Genotype-Specific HPV E6/E7 mRNA Triage Improves Risk Stratification and Reduces Referrals in DNA-Positive ASC-US/LSIL: A Real-World Cohort from Nordland, Norway

HPV DNA-positive women with ASC-US/LSIL cytology represent a heterogeneous risk group in cervical screening and require efficient triage. We evaluated a genotype-specific 7-type HPV E6/E7 mRNA assay (PreTect HPV-Proofer 7; types 16/18/31/33/45/52/58) in a real-world quality-assurance cohort at Nordland Hospital (Bodø, Norway). Among HPV-positive women with ASC-US/LSIL reflex cytology, 225 had sufficient residual liquid-based cytology material and a valid mRNA result; 175 had complete follow-up (2022-2025) and were included. Overall, 44.6% (78/175) were mRNA-positive (ASC-US 45.2%; LSIL 43.3%). For CIN2+, sensitivity was 63.4%, specificity 61.2%, PPV 33.3%, and NPV 84.5%; CIN2+ risk was 33.3% in mRNA-positive versus 15.5% in mRNA-negative women (RR 2.16, 95% CI 1.23-3.78). For CIN3+, risk was 14.1% versus 6.2%. Genotype-specific PPVs were highest for HPV33, HPV18, HPV16, and HPV31. In a referral simulation, mRNA-guided triage reduced baseline colposcopy referrals by 55% and decreased colposcopies per detected CIN2+ by ~30%, while 15 CIN2+ and 6 CIN3+ occurred in the mRNA-negative group and would be expected to be detected at 12-month follow-up among women with persistent HPV positivity. Genotype-aware HPV E6/E7 mRNA triage improves risk stratification and may increase screening efficiency.