Burden of high-risk HPV, cervical precancer, and prevention gaps among women living with HIV in India

Abstract

Women living with HIV (WLHIV) are at increased risk of persistent high-risk human papillomavirus (HPV) infection and cervical cancer, yet cervical cancer screening uptake remains low despite regular healthcare engagement. We assessed the prevalence of high-risk HPV infection among screen-eligible WLHIV, their knowledge and attitudes toward cervical cancer prevention, and completion of the screening-to-treatment pathway to evaluate the feasibility of integrating HPV DNA testing into routine HIV care. We conducted a prospective observational study among 327 screen-eligible WLHIV attending an antiretroviral therapy (ART) clinic between June 2023 and 2025. Cervical samples were tested for HPV DNA using the Cobas 4800 assay. HPV-positive women underwent colposcopy and biopsy. Knowledge, attitudes, and practices related to cervical cancer prevention were assessed using a structured questionnaire. Multivariable logistic regression was used to identify factors associated with HPV positivity. High-risk HPV was detected in 74 women (22.6%), including HPV-16 in 39.2%, HPV-18 in 18.9%, and other oncogenic genotypes in 71.6%; 25% had overlapping infections. Cervical intraepithelial neoplasia (CIN) was identified in 16 women (21.6%), including 8 (11.4%) with high-grade squamous intraepithelial lesions and one case of invasive cervical cancer. A CD4 count ≥200 cells/mm 3 at antiretroviral therapy (ART) initiation was independently associated with lower odds of high-risk HPV positivity [adjusted odds ratio (OR) 0.51; 95% confidence interval (CI) 0.28–0.91; P =0.024]. Completion of the screening-to-treatment pathway was 98.2%. Knowledge of cervical cancer prevention was poor and did not differ between HPV-positive and HPV-negative women ( P =0.479). WLHIV remain at substantial risk of high-risk HPV infection and cervical precancer, particularly those with advanced immunosuppression at ART initiation. Integrating HPV DNA testing into routine ART clinic services resulted in high screening-to-treatment pathway completion.