Female genital schistosomiasis epidemiology and clinical manifestations

Schistosomiasis is a neglected tropical disease (NTD) caused by infection with parasitic trematodes of the Schistosoma (S) genus, with 700 million people at risk globally (Buonfrate et al., Reference Buonfrate, Ferrari, Adegnika, Russell Stothard and Gobbi2025). Schistosomiasis can be broadly divided into two clinical syndromes depending on the location of the adult worms; intestinal schistosomiasis mainly caused by S. japonicum and S. mansoni, and urogenital schistosomiasis caused by S. haematobium. FGS is a morbidity associated with urogenital schistosomiasis caused when eggs of S. haematobium become trapped in the female reproductive organs. Chronic disease can result in infertility, ectopic pregnancy, and chronic inflammation (Lamberti et al., Reference Lamberti, Bozzani, Kiyoshi and Bustinduy2024).

FGS is mainly associated with urogenital schistosomiasis, which is endemic to SSA, parts of the Middle East, and the southern European island of Corsica (Boissier et al., Reference Boissier, Grech-Angelini, Webster, Allienne, Huyse, Mas-Coma, Toulza, Barré-Cardi, Rollinson, Kincaid-Smith, Oleaga, Galinier, Foata, Rognon, Berry, Mouahid, Henneron, Moné, Noel and Mitta2016). It is estimated that between 20 and 56 million women globally are affected by FGS, although challenges in the availability and accuracy of diagnostics make it difficult to make a robust estimate of the global burden (World Health Organisation, 2022).

S. haematobium eggs are highly antigenic, triggering granuloma formation which may later turn into fibrotic scar tissue which does not resolve even after the egg has been destroyed (Kjetland et al., Reference Kjetland, Leutscher and Ndhlovu2012; see Figure 1). Early symptoms of FGS include unusual vaginal discharge, genital itching, coital pain. and contact bleeding (Bustinduy et al., Reference Bustinduy, Randriansolo, Sturt, Kayuni, Leutscher, Webster, Van Lieshout, Stothard, Feldmeier, Gyapong, Rollinson and Stothard2022). The severity of symptoms is linked to the intensity of the S. haematobium infections leading to increased egg deposition, which may be exacerbated by reinfection. When left untreated, chronic FGS can lead to sub-fertility, infertility, and an increased risk of ectopic pregnancy even after the S. haematobium infection has been cured (Kjetland et al., Reference Kjetland, Leutscher and Ndhlovu2012). Additionally, there is some evidence of association between FGS and cervical pre-cancer (Rafferty et al., Reference Rafferty, Sturt, Phiri, Webb, Mudenda, Mapani, Corstjens, van Dam, Schaap, Ayles, Hayes, van Lieshout, Hansingo and Bustinduy2021; Sturt et al., Reference Sturt, Omar, Hansingo, Kamfwa, Bustinduy and Kelly2025). The diagnosis of FGS is complex and not readily accessible in most endemic settings (Bustinduy et al., Reference Bustinduy, Randriansolo, Sturt, Kayuni, Leutscher, Webster, Van Lieshout, Stothard, Feldmeier, Gyapong, Rollinson and Stothard2022).

Figure 1.

Colposcopy images of characteristic FGS pathology, including (A) Grainy sandy patches; (B) Homogenous yellow patches; (C) Rubbery papules; (D) Abnormal blood vessels; and (E) Severe contact bleeding (Figure adapted from UNAIDS, 2019).

One of the major challenges in FGS diagnosis is that symptoms overlap with those associated with sexually transmitted infections (STIs) and other gynaecological conditions (Bustinduy et al., Reference Bustinduy, Randriansolo, Sturt, Kayuni, Leutscher, Webster, Van Lieshout, Stothard, Feldmeier, Gyapong, Rollinson and Stothard2022). This can result in women not seeking medical interventions and can impart stigma on the sufferer if misdiagnosed (Engels et al., Reference Engels, Hotez, Ducker, Gyapong, Bustinduy, Secor, Harrison, Theobald, Thomson, Gamba, Masong, Lammie, Govender, Mbabazi and Malecela2020).

