The context​

With a national mandate to strengthen health and social care services, the elimination of cervical cancer has been a key priority for the Montserrat Ministry of Health. In 2017, the HPV vaccine was introduced in Montserrat, but despite its efficacy in preventing cervical cancers by up to 87 percent, uptake remained below target levels, leading the Ministry to pause the programme for review.

Screening coverage has also remained low. In 2022, only 7 percent of eligible women were screened. Screening relied on opportunistic Pap smears, with results taking 6–12 weeks and out-of-pocket costs borne by patients. In 2023, a national review of Pap smear results for the period 2012–2022 indicated that nearly 29 percent of results were abnormal, inflammatory or unsatisfactory, suggesting that a significant proportion of women screened had results requiring further clinical investigation.

Despite this need, Montserrat did not have an organized population-based cervical cancer screening programme. The lack of a formal population registry, numbered street addresses and reliable local postal services limits the feasibility of the call-recall system (whereby eligible individuals are directly invited to attend screening) in the Montserrat context. Screening therefore depends on mass communication and on healthcare professionals proactively offering screening during routine appointments such as family planning, antenatal care and sexual health services.

These structural challenges are compounded by a lack of locally generated data. HPV infection rates and the subtypes circulating in the population are largely unknown, and data and insights gaps are widened with patients seeking care overseas and whose follow-up records are not captured locally. Without this evidence base, the Ministry ability to make data-informed decisions on screening programme design and vaccination rollout strategy is limited.  

Similar data limitations affect the understanding of cervical cancer incidence itself. The population size (4,396 in 2023 census), the absence of an established cancer registry and the lack of on-island histological diagnostic capability all limit case detection. Moreover, private healthcare records are not integrated with those of the Ministry, and patients referred overseas for specialist care are often lost to follow-up. As a result, available records suggest only one to two cases of cervical cancer per year – a figure that likely underestimates true incidence.  

The small population of Montserrat, however, also presented a unique opportunity. The HPV prevalence study was able to sample approximately 14 percent of the entire eligible female population – a level of precision rarely achieved in national surveys and one that positions the experience of Montserrat as a potential model for other Small Island Developing States (SIDS).  

The development of a National Strategy for the Elimination of Cervical Cancer is directly aligned with the 2025–2028 policy agenda of the Government of Montserrat, which identifies ‘healthy lives and well-being’ as one of the national priority outcomes. It also supports the Ministry's shift in healthcare delivery towards community and preventive care, its priorities on non-communicable disease prevention and improved on-island healthcare delivery. The strategy is further aligned with the health system strengthening agenda developed in partnership with the Pan American Health Organization (PAHO), which includes expanding outreach services such as screening, education and linkage to care.

The Approach

The Montserrat Ministry of Health and Social Services partnered with the UKHSA to conduct an HPV prevalence study to generate evidence that could inform screening, vaccination and overall management of the disease. The Ministry led study design and implementation, with UKHSA providing technical support, including epidemiological expertise, behavioural science input, testing supplies and funding. The study focused on women aged 25–64 across the country, identified through random household sampling based on building footprints recorded during the 2023 census. All samples were locally tested at the Glendon Hospital Laboratory and results were made available within hours.

Aims and Objectives

The study aimed to estimate the prevalence of HPV infection, especially high-risk genotypes, among women aged 25–64 in Montserrat, to inform future cervical cancer screening and HPV vaccination programmes.

The objectives were:

• To determine prevalence rates of HPV in women aged 25–64

• To describe demographic characteristics associated with infection and high-risk HPV genotypes

• To assess the willingness of women to undertake self-sampling and determine the perceived acceptability of self-sampling

Methodology

Study design and population

The study tested a representative sample of women aged 25–64. Women were excluded if they had resided in Montserrat for less than six months, had a history of hysterectomy, were pregnant or less than three months postpartum, or had been diagnosed with cervical cancer or were undergoing treatment for cervical cancer or precancer.

Sampling and recruitment

The target sample size was 208 women (from a total eligible population of 1,316), with an estimated response rate of 30–40 percent. To account for this, 520 buildings were randomly sampled using Quantum GIS (QGIS), a geographic information system, based on building footprints recorded during the 2023 census. Recruitment took place between October 2024 and March 2025.

Data collection

Women identified through household sampling were invited to participate in the study. Those who consented completed a short questionnaire covering demographic information and risk factors associated with HPV infection. Each woman was offered the choice of self-testing or an appointment with a healthcare provider to collect the sample. This dual approach was designed both to improve participation and to assess the acceptability of self-sampling as a future screening method.  

