Background
Primary human papillomavirus (HPV) screening was introduced in Australia in December 2017.

Aims
Outcomes for women after positive HPV in their cervical screening test (CST).

Materials and Methods
A retrospective observational study of 4458 women seen at the Royal Women’s Hospital Colposcopy Clinic from 1 January 2018 to 31 July 2020.

Results
HPV16/18 was positive (considered higher‐risk CST) in 42.2% of women in the study, 16.6% with reflex possible with high‐grade squamous intraepithelial lesions (pHSIL) or worse and 54.9% with normal cytology. There were 24.8% of women with positive HPV16/18 who had histological confirmed cervical intraepithelial neoplasia grade 2 or worse (CIN2+), 10.3% CIN2+ (including six cancers) among women with reflex negative cytology and 87.7% CIN2+ among women with reflex HSIL cytology. In women with positive HPV (not 16/18), CIN2+ was found in 60.2% with reflex pHSIL or worse cytology (higher risk) and 10.2% with reflex low‐grade SIL (LSIL) or normal cytology (intermediate risk). Median waiting time to colposcopy with the intermediate‐risk group went up to 181 days. Our colposcopists were able to achieve a positive predictive value (PPV) for CIN2+ of 69.9%, higher than 57.8% PPV in the National Cervical Screening Program (NCSP) 2020 monitoring report. Women with type 3 transformation zone on colposcopy could be followed up with CST if no HSIL was suspected on screening or at colposcopy as their risk of CIN2+ was only 2.5%.

Conclusions
Our findings support direct referral to colposcopy for women with higher‐risk CST, with all cancers confined to this group. The NCSP recommendation to refer for colposcopy only after three intermediate‐risk CST will need monitoring with the LSIL triage group.