Prevalence of and risk factors for high-risk HPV and cervical cytological abnormalities in women living with HIV in Bali, Indonesia

BackgroundWomen living with HIV face a higher risk of developing cervical cancer compared to those without HIV. However, comprehensive cervical cancer screening programs for this population are still lacking in Indonesia. This has resulted in many cases of late-stage cervical cancer being diagnosed, especially in Bali, which has experienced an increase in cases of HIV and cervical cancer. This study aimed to determine the prevalence of and risk factors for cervical cytological abnormalities in women living with HIV in Bali and to explore their relationship with high-risk HPV (HR-HPV) types. MethodsThis is a cross-sectional study with eligible participants recruited from outpatient HIV clinics in Bali. Between July to December 2023, participants were interviewed to collect demographic and historical medical information, followed by physical examination including collection of cervical swabs and blood samples. Pap smear sampling and swab collection using ThinPrep for cytology. HPV DNA was then identified by PCR and genotyped for HR-HPV 16,18,31,33,35,39,45,51,52,56,58,59,66,68. Blood samples were analyzed for CD4 and CD8 cell counts. ResultsA total of 245 women with HIV at median age of 38 years old (24-50 years) and with median time of ARV therapy of 7 years (0-18 years) were enrolled. Only 239 participants were included in the analysis for their valid initial results. Overall, 26 (10.87%) of samples showed abnormal cytology including 6 (2.5%) ASC-H, 9 (3.8%) ASC-US, 4 (1.7%) H-SIL and 7 (2.9%) L-SIL. Of the 58 (24%) that tested positive for HPV DNA, 18 (31%) samples had abnormal cytology. HPV 18 was the most common genotype detected (n=16 or 28%). Bivariate analysis revealed a significant association between positive HPV DNA and abnormal cytology, with those testing HPV-positive having seven times higher risk of ASC-US or greater (PR=7.022;95%CI=3.223-15.295). Multivariate regression identified having HPV 18 infection as an independent risk factor for abnormal cytology (ExpB=9.029;p=0.007), and a history of Pap smear screening associated with reduced risk of HR-HPV infection (ExpB=0.358;p=0.013). ConclusionIn our study, 10.87% of women living with HIV had abnormal cytology and 24% had positive HPV DNA tests. HPV 18 was associated with a greater risk of abnormal cytology compared to other high-risk HPV strains, but our sample size was small. History of pap smear was also shown to decrease the risk of HR-HPV infection. The results underscore the need for increased vaccination of younger women and screening of all women living with HIV in Indonesia in order to improve their cervical health outcomes.