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Cervical Cancer Screening Positivity Among Women Living With HIV in CDC-PEPFAR Programs 2018-2022
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Dec 1 2023
The overall positivity rate was 6.1% (172,238 positive/2,807,532 total tests); this included a rate of 5.4% (n = 150,287) for precancerous lesions and 0.8% (n = 21,951) for suspected ICCs (Table 2). The positivity rate varied by country, ranging from an overall rate of 3.5% in Kenya to 17.8% in Namibia; precancerous lesion positivity ranged from 2.6% in Kenya to 17.2% in Namibia; and suspected ICC positivity ranged from 0.6% in Botswana, Mozambique, and Uganda to 1.2% in both Lesotho and Nigeria.
Global implementation guidelines for cervical cancer screening programs estimate that between 5% and 25% of the general population will screen positive using any available test.11,12 The proportion of women who screen positive with an identified precancerous lesion or a suspected invasive cervical cancer (ICC) will be higher in populations with a higher prevalence of HIV, CIN2+, and oncogenic HPV subtypes.13Screen-positive rates are higher among WLHIV screened with VIA, cytology, and HPV DNA testing when compared with people without HIV.3 Women younger than 30 years are more likely to screen positive compared with all other age groups because of the higher rates of cervical metaplasia and dysplasia, HPV infection, and low-grade epithelial lesions among young women.3,14 In addition to these patient characteristics, VIA diagnostic accuracy also varies with procedural characteristics, including the light source, the acetic acid concentration, and the training and experience of the test provider, because VIA is inherently subjective and dependent on the judgement of the provider.3
Abstract
Background:
The US President's Emergency Plan for AIDS Relief aims to address the higher risk of cervical cancer among women living with HIV by offering high-quality screening services in the highest burden regions of the world.
Methods:
We analyzed the US President's Emergency Plan for AIDS Relief Monitoring, Evaluation, and Reporting data from Centers for Disease Control and Prevention-supported sites in 13 countries in sub-Saharan Africa for women living with HIV aged older than 15 years who accessed cervical cancer screening services (mostly visual inspection, with ablative or excisional treatment offered for precancerous lesions), April 2018-March 2022. We calculated the positivity by age, country, and clinical visit type (first lifetime screen or routine rescreening). We fitted negative binomial random coefficient models of log-linear trends in time to estimate the probabilities of testing positive and any temporal trends in positivity.
Results:
Among the 2.8 million completed cancer screens, 5.4% identified precancerous lesions, and 0.8% were positive for suspected invasive cervical cancers (6.1% overall). The positivity rates declined over the study period among those women screening for cervical cancer for the first time and among those women presenting to antiretroviral therapy clinics for routine rescreening.
Conclusions:
These positivity rates are lower than expectations set by the published literature. Further research is needed to determine whether these lower rates are attributable to the high level of consistent antiretroviral therapy use among these populations, and systematic program monitoring and quality assurance activities are essential to ensure women living with HIV have access to the highest possible quality prevention services.
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