine (61, 63, 64). These are related to the late production and development of vaccines (65). There is a lack of awareness and knowledge about HPV vaccination among Chinese people (66, 67), which is related to factors such as education, income and occupation. The awareness of those employed in health work is relatively high (68), but there is a gap compared to developed countries (69, 70). The literature shows that the population has a relatively high propensity for HPV vaccination, but the price dampens the demand for the vaccine (71). The domestic bivalent vaccine is priced at 329 RMB for one dose, and the full vaccination costs approximately 1000 RMB. The group with the best vaccination effect is junior high school students (72, 73), whose parents accept the price of domestic and imported vaccines at 130 RMB and 166 RMB, respectively, which is far below the market price of vaccines. Parental acceptance of the HPV vaccine could increase to 61.3% if the vaccine is incorporated into the NIP (74). Moreover, the HPV vaccine is in short supply due to the long production cycle and slow approval process (75). This shortage of supply is most evident in the 9-valent HPV vaccine.

Regarding the treatment rate of precancerous lesions, there was no significant difference between rural and urban areas. The treatment rates of CIN2/3 were 95% and 89% in urban and rural areas, respectively (50). Overall, treatment rates for rural and urban CIN2/3 are close to or have reached the WHO target. However, there is a gap in cervical cancer treatment coverage in China compared to developed countries (76). High treatment rates are not necessarily due to positive cervical cancer screening results that force patients to seek further treatment. Many women have already missed out on cervical cancer screening (77), and they seek health care and treatment when they are not feeling well. One study showed that at least half of patients with CIN1 were lost to follow-up (50). The management of cervical cancer prevention and control in China has not formed a closed-loop management of screening, follow-up and treatment, which requires the joint efforts of the government and institutions.

Strategic policies must be developed to promote cervical cancer prevention and control in a comprehensive manner. Cervical cancer prevention and control receive unprecedented attention and support from the Chinese government. Health has been made a priority development goal and integrated into all policies. Increasing cervical cancer screening coverage has become a policy goal, which is clearly stated in the Outline for Women’s Development in China (2021-2030) as well as in the Healthy China initiative (2019-2030) (78, 79). In 2023, the National Health Commission of the People’s Republic of China released an action plan to accelerate the elimination of cervical cancer, specifying the goals to be achieved by 2025 and 2030 (80). In the next step, the policy should focus on the evaluation of the effectiveness of prevention and control, especially the evaluation of the effectiveness of the coverage of the three measures.

Prevention and control measures should be integrated into basic public health services. Although modeling predictive analysis provides strategies to eliminate cervical cancer, health policies are required at the national level to ensure that interventions are widespread and sustained (81). In the WHO Global Strategy for the Eradication of Cervical Cancer, primary health care is repeatedly mentioned as the best way to address public problems (82). This means that cervical cancer interventions should be widely provided at the primary health care level, which would improve the accessibility of services.

High coverage of cervical cancer interventions is achievable. This is not entirely determined by national economic capacity, despite the relatively high coverage of interventions in high-income countries. Data from 2018 show that cervical cancer screening coverage in the United States is 80.5%, while the vaccination rate for adolescents is less than 40% (83). Rwanda has implemented a national cervical cancer screening program and included the HPV vaccine in its immunization schedule, and its HPV vaccine coverage has exceeded 90% (84, 85). Therefore, even with limited costs, China has the potential to achieve the 90-70-90 strategic goals.

As one of the countries committed to eradicating cervical cancer, cervical cancer screening is currently the focus of Chinese government interventions. Cytology screening is the main screening modality for cervical cancer in China, but it is difficult to meet the screening needs of a large-scale population. Cytology diagnosis relies on pathologists, and the lack of pathologists affects not only cytology screening services but also pathology biopsy services (57) Although HPV testing has the advantage of high sensitivity and relatively objective test results, further evidence is needed to support whether HPV testing can be performed on a large scale in China (86). To some extent, artificial intelligence-assisted cervical cancer cytology screening technology, which has emerged in recent years, avoids the disadvantages of the above two screening methods.

AI technology has a wide range of applications in early cancer screening, and it has shown strong potential in cytology screening (87, 88). It can greatly improve the efficiency of cervical cancer screening and reduce errors caused by subjective factors (89, 90). A study of 0.7 million people demonstrated an overall compliance rate of 94.7% between AI-assisted diagnosis and pathologists’ diagnosis (91), and the sensitivity of AI diagnosis was higher as the grade of cervical lesions increased (92). Other research has also proven the excellent diagnostic performance of AI technology (93, 94). More importantly, the speed of AI-assisted diagnostic cytology screening is geometrically increased compared to traditional cytology screening, which can help to rapidly enhance screening coverage in a shorter period of time.

