Performance of the cervical cancer screening program in Souss-Massa, Morocco: evidence for strategic transition toward HPV testing

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BACKGROUND: Cervical cancer remains a major public health concern in Morocco. Since 2012, the national program for early detection, based on visual inspection with acetic acid (VIA), has targeted women aged 30 to 49 years. This study assesses the program's performance in the Souss-Massa region in 2024, focusing on screening coverage, diagnostic quality, and therapeutic management. METHODS: A retrospective descriptive analysis was conducted across six provinces using routinely collected indicators: coverage of cervical screening by visual inspection with acetic acid (VIA), referral rate, colposcopy completion, treatment uptake, and histopathology outcomes. Data completeness was assessed, and adjusted coverage estimates were computed to correct under-reporting using proportional imputation. Analyses used both raw and adjusted data, with 95% confidence intervals (CI) and appropriate non-parametric or categorical tests. RESULTS: In 2024, 31,034 women were screened (crude coverage 7.07% [95% CI 6.99-7.15]). After under-reporting was adjusted for using proportional imputation - an exploratory correction given that 70% of the data was missing - the regional coverage was estimated at 28.85% (95% CI: 28.60-29.10). However, this figure should be treated as an illustrative estimate rather than a definitive programme indicator. Overall, 1,975 women were referred (referral rate 5.52% [95% CI 5.28-5.76]), 1,615 underwent colposcopy (completion 81.77% [95% CI 79.92-83.62]), and 330 cervical abnormalities were diagnosed (300 CIN1; 30 CIN2+), including 33 histologically confirmed CIN2 + when pathology was available. The CIN2 + detection rate was 1.04 per 1,000 women screened. Treatment uptake among women with diagnosed lesions was 44.85% [95% CI 39.33-50.37], with marked inter-provincial disparities. Only 0.58% of screened women were migrants. Statistically significant differences were observed between provinces for multiple indicators. However, these differences suggest an association with structural and organisational factors rather than indicating a causal relationship. CONCLUSION: Program performance in Souss-Massa remains below WHO-recommended thresholds for both coverage and treatment. Strengthening medicalization and workforce capacity, improving digital data systems, and piloting a transition to primary HPV testing - including self-sampling and a test-and-treat approach - are key priorities to improve equity and detection performance.

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