This study determined the prevalence of high-risk HPV genotypes and associated factors among women living with HIV in selected health facilities in Uganda. We found that about 34.3% of HIV positive women aged 25–49 years attending ART at public health facilities in Uganda had high risk HPV infections. The prevalence of HPV 16 genotype was 317 (15.8%), 308 (15.4%) for HPV 18–45 and 1381 (68.8%) for other hrHPV. The independent factors associated with all hrHPV, and the individual genotypes (16, 18 = 45 and other hrHPV) were parity, education level, having more than one partner, and engaging in early sex. Smoking was associated with HPV 16, HPV 18–45 and other hrHPV. Age was associated with all hrHPV and HPV 18–45, marital status with all hrHPV and HPV 16, and occupation with HPV 16.
HPV infection is a well-established cause of cervical cancer. Routine HPV screening provides an opportunity to identify women with HPV and facilitate follow-up care as needed. Our study found a high 86% HPV prevalence among women living with HIV, compared to 59% in HIV-negative women. HIV impacts immune function in ways that can increase susceptibility to persistent HPV infection. Specifically, HIV leads to reduced CD4 + and CD8+, T-cell numbers and function, along with higher regulatory T-cell levels. This dampened, anti-inflammatory state makes it harder to clear HPV infection. Given the high HPV prevalence and immune dysfunction, women with HIV are at substantially increased risk for not only HPV acquisition but also progression to invasive cervical cancer compared to HIV-negative women. Active and persistent HPV infections are more likely during uncontrolled HIV disease. [19]. Other research has also found that women living with HIV have a higher incidence and faster progression of cervical precancerous lesions compared to HIV-negative women [20]. Persistent infection with high-risk HPV types, especially HPV16 and 18, is a major risk factor for developing cervical cancer. The increased vulnerability to persistent infection in HIV-positive women further escalates their risk of cervical cancer.
Hausen's research demonstrated that persistent infection with high-risk types of human papillomavirus (HR-HPV) can lead to the development of cervical lesions and abnormalities. His work established HR-HPV infection as a necessary factor in the pathogenesis of cervical cancer [21, 22]. Cervical cancer screening should be incorporated into HIV care programs in order to increase early detection and save lives. Using self-collected vaginal samples for HPV testing is a feasible approach to improve screening access and coverage in resource-limited settings. This strategy holds promise for enhancing cervical cancer prevention efforts among women living with HIV in low-income regions. Integrating cervical cancer screening into routine HIV care could help address the elevated burden of cervical cancer morbidity and mortality in this high-risk population. [23] [24].
The modifiable factors that were associated with a high prevalence of all hrHPV and the individual genotypes were high parity, multiple sexual partners, and early sexual debut. These factors have been well documented in literature as associated with HPV infection [25–27] including among HIV positive women [25, 28, 29]. Education about the importance of these risk factors should be conducted among all women to contribute to cervical cancer prevention and control efforts. Besides HPV 16, those with primary and tertiary education level had a higher prevalence of HPV. The association between HPV infection and education level has been established in previous studies [20]. It is possible that those with higher education level are at low risk of HPV infections due to access to information. The other important factor was smoking which was associated with HPV 16, HPV 18–45 and other hrHPV. Smoking is also a well-established risk factor for HPV infection [30–32]. As a modifiable factor, health education and behaviour change programmes should support HPV positive women to cease smoking. Women aged 36–49 years had a lower prevalence of HPV compared to those 25–35 years. Older women are more likely to be married and not have several sexual partners which are key HPV risk factors [27, 28]. Moreover, in this study, being married was associated with a lower HPV prevalence across all hrHPV and the individual genotypes (HPV 16, HPV 18–45 and other hrHPV). The association between occupation and HPV 16 requires further inquiry.
While cervical cancer screening programs exist in most developing countries, they often lack systematic, organized population-based screening. There is a need for both opportunistic and coordinated screening integrated into HIV services to promote early detection. Provider-initiated screening programs could help identify precancerous cervical lesions earlier. Self-collection of urine or vaginal samples for HPV testing is a non-invasive approach that could improve patient compliance with screening. Leveraging these types of strategies that are feasible in resource-limited settings provides a major opportunity to strengthen cervical cancer prevention efforts and reduce the heavy burden of cervical cancer among women living with HIV. [33] [34] .
This study has some limitations. The cross-sectional design prevented us from prospectively examining whether sexual activity leads to HPV infection and subclinical disease in these women. We also could not assess prior HPV exposure. Additionally, we lacked complete details on antiretroviral treatment regimens, duration, current viral load, and CD4 + counts for the HIV-positive participants. However, a strength of our study is the use of HPV molecular assays (DNA or RNA), which are more specific than other tests. Also, with a large sample size, this is the first major study in Uganda to evaluate HPV prevalence in this population. Going forward, we propose that studies: prospectively evaluate HPV outcomes in a population of HIV positive women vs. non- HIV positive women. Also, studies looking at determinants of other important risk factors for HPV pathogenesis and progression such as smoking, multiple sexual partners, high parity and sexual debut among HIV positive women are welcome.