AI screening can also improve the accessibility of screening services, especially in areas with poor economic levels. In other words, AI technology could greatly contribute to improving the equity of cervical cancer screening services. Technicians at the primary health service institutions simply take samples from the cervix, which are sent to a specialized laboratory. Then, the laboratory’s AI technology assists the specialist pathologist in reading the slides to make the final cytological diagnosis. AI technology can also be applied to colposcopic diagnosis, and it has shown good diagnostic performance and adaptability in less economically developed areas (95, 96). NIH has also indicated that AI can help improve cervical cancer screening, particularly in areas with insufficient health resources (97).

AI-assisted cytology screening not only has the good diagnostic performance described above but also has relatively low cost and adaptability to mass screening (98). AI-assisted cytology screening is not completely dependent on the pathologist and saves more labor costs than traditional cytology screening. In terms of the cost of consumables, AI-assisted cell screening is lower than HPV testing. In the National Free Cervical Cancer Screening Program, cervical cancer screening is priced at 49 RMB a case, which includes AI cytology screening, colposcopy, pathology biopsy, and follow-up visits.

Unlike HPV testing technology, AI-assisted cytology diagnostic technology has been widely used in China, especially in the national cervical cancer screening program. In addition to China, this new screening technology has been applied in Pakistan, and in the future, this technology will also benefit more countries along the Belt and Road. The province with the most extensive use of AI-assisted cytology screening in China is Hubei Province, which has the second highest incidence of cervical cancer among all provinces in China. Full coverage of cervical cancer screening in Hubei Province means approximately 12.67 million women, including all women aged 35-64 in urban and rural areas. For the first time, AI technology will make full cervical cancer screening coverage a reality in provinces with over 10 million women in a short period of time.

An HPV vaccination pilot should be promoted to advance HPV vaccination into the NIP. The biggest challenge to improving coverage is that the vaccine is not included in the NIP (61). The Chinese government also intends to gradually include the HPV vaccine in the NIP. The strategy to promote HPV vaccine inclusion in the NIP is to accumulate evidence and experience through a pilot approach to progressively expand HPV vaccination coverage to all target populations. Inclusion in the NIP includes two basic requirements: one is the availability of a cost-effective vaccine, and the other is that the cost of the vaccine is affordable to the government. For the first requirement, the domestic bivalent HPV vaccine has good protective efficacy (99), which creates more possibilities for HPV vaccination to be included in the NIP (100, 101). For the second requirement, free HPV vaccination should be encouraged for cities with good economic conditions. The government can give certain financial subsidies or explore multifunding models for less economically developed areas.

HPV vaccine inclusion in the NIP has boosted both vaccination and screening rates. Inclusion in the NIP means that the HPV vaccine could be made available to girls for free, which would directly reduce the impact of vaccine prices. Few crises of confidence or vaccine hesitation regarding HPV vaccination in China have been found in previous studies. Moreover, the inclusion of the vaccine in the NIP confirms the vaccine’s safety. Studies have also supported that HPV vaccination rates can be significantly increased if HPV vaccination is included in the NIP (64, 74). In addition, HPV vaccination helps increase women’s utilization of cervical cancer screening services (102), which can further reduce the probability of cervical cancer in this group of women.

The supply of vaccines should be increased to lay the foundation for higher vaccination rates. Furthermore, the approval process for HPV vaccination should be optimized to promote the supply of vaccines. The choice of experimental endpoint indicators affects the progress of approval and the supply of vaccines (103). The primary function of vaccines is to prevent disease rather than infection, so we often use disease as an endpoint indicator. Chinese regulators mainly use two indicators of persistent 12-month infection and CIN2+ lesions as endpoints. However, the WHO has used persistent 12-month infection and persistent 6-month infection as endpoints (104, 105). One study showed that there was little difference in HPV vaccine efficiency when HPV infection persisted for 12 months, when HPV infection persisted for 6 months, and when CIN2+ lesions were used as endpoints (106). Therefore, China should select appropriate endpoints based on WHO guidance and study results to increase the supply of vaccines, especially the availability of quadrivalent and nine-valent vaccines.

Health knowledge and awareness should be improved to promote the utilization of HPV vaccination services. First, knowledge dissemination efforts should be expanded. Knowledge of the HPV vaccine among adolescent girls and their parents can be promoted through campus and community outreach. It is also possible to follow examples of campus publicity and campus vaccination programs from developed countries. Second, the incorrect behavior of residents should be corrected. Many Chinese residents believe that the higher the valent of the vaccine, the more effective it is in preventing cervical cancer. Therefore, they choose to wait for the 9-valent vaccine and miss the optimal age for HPV vaccination. However, the WHO has emphasized in its HPV vaccination position paper that bivalent, quadrivalent and nine-valent vaccines have approximately equivalent effects in protecting against cervical cancer (107). The Chinese government needs to clearly promote the idea that girls should be vaccinated as soon as possible before they have sex.