Female genital schistosomiasis diagnosis

FGS diagnostics vary widely depending on the setting and resources available. The simplest form of FGS diagnosis is based on associated symptoms in combination with the routine diagnosis of S. haematobium infections, typically by urinary egg microscopy (Lamberti et al., Reference Lamberti, Bozzani, Kiyoshi and Bustinduy2024). However, symptoms are non-specific and urinary egg microscopy has low correlation with genital lesions.

Other diagnostic methods including urine-based NAATs (Cnops et al., Reference Cnops, Soentjens, Clerinx and Van Esbroeck2013) and antigen tests for circulating anodic antigen (CAA; Hoekstra et al., Reference Hoekstra, van Dam and van Lieshout2021) have been used to confirm infection with S. haematobium as a proxy method of FGS risk with unclear link to genital track involvement. More specific methods are needed to accurately diagnose FGS and monitor levels of pathology and associated morbidity (Bustinduy et al., Reference Bustinduy, Randriansolo, Sturt, Kayuni, Leutscher, Webster, Van Lieshout, Stothard, Feldmeier, Gyapong, Rollinson and Stothard2022).

The specific diagnosis for FGS currently necessitates either visualizing the cervix directly or taking cervicovaginal samples such as swabs or cervicovaginal lavage (CVL) for Schistosoma egg or DNA retrieval (Sturt et al., Reference Sturt, Webb, Francis, Hayes and Bustinduy2020). In low-resource settings, visualizing the cervix through colposcopy to detect FGS-associated lesions is the most common diagnostic method (Lamberti et al., Reference Lamberti, Bozzani, Kiyoshi and Bustinduy2024). However, colposcopy is limited as it requires highly trained personnel to conduct the procedures and identify FGS-associated lesions. Furthermore, visual identification lacks specificity, expert agreement between diagnoses remains poor, and not all cases present with lesions (Bustinduy et al., Reference Bustinduy, Randriansolo, Sturt, Kayuni, Leutscher, Webster, Van Lieshout, Stothard, Feldmeier, Gyapong, Rollinson and Stothard2022; Sturt et al., Reference Sturt, Bristowe, Webb, Hansingo, Phiri, Mudenda, Mapani, Mweene, Levecke, Cools, van Dam, Corstjens, Ayles, Hayes, Francis, van Lieshout, Vwalika, Kjetland and Bustinduy2023). Current developments in equipment, such as hand-held colposcopes and artificial intelligence-aided diagnostic technology, aim to make colposcopy more accurate and more accessible to women in low-resource areas (Lamberti et al., Reference Lamberti, Bozzani, Kiyoshi and Bustinduy2024).

NAATs that specifically detect S. haematobium eggs or DNA, typically based on PCR, have been performed using different genital samples including CVL (Kjetland et al., Reference Kjetland, Hove, Gomo, Midzi, Gwanzura, Mason, Friis, Verweij, Gundersen, Ndhlovu, Mduluza and Van Lieshout2009), operator-collected cervical swabs (Ursini et al., Reference Ursini, Scarso, Mugassa, Othman, Yussuph, Ndaboine, Mbwanji, Mazzi, Leonardi, Prato, Pomari, Mazigo and Tamarozzi2023), and cervico-vaginal self-swabs (Sturt et al., Reference Sturt, Webb, Francis, Hayes and Bustinduy2020; Shanaube et al., Reference Shanaube, Ndubani, Kelly, Webb, Mayaud, Lamberti, Fitzpatrick, Kasese, Sturt, Van Lieshout, Van Dam, Corstjens, Kosloff, Bond, Hayes, Terris-Prestholt, Webster, Vwalika, Hansingo, Ayles and Bustinduy2024). Isothermal assays utilizing LAMP and RPA have been developed more recently (Gandasegui et al., Reference Gandasegui, Fernández-Soto, Carranza-Rodríguez, Pérez-Arellano, Vicente, López-Abán and Muro2015; Archer et al., Reference Archer, Patwary, Sturt, Webb, Phiri, Mweene, Hayes, Ayles, Brienen, van Lieshout, Webster and Bustinduy2022) demonstrating that molecular diagnostic assays can maintain high levels of sensitivity and specificity while being suitable for low-resource settings. While NAATs are likely more specific and sensitive than colposcopy, older lesions where the causative eggs has already degraded will not be DNA-positive, so may be missed if DNA amplification methods are used in isolation. This is especially relevant for FGS as lesions persist even when there is no active S. haematobium infection.

