Background/Objectives: Self-sampling is recognized as a viable alternative to clinician-sampling for HPV primary screening. This study aimed to assess, within an Italian organized cervical cancer screening program, the acceptance and ease of use of self-sampling and the adherence to follow-up. The prevalences of HPV infection, cervical dysplasia, and cancer were contextually evaluated. Methods: Electronic records of 19,327 women, 30–64 years-old, residing within the Bologna Local Health Authority territory, who were offered self-sampling as an alternative to clinician-sampling, were retrospectively reviewed. They had never or irregularly attended and were overdue for a screening invitation due to the COVID-19 pandemic. An opt-in approach was adopted, involving local pharmacies for kit delivery and sample collection. Initially, HPV-positive results led to direct referral to colposcopy; later, cytological triage on clinician-samples was provided. Results: Self-sampling reached over twice as many women (11.5%) compared to historical clinician-sampling alone (<5%), showing high acceptance. Additionally, a high screening completion level was observed, with 79.5% of self-samples returned to pharmacies. A low percentage of self-samples resulted in inadequate results (1.1%), suggesting the method’s ease of use. HPV-positivity was 13.1%, higher than the 9.9% recorded in the ordinary screening population in 2019 (p < 0.001), the last year before the pandemic. Compliance to both immediate colposcopy and cytology triage exceeded 90% (p = 0.675). The rate of cervical adenocarcinoma was twice as high as in the routinely screened population in 2019 (0.9‰ versus 0.4‰). Finally, 6% of women opted for clinician appointments. Conclusions: Self-sampling proved to be an easy-to-use and effective tool for reaching non-attenders, who are at high risk of cancer. Cytology triage on clinician-samples did not negatively impact follow-up adherence. It seems appropriate to maintain a clinician-collection option even among non-attenders.

Background: Under the current Italian HPV-based cervical screening protocol, women with persistent high-risk human papillomavirus (HR-HPV) positivity at the 12-month recall are referred to colposcopy regardless of cytology results. Although this strategy maximizes lesion detection, it may generate substantial over-referral. We evaluated whether partial HPV genotyping combined with cytology can improve risk stratification in women with persistent HPV positivity at the 12-month recall. Methods: A multicenter retrospective analysis of cervical screening data collected from four Italian screening programs (Florence, Padua, Umbria and Emilia-Romagna) was performed. Among the 270,714 women screened between 2015 and 2019, 4,589 women with persistent HR-HPV positivity at 12-month recall after baseline HPV-positive/NILM results were included. Four alternative triage strategies based on cytology and HPV 16/18 genotyping were retrospectively simulated and compared with the current protocol. Outcomes included CIN2+ detection, relative sensitivity for CIN2+ and CIN3+, positive predictive value (PPV) and reduction in colposcopy referrals. Results: Under the current protocol, 4,589 colposcopies identified 327 CIN2+ lesions, including 113 CIN3+ lesions, yielding a PPV for CIN2+ of 7.1%. Overall, 36.7% of CIN2+ lesions were associated with NILM cytology at recall. HPV 16/18 genotyping identified 43.3% of these cytologically occult lesions. Among the evaluated strategies, referral of HPV 16/18-positive women regardless of cytology and referral of women with low-grade or worse cytology regardless of genotype achieved the most favorable balance between sensitivity and efficiency. This approach reduced colposcopy referrals by 57.7%, nearly doubled the PPV for CIN2+ to 13.4% and maintained relative sensitivities of 79.2% for CIN2+ and 85.0% for CIN3+. Conclusions: Combining partial HPV genotyping with cytology substantially improves risk stratification in women with persistent HR-HPV positivity at 12-month recall. A risk-based approach may markedly reduce unnecessary colposcopies while maintaining acceptable sensitivity for high-grade cervical lesions. These findings support the integration of molecular and cytological information into 12-month recall management strategies within HPV-based cervical screening programs.