Cervical cancer is reported to be the fourth most common cancer affecting women worldwide and Africa’s second most common cancer [
1,
2]. Developing countries account for about 70% of the global burden of this disease. Approximately 85% of cervical cancer deaths occur in developing countries, with the highest regional occurrence in Sub-Saharan Africa, where about 59% of women and girls are living with HIV [
3,
4]. In 2020, there were about 604,127 new cases and 341,831 deaths globally, with about 76, 745 of these deaths occurring in Africa alone [
2]. These deaths are unnecessary because cervical cancer can be prevented [
2,
5]. By 2040, the burden of cervical cancer is expected to double what was reported in 2020 [
6]. Therefore, if cervical cancer screening is to gain success in many parts of the world, target populations must effectively participate in regular screening [
7]. With more than 95% of cervical cancer cases occurring due to persistent infection with high-risk human papillomaviruses, the World Health Organization (WHO) recommends human papillomavirus DNA testing for screening [
8]. Screening by HPV detection provides about 60–70% protection against invasive cervical cancer, and also allows for self-sampling [
9]. HIV-infected women are about six times more like to develop cervical cancer compared to their HIV-negative counterparts [
10]. With the efforts made to expand HIV treatment to the people that need it, there is a need to make certain that these women’s lives are not cut short by cervical cancer when it can be prevented [
10]. The integration of cervical cancer screening into HIV/AIDS services is a good opportunity to increase screening coverage in this population. However, if this service is not well-utilized, cervical cancer cases will continue to increase.
According to the 90–70–90 global strategy, the World Health Organization targets to screen 70% of women worldwide for cervical cancer twice by the year 2030, first by the age of 35 and again by the age of 45 [
10]. However, cervical and vaginal sampling are invasive and therefore some women are not encouraged to go for screening. Factors contributing to the poor acceptability of cervical and vaginal sampling by some women include fear of pain, embarrassment, and religious and cultural beliefs. Therefore, we need to explore alternative methods of sampling in order to improve screening coverage [
11]. Urine sampling provides an opportunity to expand cervical cancer screening coverage by reaching populations reluctant to undergo cervical or vaginal sampling [
12]. The first 20 mL of urine flush (first void) is contaminated with exfoliated cells from the cervix and vagina, and thus provides an acceptable sample for HPV DNA testing [
4,
12,
13].
Cervical cancer is the most prevalent cancer affecting females in Zambia and the leading cause of death in this population. Despite the introduction of free screening through the establishment of the Cervical Cancer Prevention Programme in Zambia (CCPPZ) in 2006, there are still women reluctant to go for screening. Zambia recorded the third-highest incident rate of cervical cancer in the year 2018, with about 66.4 new cases per 100, 000 women. Later in 2020, the prevalence of cervical cancer in Zambia was 40.2% [
14]. This represented one of the world’s highest disease burden, suggesting an urgent need for more effective preventative measures in the country [
14]. Only a few studies have assessed the performance of first void urine sampling for HPV testing using the GeneXpert platform [
11,
15,
16]. To date, there has been no study done in Zambia to assess the performance of first void urine for HPV DNA testing. Human papillomavirus detection in first void urine can help increase screening coverage by reaching women reluctant to undergo vaginal self-sampling or clinician-based cervical sampling [
17]. Therefore, we aimed to determine the performance of first void urine sampling for high-risk HPV DNA testing as an alternative sample for cervical cancer screening using the clinician-collected cervical samples as reference using the GeneXpert platform. We also assessed the acceptability of first void urine sampling for cervical cancer screening.