Female genital schistosomiasis treatment and management

Schistosomiasis can be treated with praziquantel, a drug that kills the adult worms in the blood vessels. Distribution of praziquantel by mass drug administration (MDA) is the primary form of control of schistosomiasis in endemic areas. Although people in endemic regions often become re-infected, regular treatment is essential in limiting symptoms and preventing morbidity (Faust et al., Reference Faust, Osakunor, Downs, Kayuni, Stothard, Lamberton, Reinhard-Rupp and Rollinson2020).

There is limited evidence from small studies, and only one randomized controlled trial, that indicates that praziquantel has limited action against FGS lesions (Arenholt et al., Reference Arenholt, Randrianasolo, Rabozakandraina, Ramarokoto, Jøker, Kæstel Aarøe, Brønnum, Bundgaard Nielsen, Sørensen, Lumholdt, Jensen, Lundbye-Christensen, Jensen, Corstjens, Hoekstra, van Dam, Kobayashi, N and Leutscher2024). Therefore, diagnosis should be coupled with other approaches to case management to improve patient outcomes. With the increasing awareness of FGS, it is now recognized that it is essential that schoolgirls, female adolescents, and women of all ages in S. haematobium endemic areas, receive praziquantel treatment regularly to prevent FGS or help reduce the risk of high levels of associated morbidity (Engels et al., Reference Engels, Hotez, Ducker, Gyapong, Bustinduy, Secor, Harrison, Theobald, Thomson, Gamba, Masong, Lammie, Govender, Mbabazi and Malecela2020; Lamberti et al., Reference Lamberti, Bozzani, Kiyoshi and Bustinduy2024).

Human papillomavirus epidemiology and clinical manifestations

HPV is one of the most common STIs worldwide; over 80% of sexually active individuals will acquire HPV at least once in their lifetime (Chesson et al., Reference Chesson, Dunne, Hariri and Markowitz2014). Up to half of infections clear within 6 months and approximately 90% clear within two years after acquisition (Plummer et al., Reference Plummer, Schiffman, Castle, Maucort-Boulch and Wheeler2007). Over 200 genotypes have been identified, 40 of which affect the genital tract. HPV genotypes are classified into low-risk (non-oncogenic) and high-risk (oncogenic) types based on their potential to cause cancer. Persistent infection with any of the known 14 HR-HPV types can result in the development of cervical cancer (International Agency for Research on Cancer, 2022; Wei et al., Reference Wei, Georges, Man, Baussano and Clifford2024; see Table 1).

Table 1.

Over 200 types of HPV have been characterized, 40 of which are associated with genital tract infections. Fourteen are classified as high-risk as persistent infections can lead to cervical cancer, while other low-risk types are associated with genital warts

^a These are the most common.

Carcinogenicity varies by genotype with HR-HPV types 16 and 18 contributing to 70% of all cervical cancers, and a further 6 HR types (31, 33, 35, 45, 52 and 58) contributing to an additional 10% of all cervical cancers (International Agency for Research on Cancer, 2022; Wei et al., Reference Wei, Georges, Man, Baussano and Clifford2024). There is some geographic variation in the prevalence of different HR-HPV types. For example, HPV 45, 35 and 52 were found to be more common in African women diagnosed with cervical cancer than European, North American, or Chinese women (Wang et al., Reference Wang, Liang, Yan, Bian, Huang, Zhang and Nie2024), although HPV 16 and 18 remained responsible for the majority of cervical cancer.

SSA has the highest HR-HPV prevalence globally at 24% (Bruni et al., Reference Bruni, Serrano, Roura, Alemany, Cowan, Herrero, Poljak, Murillo, Broutet, Riley and de Sanjose2022) and the highest global burden of cervical cancer (Singh et al., Reference Singh, Vignat, Lorenzoni, Eslahi, Ginsburg, Lauby-Secretan, Arbyn, Basu, Bray and Vaccarella2023). Moreover, cervical cancer is the leading cause of cancer death in sub-Saharan African women (Sung et al., Reference Sung, Ferlay, Siegel, Laversanne, Soerjomataram, Jemal and Bray2021).

