The present pilot implementation study demonstrates that HPV-based cervical cancer screening using self-sampling can be initiated and maintained in a conflict-affected setting with high uptake, timely laboratory processing and appropriate referral of women at highest risk. Despite the absence of an organised screening programme prior to the war and substantial operational constraints, including population displacement, infrastructure disruptions and limited clinical capacity, fewer than 0.7% of eligible women declined participation. These findings indicate that self-sampling is both acceptable and feasible in settings where traditional clinic-based screening is difficult to implement.

At any given time, a substantial proportion of the global population lives in settings affected by war or active military conflict.(13, 14) Achieving global cervical cancer elimination therefore requires screening strategies that remain functional under wartime conditions, rather than assuming stable health systems. In this context, the present study provides rare implementation evidence showing that HPV self-sampling–based screening can be sustained during an active war, with high uptake, timely laboratory processing and effective referral of women at highest risk.

Participant feedback further supports the acceptability of self-sampling. All recorded feedback was positive, with women frequently describing the procedure as comfortable, fast and easy. While feedback was collected as part of routine care and may be subject to social desirability bias, the consistency of responses aligns with extensive evidence from stable settings demonstrating a strong preference for self-sampling.(7)The absence of negative feedback should be interpreted cautiously but nonetheless suggests high user acceptability in this context.

Screening uptake was high across recruitment channels, and HPV positivity was detected in all sample collection settings, demonstrating the ability of decentralised approaches to reach women who may otherwise remain unscreened. The overall prevalence of HPV (9.1%) and the higher positivity observed among women aged 30–39 years are consistent with patterns reported in other populations and reinforce the importance of targeting younger adult women for screening initiation.(15)

An important operational finding was the difference in kit return rates by setting and distribution model. When self-sampling was performed on site, either at outpatient clinics or during community outreach activities, or when kits were taken home after clinic-based distribution, sample return was complete. In contrast, nearly one fifth of kits distributed in refugee centres were not returned. This finding highlights the vulnerability of screening approaches that rely on delayed or unsupervised kit return in highly mobile populations, rather than a limitation of home-based self-sampling itself. The results support simplified, single-visit screening models in humanitarian and displacement settings, where population mobility and competing priorities may undermine multi-step pathways. Similar challenges have been reported in other low-resource and fragile contexts, where attrition increases when screening requires repeated contacts or delayed sample return.(16–18)

For security reasons and prioritisation of limited clinical resources, the screening pathway was intentionally designed to minimise multiple visits and triage steps. By directly referring only women positive for HPV16/18, immediate follow-up was required for just 3.8% of screened women, while women positive for HPV31/33/35/45/52/58 could safely be scheduled for later repeat testing. All women who tested positive for HPV16 or HPV18 were contacted and referred for specialist follow-up. Among those who completed colposcopic assessment within the study period, all were seen within the predefined two-month window, and no high-grade lesions were identified. Follow-up was incomplete for women diagnosed later in the enrolment period, largely reflecting population mobility and the timing of the data cut-off rather than failures in referral or care pathways. These findings demonstrate that linkage to care for women at highest risk can be achieved under wartime conditions when referral pathways are clearly defined and actively managed. At the same time, they highlight the potential value of further shortening diagnostic and treatment pathways, through rapid testing, same-day triage, or co-location of services, to minimise loss to follow-up in highly mobile and insecure settings.

Operationally, the screening pathway remained functional despite intermittent electricity and internet outages. Median turnaround time from self-sampling to availability of results in the digital platform was approximately six days, indicating that laboratory processing and reporting can be achieved within clinically meaningful timeframes even in insecure environments. Temporary adaptations, including manual registration during infrastructure disruptions, did not result in loss of samples or data, underscoring the importance of flexible, low-tech contingencies in fragile health systems.

This study has several strengths. It provides rare real-world data on cervical cancer screening implementation during active conflict, integrates external laboratory quality assurance, and evaluates the full screening pathway from recruitment to follow-up. However, limitations should be acknowledged. The study was not designed to formally compare recruitment channels or screening modalities, and sample sizes in some subgroups were small. HPV assays used locally were not formally validated for primary screening, although external proficiency testing demonstrated acceptable analytical performance. Feedback data were brief and qualitative, and more in-depth qualitative assessments are currently under preparation.