Co-testing with human papillomavirus (HPV) DNA testing plus liquid-based cytology is still used in parts of China, although many screening programmes are moving toward HPV-based strategies. We aimed to compare co-testing with HPV-based and cytology-only approaches in routine county services in resource-limited areas. We analysed a screening cohort of 33,387 women aged 35–64 years from four primary care sites. Because all women received both HPV testing and cytology, we reconstructed four strategies within the same population: co-testing, HPV primary screening with cytology triage, HPV-only, and cytology-only. For each strategy we estimated detection of cervical intraepithelial neoplasia grade 2 or worse (CIN2 + ), referrals for specialist examination of the cervix, and cytology workload per 1000 women screened. Here we show that co-testing detects 6.7 CIN2+ cases per 1000 women screened, compared with 6.5 for HPV primary screening with cytology triage, 4.3 for HPV-only, and 4.9 for cytology-only. However, co-testing requires more resources than HPV primary screening with cytology triage, including 33.1 additional colposcopy referrals and 888.8 extra cytology slides per 1,000 women screened, with little gain in detection. Cytology-only increases referrals while detecting fewer CIN2+ cases, whereas HPV-only reduces referrals but detects fewer CIN2 + . In resource-limited county programmes, HPV primary screening with cytology triage provides the most favourable balance between detecting cervical pre-cancer and limiting unnecessary procedures. These findings support transitioning from routine co-testing to HPV-based screening tailored to local capacity. Regular screening can prevent cervical cancers, but programmes must choose which tests to use. In parts of China, women still have both a human papillomavirus (HPV) test and a cervical cell test at the same visit, which increases workload. We studied 33,387 women from four county clinics where all women had both tests, and compared four ways of using these results. Here we show that doing both tests on everyone found almost the same number of important cell changes as using the HPV test first and then a cervical cell test only for HPV-positive women, but needed many more referrals and examinations. Cytology-only increased referrals while finding fewer problems, and HPV-only reduced referrals but missed some changes. In resource-limited areas, HPV-first screening with cytology triage offers the best balance between benefits and workload. Jia et al. compared the performance of 4 counterfactual screening strategies: co-testing, HPV primary with liquid-based cytology (LBC) triage, HPV-only, and LBC-only. They show that LBC-only detects fewer CIN2+ cases yet still increased referrals while HPV-only reduces referrals but had a lower CIN2+ detection rate.
Jia et al. (Thu,) studied this question.