HR-HPV prevalence has been linked to sociological factors including stigma regarding women’s health (Kutz et al., Reference Kutz, Rausche, Gheit, Puradiredja and Fusco2023a) and high human immunodeficiency virus (HIV) prevalence (Clifford et al., Reference Clifford, de Vuyst, Tenet, Plummer, Tully and Franceschi2016). Difficulties accessing the HPV vaccine, difficulties accessing condoms, and a lack of sexual health education also contribute to high HR-HPV prevalences (Tchouaket et al., Reference Tchouaket, Ka’e, Semengue, Sosso, Simo, Yagai, Nka, Chenwi, Abba, Fainguem, Perno, Colizzi and Fokam2023).

HR-HPV infection often first presents as cervical intraepithelial neoplasia (CIN), abnormal changes in the cervical cells (see Figure 2). CIN is currently graded on a scale of 1–3, measured by the area of the cervix that the abnormal cells cover. Other than the visual cell disruption, CIN can be completely asymptomatic, leading to delays in treatment. This is especially problematic as CIN can develop into cervical cancer.

Figure 2.

Cervixes with progressively advanced stages of cervical intraepithelial neoplasia (CIN), associated with HR-HPV and the precursor to cervical cancer. The blue ring highlights where pathology is concentrated. (A) CIN 1; (B) CIN 2; and (C) CIN 3. (Figure adapted from Sellor. JW and Sankaranarayanan. R, Colposcopy and Treatment of Cervical Intraepithelial Neoplasia: A Beginner’s Manual, Sellors, Reference Sellors and Sankaranarayanan2003).

Human papillomavirus diagnosis

HPV NAATs allow detection of HR-HPV infections before cervical precancer develops. Routine cervical cancer screening using HR-HPV NAATs, visual inspection or cervical cytology followed by treatment of precancerous lesions where necessary is highly effective at preventing cervical cancer (World Health Organisation, Reference Organisation2021). It is recommended for women aged 30 years and over for the general population, and 25 years and over for those with HIV (World Health Organisation, Reference Organisation2021). Visual inspection using acetic acid (VIA), is the most common diagnostic method in low resource settings, but the method lacks sensitivity and specificity to detect cervical precancer (Arbyn et al., Reference Arbyn, Gultekin, Morice, Nieminen, Cruickshank, Poortmans, Kelly, Poljak, Bergeron, Ritchie, Schmidt, Kyrgiou, Van den Bruel, Bruni, Basu, Bray and Weiderpass2021).

HR-HPV NAATs are recommended in primary screening over VIA or cytology because it has higher sensitivity and specificity to detect cervical precancer risk. Both clinician-collected and self-collected cervico-vaginal swabs can be used for HPV detection (Arbyn et al., Reference Arbyn, Gultekin, Morice, Nieminen, Cruickshank, Poortmans, Kelly, Poljak, Bergeron, Ritchie, Schmidt, Kyrgiou, Van den Bruel, Bruni, Basu, Bray and Weiderpass2021).

Human papillomavirus and cervical cancer prevention

An important facet of HPV control is vaccination, aimed at reducing HR-HPV infections and so reducing the risk of HPV-related cervical cancer. Globally, the uptake of the HPV vaccine remains lower than the WHO target of 90% of 15-year-old girls (Han et al., Reference Han, Zhang, Chen, Zhang, Wang, Cai, Li, Dai, Dang, Chen and Zhu2025). Vaccine uptake is lowest regionally in SSA, with a pooled uptake of only 28.53% (Bruni et al., Reference Bruni, Serrano, Roura, Alemany, Cowan, Herrero, Poljak, Murillo, Broutet, Riley and de Sanjose2022).

