Undertreatment of Cervical Precancer Among Screen-Positive Women Living with HIV in Kenya

Abstract

Cervical cancer remains a leading cause of cancer-related morbidity and mortality among women living with HIV (WLWH) in sub-Saharan Africa. Although screening coverage has improved, evidence on completion of post-screening diagnostic evaluation and treatment remains limited. We described screening results and the post-screening management cascade among WLWH receiving HIV care in Nairobi, Kenya. We analyzed Project CN001 data from the National Cancer Institute-funded CASCADE Clinical Trials Network at the Coptic Hope Center for Infectious Diseases in Nairobi. We included WLWH aged 25-49 years who underwent visual inspection with acetic acid (VIA) and/or high-risk human papillomavirus (hrHPV) testing between March 11, 2025, and January 16, 2026, with at least 1 month of follow-up. VIA-positive women with fully visualized transformation zones (TZ) were eligible for same-day thermal ablation; those with non-fully visualized TZ or suspicious findings were referred for colposcopy. hrHPV-positive women were recommended for VIA triage. Among 988 WLWH screened with VIA (n = 857) and/or hrHPV testing (n = 136), median age was 41 years (IQR, 35-46), and median time since HIV diagnosis was 10.5 years (IQR, 5-16). Among VIA-screened women, 63 (7.4%) had VIA-positive or suspicious findings and 794 (92.6%) were VIA-negative. TZ distribution varied by age, with younger women more likely to have TZ1 and older women more likely to have TZ3. Among 63 women with VIA-positive or suspicious findings, 37 (58.7%) received same-day thermal ablation and 26 (41.3%) were referred for colposcopy. Only 4 referred women (15.4%) underwent colposcopy: CIN3 was detected in 1, CIN2 in 1, and no CIN in 2. The woman with CIN2 received LEEP/LLETZ 9 days after; the woman with CIN3 and the remaining 24 referred women received no treatment (96.2%). Among 136 women undergoing hrHPV testing, 31 (22.8%) were hrHPV-positive; only 5 (16.1%) underwent VIA triage, and all were VIA-negative. Among WLWH engaged in HIV care in Kenya, screening uptake was high and same-day ablation was feasible. However, screen-positive women referred for further evaluation rarely completed it and often received no treatment. Reducing financial and logistical barriers and strengthening pragmatic screen-and-treat pathways are essential to improve cervical cancer prevention among WLWH.