Age-specific burden of cervical cancer associated with HIV: A global analysis with a focus on sub-Saharan Africa

Abstract

HIV substantially worsens human papillomavirus (HPV) carcinogenicity and contributes to an important population excess of cervical cancer, particularly in sub-Saharan Africa (SSA). We estimated HIV- and age-stratified cervical cancer burden at a country, regional and global level in 2020. Proportions of cervical cancer (a) diagnosed in women living with HIV (WLHIV), and (b) attributable to HIV, were calculated using age-specific estimates of HIV prevalence (UNAIDS) and relative risk. These proportions were validated against empirical data and applied to age-specific cervical cancer incidence (GLOBOCAN 2020). HIV was most important in SSA, where 24.9% of cervical cancers were diagnosed in WLHIV, and 20.4% were attributable to HIV (vs 1.3% and 1.1%, respectively, in the rest of the world). In all world regions, contribution of HIV to cervical cancer was far higher in younger women (as seen also in empirical series). For example, in Southern Africa, where more than half of cervical cancers were diagnosed in WLHIV, the HIV-attributable fraction decreased from 86% in women ≤34 years to only 12% in women ≥55 years. The absolute burden of HIV-attributable cervical cancer (approximately 28 000 cases globally) also shifted toward younger women: in Southern Africa, 63% of 5341 HIV-attributable cervical cancer occurred in women <45 years old, compared to only 17% of 6901 non-HIV-attributable cervical cancer. Improved quantification of cervical cancer burden by age and HIV status can inform cervical cancer prevention efforts in SSA, including prediction of the impact of WLHIV-targeted vs general population approaches to cervical screening, and impact of HIV prevention.

Keywords: HIV; age-specific incidence rates; cervical cancer; population-attributable fraction; sub-Saharan Africa.

FIGURE 1

HIV prevalence in cervical cancer in 2020, by age group. The designations used and the presentation of the material in this article do not imply the expression of any opinion whatsoever on the part of WHO and the IARC about the legal status of any country, territory, city, or area, or of its authorities, or concerning the delimitation of its frontiers or boundaries

FIGURE 2

HIV‐attributable fraction in cervical cancer in 2020, by age group. PAF, population‐attributable fraction. The designations used and the presentation of the material in this article do not imply the expression of any opinion whatsoever on the part of WHO and the IARC about the legal status of any country, territory, city, or area, or of its authorities, or concerning the delimitation of its frontiers or boundaries

FIGURE 3

Variation in HIV prevalence in cervical cancer by age: comparison of IARC estimates and empirical data for selected countries. IARC, International Agency for Research on Cancer

FIGURE 4

Burden of invasive cervical cancer cases according to HIV status, by world region. Non‐AFRO includes WHO regions: Europe (EURO), South‐East Asia (SEARO), Americas (PAHO), East Mediterranean (EMRO) and Western Pacific (WPRO)

FIGURE 5

Age‐specific incidence rates of cervical cancer according to HIV‐attribution status, by sub‐Saharan Africa region (not shown for 0‐24 years as negligible [<1 per 100 000 in all regions]). ASIR, age‐standardized incidence rate; pys, person years