Disparities remain in screening coverage (screened at least once in a lifetime) between high-income countries, with average screening coverage of 88%, and low-income countries at only 15% (Bruni et al., Reference Bruni, Serrano, Roura, Alemany, Cowan, Herrero, Poljak, Murillo, Broutet, Riley and de Sanjose2022). This low coverage is exacerbated in SSA countries due to a lack of organized cervical cancer screening programmes (Anaman-Torgbor et al., Reference Anaman-Torgbor, Angmorterh, Dordunoo and Ofori2020).

Human papillomavirus molecular diagnostic DNA regions

NAATs for HPV have been in development since the 1980s (Saraiya et al., Reference Saraiya, Steben, Watson and Markowitz2013). At least 264 distinctive commercial molecular tests were available as of December 2023 (Poljak et al., Reference Poljak, A, Cuschieri, Bohinc and Arbyn2024). Despite the high number of available tests, the same target regions of the HPV genome are employed (see Table 2). This is partially due to the HPV genome being relatively small at 7900–8000 kb and having a limited number of genes suitable for molecular diagnostic targets. The HPV genome is divided into 3 major regions – the early gene-coding region (E), the late gene-coding region (L) and the long control region (LCR; see Figure 3).

Figure 3.

Structure of the HPV genome (figure taken from D’Abramo and Archambault, Reference D’Abramo and Archambault2011). The L1 and L2 genes encode for the major and minor capsid proteins respectively. The E6 and E7 genes are oncoproteins.

Table 2.

Widely used molecular targets in HPV diagnostic assays

L1 and L2 are not expressed at a consistent level throughout the virus lifecycle, with expression being highest in the final stage, during virion formation (Kirk and Graham, Reference Kirk and Graham2024). E6 and E7 are known as oncoproteins as their activity is responsible for cells becoming oncogenic as a by-product of the virus hijacking the cell molecular machinery. When E6 and E7 are rendered inactive, oncogenic cells senesce or undergo apoptosis (Yamato et al., Reference Yamato, Yamada, Kizaki, Ui-Tei, Natori, Fujino, Nishihara, Ikeda, Nasu, Saigo and Yoshinouchi2008; Jabbar et al., Reference Jabbar, Abrams, Glick and Lambert2009).

Due to the strong connection of E6 and E7 gene expression with oncogenicity, with expression increasing as infection develops into cervical precancer and then cervical cancer (Pal and Kundu, Reference Pal and Kundu2020), these genome regions are often used for HR-HPV detection. Additionally, as the E6/E7 regions are linked with disease progression, these regions can be used to identify patients at risk of cervical precancer or cancer in quantitative assays (Zhang et al., Reference Zhang, Du, Du, Duan, Yao, Jing, Feng and Song2024).

Human papillomavirus polymerase amplification/ assays

Similarly to FGS, RPA/RAA is being explored as suitable low-resource HPV diagnostic platform (see Table 4 for HR HPV RPA assays). However, as HPV is a global pathogen prevalent in high-resource areas, there is less research focus into the development of low-resource NAATs in comparison to a disease such as schistosomiasis.

Table 4.

Published Recombinase Polymerase Amplification/Recombinase Aided Amplification assays for high-risk human papillomavirus with the purpose of risk assessment for cervical cancer. Adapted from (Ying et al., Reference Ying, Mao, Tang, Fassatoui, Song, Xu, Tang, Li, Liu, Jian, Du, Wong, Feng and Berthet2023)

^a Viral genomic DNA Extraction Kit (Bioteke).

^bQIAamp DNAminikits (Qiagen).

^cMaxwell RSCVR ccfDNA plasma kit (Promega).

^dQIAamp Viral DNA.

^e Automated extraction machine.

^f Reverse blot hybridization-based assay.

No, number; Prep., preparation; Se., sensitivity; LoD, limit of detection; Sp., specificity; Ref., reference; CS, cervical swab; CB, cervical biopsy; CT, cervical tissue; NI, not included; Syn., synthetic; LF, lateral flow device; RDB, reverse dot blot; GE, gel electrophoresis.

