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. 2025 Jun 1;39(7):829-837.
doi: 10.1097/QAD.0000000000004120. Epub 2025 Jan 10.

Cervical dysplasia in women with HIV in the modern treat-all era: elevated risk remains despite long-term ART and normal CD4 + cell count

Rebecca Luckett  1   2   3   4   5 , Doreen Ramogola-Masire  3   6 , Rebecca Zash  2   4   7   8 , Ellen Sears  9 , Jessie Lan  9 , Annika Gompers  1 , Anna Modest  1 , Thabo Moloi  3 , Devon A Harris  1 , Avina Joshi  1 , Rachel Gutfreund  10 , Sikhulile Moyo  2   7   11   12 , Thanolo Kashamba  13 , Maduke Kula  14 , Greta Dreyer  6 , Gaerolwe Masheto  2 , Matthys H Botha  5 , Michele R Hacker  1   4   15 , Roger L Shapiro  2   4   7   8
Affiliations

Cervical dysplasia in women with HIV in the modern treat-all era: elevated risk remains despite long-term ART and normal CD4 + cell count

Rebecca Luckett et al. AIDS. .

Abstract

Objective: To evaluate the impact of antiretroviral therapy (ART) duration and CD4 + cell count on risk for high grade cervical dysplasia in women with HIV (WWH) compared to women without HIV in the treat-all era with integrase strand inhibitors (INSTIs).

Design: A prospective longitudinal cohort study in Botswana.

Methods: From February 2021 to July 2022, baseline HPV self-sampling was offered to women with and without HIV. Those HPV+ underwent biopsy for histopathological diagnosis. Using women without HIV as reference, risk ratios were calculated for HPV, cervical intraepithelial neoplasia (CIN) 2 or worse (CIN2+), and CIN3+, stratified by ART duration and CD4 + cell counts.

Results: Of 3000 women enrolled, 2953(98.4%) underwent HPV testing, which was positive in 823(55.7%) WWH and in 654(44.3%) women without HIV. Histopathology was available for analysis in 1291(87.4%) women (709 WWH, 582 women without HIV). Over 99% of WWH had an undetectable HIV viral load and 94.4% were on a dolutegravir-based ART regimen. WWH had a higher risk of HPV [risk ratio 1.27, 95% confidence interval (95% CI): 1.18-1.37], CIN2+ (risk ratio 1.52, 95% CI: 1.16-1.98), and CIN3+ (risk ratio 1.75, 95% CI: 1.25-2.45) compared to women without HIV. There was attenuation of risk for CIN2+ with higher recent CD4 + cell count, and those with higher nadir CD4 + cell count had similar risk to those without HIV (nadir CD4 + ≥500 CIN2+ risk ratio 1.15 [95% CI: 0.56-2.37], CIN3+ risk ratio 1.81 [95% CI: 0.86-3.79]; nadir CD4 + 350-499 CIN2+ risk ratio 1.23 [95% CI: 0.71-2.12], CIN3+ risk ratio 1.34 [95% CI: 0.68-2.64]).

Conclusion: Although some attenuation of risk for CIN2+ was observed with higher recent and nadir CD4 + cell counts, WWH continue to have a higher risk of CIN2+/CIN3+ compared to women without HIV. These findings support tailored cervical screening algorithms for WWH.

Keywords: ART duration; CIN2+; CIN3+; HIV; cervical dysplasia; cervical screening; immune status.

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Conflict of interest statement

Declaration of interests: The authors have no conflicts of interest.

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