Laboratory testing

All samples were tested at the Glendon Hospital Laboratory using the GeneXpert PCR platform. This technology is already available in many health systems in low- and middle-income countries, making the approach replicable in similar settings. The assay (diagnostic test) detected 14 high-risk HPV genotypes across three separate channels. Negative results were notified by phone, while patients with positive results were given a follow-up appointment with a gynaecologist.

Data analysis

Prevalence rates were adjusted for age to allow comparison across different age groups and with other populations. The age distribution of the study sample was compared with that of the wider female population of screening age to confirm that the sample was representative. Statistical analysis was then used to identify demographic and behavioural factors associated with a higher likelihood of infection.¹

Results and Key Findings

Of those contacted through household sampling, 225 women were eligible for the study. Of these, 206 (92 percent) consented to participate and 187 women submitted a sample (83 percent of eligible women). The women who participated closely matched the age profile of the broader female population of Montserrat, supporting the applicability of the findings with confidence to the rest of the island. The consent rate is particularly notable given the island’s historically low screening uptake, and reflects strong community trust in the study.  

Of the 187 samples tested, 28 samples tested positive for high-risk HPV. Overall age-adjusted high-risk HPV prevalence was 14.6 percent – roughly 1 in 7 women of screening age on the island at elevated risk of cervical disease. Most infections involved HPV types beyond the two most commonly known strains (HPV 16 and HPV 18/45) – a finding with direct implications for vaccine selection.

Additionally, most participants indicated willingness to use self-sampling, which validated self-sampling as a viable testing option. This insight provides a critical basis for informing the design of future screening programmes.

Clinical protocols were developed as part of the HPV prevalence study to ensure adequate follow-up of women who tested positive. These protocols have been incorporated into the health system and will standardise and improve the quality of care provided to women. The data received from the study will also strengthen evidence-based decision-making on resource allocation, such as for equipment and training.

How can better data contribute to better health policy?

The generation of local HPV infection data marks an important milestone, providing Montserrat with the evidence needed to make targeted and effective policy decision. The findings informed the following policy areas:

• Vaccine procurement: Knowledge of the dominant HPV subtypes circulating in the population enables the Ministry to select the most appropriate vaccine formulation.

• Diagnostic investment: The quantified burden of HPV infection justifies investment in cervical ablation devices and additional colposcopy machines, linking capital expenditure directly to local data.  

• Screening programme design: The demonstrated acceptability of self-sampling among women in Montserrat supports a screening model that improves resource efficiency and empowers women to take an active role in their own healthcare.

• Laboratory capacity: The study has established on-island HPV DNA testing capability, reducing turnaround from 6–12 weeks to 6–8 hours and eliminating off-island costs.  

However, as testing volumes grow with the launch of the screening programme, the laboratory’s capacity will need to be actively managed, including workforce planning and ensuring continuous supply of testing consumables.

Where do we go from here?

The data from the survey are being used by the Ministry of Health to develop a cervical cancer elimination strategy. Once the strategy is finalised, a comprehensive screening package tailored to the Montserrat context will be implemented, along with further investments in equipment and diagnostics. The strategy outlines how the Ministry plans to sustain the interventions over a longer term.

A dedicated governance committee will provide oversight, manage resources, coordinate with stakeholders and work with the hospital laboratory to streamline the procurement of testing consumables. Screening programmes will be organized during fixed periods throughout the year, aligning with procurement cycles and staffing availability.

Several elements of this experience in Montserrat may be relevant to other SIDS facing similar constraints, including the use of geographic information systems for population sampling in the absence of formal addresses; rapid on-island testing using widely available GeneXpert technology; and the direct link between a prevalence study and a national elimination strategy.  

References

1. Government of Montserrat. Government Confirms Policy Agenda for 2025–2028 Planning Cycle (2025). https://www.gov.ms/2025/08/28/government-confirms-policy-agenda-for-2025-2028-planning-cycle/

2. Government of Montserrat. Ministry of Health and Social Services. https://www.gov.ms/government/ministries/ministry-of-health-and-social-services/

3. Pan American Health Organization. PAHO and Montserrat Advance a Comprehensive Health System Strengthening Agenda (2025). https://www.paho.org/en/news/30-9-2025-paho-and-montserrat-advance-comprehensive-health-system-strengthening-agenda

4. United Kingdom Health Security Agency and Government of Montserrat Ministry of Health and Social Services. High-Risk Human Papillomavirus (hrHPV) Prevalence and Associated Risk Factors in Women from Montserrat (2025).