Due to high number of HPV types, there has been significant development in multiplex RPA assays for HR-HPV. NAATs testing for 34 types, defined in the paper as 20 HR and 14 LR, simultaneously have been developed (Wongsamart et al., Reference Wongsamart, Bhattarakasol, Chaiwongkot, Wongsawaeng, Okada, Palaga, Leelahavanichkul, Khovidhunkit, Dean and Somboonna2023). This level of multiplexing was achieved through the innovative detection of both E6/E7 and L1. Both targets had one forward primer, but the L1 target had 2 reverse primers and the E6/E7 target 4 reverse primers, allowing for the selection of different types. The assay proved specific and did not cross react with common bacteria, viruses, and mammalian cells. However, a sensitivity of only 75% for DNA detection all 34 HPV types was achieved, which may have been a result of the primer design which allowed for high levels of multiplexing. The target product profile (TPP) of HPV DNA molecular diagnostics required by the WHO requires a sensitivity of 90–98% for CIN2+ or greater (World Health Organisation, 2024).

Most HR-HPV RPA NAATs target fewer types with a focus on the most oncogenic, typically HPV 16, 18 and occasionally 45. They also focus on achieving higher sensitivity and applicability to low-resource settings. An RPA assay targeting HPV 16 and 18 individually achieved a clinical sensitivity of 97.6–98.5% and specificity of 100% when tested on 335 liquid-based cytology samples extracted using a commercial extraction kit (Viral genomic DNA Extraction Kit) (Bioteke, China) (Ma et al., Reference Ma, Fang, Wang, He, Dai, Lin, Su and Zhang2017). Ma et al. continued development, multiplexing the assay to detect 25 total HPV types – 12 HR and 13 LR. The assay was tested using plasmids containing the cloned HPV target sequences prepared using a simplified DNA extraction method that involved the addition of a lysis buffer and heating (Ma et al., Reference Ma, Fang, Lin, Yu, Sun and Zhang2019). The analytical sensitivity was lower in the 2019 assay, at a limit of 10²/μL−1 of gDNA, than in the 2017 assay at 0.1 fg/μL (Ma et al., Reference Ma, Fang, Wang, He, Dai, Lin, Su and Zhang2017, Reference Ma, Fang, Lin, Yu, Sun and Zhang2019). This reduction in analytical sensitivity is often seen in NAATs with high levels of multiplexing. This should be kept in consideration as higher sensitivity for HR-HPV types only may be more beneficial clinically than lower sensitivity for a broader range of HPV types.

CRISPR technology has been extensively used alongside RPA assays in HPV diagnostic assays (Tsou et al., Reference Tsou, Leng and Jiang2019;  Gong et al., Reference Gong, Zhang, Wang, Liang, Li, Liu, Xue and Tang2021; Ying et al., Reference Ying, Mao, Tang, Fassatoui, Song, Xu, Tang, Li, Liu, Jian, Du, Wong, Feng and Berthet2023) with an aim of increasing sensitivity and specificity. Cai et al.’s use of a CRISPR/Cas12a dual-chamber ‘one-pot’ (DROPT) system, targeting HPV 16/18 had both high sensitivity at 100% and specificity of 95.8% when compared against PCR (Cai et al., Reference Cai, Zhuang, Yu, He, Wang, Hu, Li, Li, Zhou and Huang2024). This shows concordance between the DROPT system and PCR. The DROPT system is a one-pot test, and so does not require other large laboratory equipment, which would make it more suitable for field diagnostics. However, issues regarding reliable cold-chain transportation and the extensive extraction process needed for CRISPR Cas technologies means assays utilizing them remain generally unsuitable for low-resource diagnostics.

Alternative assay designs, such as the use of tailed primers (Chang et al., Reference Chang, Ma, Novak, Barra, Kundrod, Montealegre, Scheurer, Castle, Schmeler and Richards-Kortum2023), may increase suitability as they allow for lateral flow devices (LFD), a low-resource assay output method, to be used. An analytical sensitivity of 50 copies/reaction for HPV 16 and 18, and 500 copies/reaction for HPV 45 was achieved. However, as clinical sensitivity and specificity was not investigated, further testing is needed before its suitability as a low-resource diagnostic can be assessed.

The high sensitivity and specificity of HR-HPV RPA/RAA assays in addition to the multiplexing demonstrated shows that the platform has potential to be used as a multiplex diagnostic in clinical settings.

