Objectives. A “screen-and-treat” cervical cancer prevention program for low-resource regions is now possible because an HPV test has been designed for such settings. Practitioners will visually triage women testing positive (HPV+) to either immediate treatment with cryotherapy or referral for advanced care when women have suspect cancer, large precancerous lesions, or benign abnormalities that risk failure. Before adopting this strategy, we need to know how many HPV+ women are not treatable by cryotherapy and whether practitioners can accurately identify these women.

Methods. Among 559 HPV+ women aged 25-55 at enrollment in a 10,000-woman population-based Costa Rican cohort, we estimated the proportion not treatable by cryotherapy. Two lead reviewers evaluated a complete, 7+ years, longitudinal series of clinical histories including cervigrams (cervical images) and merged their evaluations. They assessed treatability by cryotherapy versus need for referral for advanced care. Using an Internet-based evaluation tool, 12 Peruvian midwives and 5 international gynecologists simulated an unmagnified and magnified “visual triage” exam in the same women by evaluating only enrollment cervigrams. Accuracy was measured by comparing evaluations with lead reviewers' consensus.

Results. Lead reviewers determined 144 (25.8%) of 599 HPV+ women overall and 73 (48.3%) of 151 HPV+ women requiring treatment, as not treatable by cryotherapy. Almost all HPV+ women (554) had a readable enrollment cervigram. Midwives and gynecologists correctly judged 61.4% and 66.1% of 139 women determined not treatable by lead reviewers. Of 413 determined treatable by lead reviewers, midwives and gynecologists correctly judged 79.4% and 67.2%, respectively. Accuracy to judge women not treatable did not improve among women requiring treatment. Magnification did not improve performance. Compared with triage, restriction of HPV screening to the most important HPV types would have led to equal numbers of women receiving cryotherapy among women requiring treatment, while reducing unnecessary treatment.

Conclusions. Because many HPV+ women with precancerous lesions are not treatable by cryotherapy and practitioners have difficulty identifying them, screen-and-treat programs using cryotherapy might be ineffective at treating precancerous lesions, instead “treating” low-risk women. Other safe, low-technology treatment methods are needed. A possible alternative is a more specific test for only the most important HPV types.