Utility of potential multiplex diagnostics for female genital schistosomiasis and human papillomavirus

FGS and HR-HPV are common in low-resource areas of SSA, and HR HPV presents a high risk of developing cervical cancer. Additionally, as both FGS and HR-HPV cause physical disruption in the cervix and vaginal canal, making invasion by other pathogens easier, it is hypothesized that having FGS or HR-HPV will increase the risk of acquiring STIs. Relationships have been observed between urogenital schistosomiasis and HIV (Patel et al., Reference Patel, Rose, Kjetland, Downs, Mbabazi, Sabin, Chege, Watts and Secor2021) and between HR-HPV and HIV (Okoye et al., Reference Okoye, Ofodile, Adeleke and Obioma2021). In relation to associations between FGS and HR-HPV, data showed no relationship between FGS and HR-HPV infections in Madagascar (Kutz et al., Reference Kutz, Rausche, Rasamoelina, Ratefiarisoa, Razafindrakoto, Klein, Jaeger, Rakotomalala, Rakotomalala, Randrianasolo, McKay-Chopin, May, Rakotozandrindrainy, Puradiredja, Sicuri, Hampl, Lorenz, Gheit, Rakotoarivelo and Fusco2023b), although an association was found between FGS and non-specified LR and HR-HPV types in a South African study (Shukla et al., Reference Shukla, Kleppa, Holmen, Ndhlovu, Mtshali, Sebitloane, Vennervald, Gundersen, Taylor and Kjetland2023). Additionally, an association between FGS and HPV 16, 18, and 45 was reported in a recent study conducted in Zambia (Lamberti, Reference Lamberti2025). A recent literature review found that data was too limited to confirm or deny a causative connection between FGS and HR-HPV infection (Sturt et al., Reference Sturt, Omar, Hansingo, Kamfwa, Bustinduy and Kelly2025), in part due to sample size and data quality challenges within individual studies. However, even without a direct association, this does not limit the burden FGS and HR-HPV has on women’s health in SSA.

Multiplex NAATs which detect either Schistosoma spp. or HR-HPV with other sample-related pathogens have been developed. For example, a multiplex PCR assay that detects S. haematobium and S. mansoni in stool samples reported a detection rate of 84.1% in comparison to stool microscopy at 79.5% (ten Hove et al., Reference ten Hove, Verweij, Vereecken, Polman, Dieye and van Lieshout2008) and a probe-based LAMP assay for S. mansoni and Strongyloides spp., a soil-transmitted helminth, has been optimized to work at room temperature for field settings (Crego-Vicente et al., Reference Crego-Vicente, Fernández-Soto, García-Bernalt Diego, Febrer-Sendra and Muro2023).

As described, extensive multiplex NAATs for different combinations of HPV types have been developed across different molecular platforms. Additionally, multiplex assays that combine different HPV types with other pathogens that can be found in the same sample types, such as Chlamydia trachomatis, Mycoplasma hominis, Mycoplasma genitalium, Ureaplasma urealyticum and Neisseria gonorrhoeae simultaneously have been developed (Lima et al., Reference Lima, Hoelzle, Simões, Lima, Fradico, Mateo, Zauli and Melo2018).

These studies suggest that the development of a multiplexed NAAT that can detect S. haematobium and HR-HPV simultaneously is feasible using different molecular diagnostic platforms and moreover, this has the potential to address a current gap in women’s health screening in SSA.

Currently, no studies have evaluated a combined diagnostic for FGS and HR-HPV. A multiplex molecular diagnostic for FGS and HR-HPV would be beneficial in terms of delivering diagnostic information, but there may be logistical challenges in its implementation in resource-limited settings. Logistical challenges such as supply chain management can result in delays in test-delivery, which is especially pertinent to NAATs which often require cold storage (Kuupiel et al., Reference Kuupiel, Tlou, Bawontuo, Drain and Mashamba-Thompson2019). Additionally, the initial training needed to familiarize medical personnel, who may not have received molecular biology training before, with new technologies will require significant time and funding (Mfuh et al., Reference Mfuh, Abanda and Titanji2023).