---
title: "Precancerous Cervical Lesions in HIV-Positive Women in Southern and Eastern Africa: Pooled Prevale"
id: "plos-one-16-precancerous-cervical-lesions-and-associated-factors-among-hiv-positive-women"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-16-precancerous-cervical-lesions-and-associated-factors-among-hiv-positive-women"
content_type: "clinical_feed_article"
specialty: "Oncology"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361185"
published_at: "2026-10-23T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Precancerous Cervical Lesions in HIV-Positive Women in Southern and Eastern Africa: Pooled Prevale
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-16-precancerous-cervical-lesions-and-associated-factors-among-hiv-positive-women
- **Specialty:** [Oncology](https://medichelpline.com/clinical-feed/oncology.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361185)
- **Published At:** 2026-10-23T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- Investigators conducted a systematic review and meta-analysis of primary studies from Southern and Eastern Africa, registered in PROSPERO (CRD420251123583), following PRISMA 2020 standards. - The pooled analysis included 44 studies with a combined sample of 47,009 women living with HIV (WLHIV); data sources extended from inception to August 15, 2025. - Data extraction and analyses were performed using Microsoft Excel and STATA 17; study quality was appraised with the Newcastle–Ottawa Scale. - The pooled prevalence of **precancerous cervical lesions** (PCCL) among WLHIV was reported at 22.25% (95% CI: 19.57–24.93) in the included studies. - The literature showed wide between-study prevalence variation, with reported site-level estimates ranging from 1.87% to 76.00% across countries in the region. - Factors associated with increased odds of PCCL (reported as ORs) included: age at first sexual intercourse <18 years (OR 2.99), multiparity (OR 4.97), multiple sexual partners (OR 3.06), history of STIs (OR 3.93), smoking (OR 7.01), ever using oral contraceptive pills (OR 2.69), low **CD4** count (OR 1.79), and not initiating **ART** (OR 2.02). - Investigators reported statistical significance for the listed associations (p<0.05 threshold used in source); heterogeneity, subgroup, sensitivity, and publication-bias assessments were performed as part of the SRMA. - The authors concluded the pooled prevalence was high and recommended interventions targeting the identified factors; they noted large variability across studies and geographic settings within Southern and Eastern Africa.
## Clinical Analysis & Structured Key Points
Precancerous cervical lesions and associated factors among HIV-positive women in Southern and Eastern African countries: A systematic review and meta-analysis | PLOS One Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click here . Article Authors Metrics Comments Media Coverage Peer Review Reader Comments Figures Figures Abstract Background Women living with HIV (WLHIV) face a sixfold increased risk of cervical cancer compared to HIV-negative women. Most WLHIV residing in the Southern and Eastern African regions have a substantial HIV-related cervical cancer burden. Studies on precancerous cervical lesions (PCCL) and associated factors in WLHIV from these regions have inconsistent and inconclusive findings. Therefore, we aimed to synthesize the pooled prevalence of PCCL and associated factors among WLHIV in Southern and Eastern Africa. Methods This study was registered under PROSPERO (CRD420251123583) and conducted in accordance with PRISMA 2020 standards. Primary studies published from inception to 2025 in Southern and Eastern Africa were included. The methodological quality of studies was assessed using the Newcastle-Ottawa scale. Data extraction and statistical analyses were done in Microsoft Excel and STATA 17, respectively. Pooled prevalence, publication bias, subgroup, and sensitivity analysis were conducted. Associations were expressed as odds ratios (OR), and a p-value of less than 0.05 was considered statistically significant. Results 44 studies met the inclusion criteria, with a sample size of 47,009. The pooled prevalence of PCCL was 22.25% (95% CI: 19.57, 24.93). Age at first sexual intercourse (< 18 years) (OR = 2.99, (2.34, 3.82)), multiparity (OR = 4.97, (3.21, 7.69)), having multiple sexual partners (OR = 3.06 (2.45, 3.83)), having a history of sexually transmitted infections (STI) (OR = 3.93 (3.23, 4.78)), smoking (OR = 7.01, (3.39, 14.49)), ever taking oral contraceptive pills (OR = 2.69, (1.85, 3.90)), low CD4 count (OR = 1.79, (1.56, 2.05)), and having not initiated antiretroviral therapy (ART) (OR = 2.02, (1.56, 2.62)) were significantly associated with an increased risk of PCCL. Conclusion and recommendations The pooled prevalence of PCCL was high. Additionally, early first sexual intercourse, parity, STIs, multiple sexual partners, smoking, oral contraceptive use, CD4 count, and ART were positively associated with the occurrence of PCCL. Therefore, stakeholders shall implement interventions to avert future incidents of PCCL and address the identified factors. Citation: Alemu GG, Bazezew AM, Yirsaw AN, Wondie WT, Mengistie BA, Dagnaw TE, et al. (2026) Precancerous cervical lesions and associated factors among HIV-positive women in Southern and Eastern African countries: A systematic review and meta-analysis. PLoS One 21(10): e0361185. https://doi.org/10.1371/journal.pone.0361185 Editor: Ricardo Ney Oliveira Cobucci, UFRN: Universidade Federal do Rio Grande do Norte, BRAZIL Received: November 28, 2025; Accepted: October 5, 2026; Published: October 23, 2026 Copyright: © 2026 Alemu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: All relevant data are within the paper and its Supporting Information files. Funding: The author(s) received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist. Abbreviations: OR, Odds Ratio; ART, Antiretroviral Therapy; CD4, Cluster of Differentiation 4; CI, Confidence Interval; HPV, Human Papillomavirus; HIV, Human Immunodeficiency Virus; LMICs, Low-and Middle-Income Countries; NOS, Newcastle‒Ottawa Scale; PCCL, Precancerous Cervical Lesions; STI, Sexual Transmitted Infections; SEA, Southern and Eastern Africa; SSA, sub-Saharan Africa; SRMA, Systematic Review and Meta-Analysis; WHO, World Health Organization; WLHIV, Women Living with HIV Introduction A precancerous cervical lesion (PCCL) is a cervical intraepithelial neoplasia or squamous intraepithelial lesion that can progress to cervical cancer in people living with human immunodeficiency virus (HIV) if untreated [ 1 ]. Cervical cancer is largely preventable through human papillomavirus (HPV) vaccination and regular screening and is curable when detected and treated early [ 2 ]. Cervical cancer screening is intended to identify women who are at risk and to make sure that those who have a positive or abnormal test result receive the proper follow-up. The World Health Organization (WHO) advises using a “screen-and-treat” strategy to detect and cure precancerous lesions in order to avoid cervical cancer. Following a positive screening test, treatment should be administered quickly. Screening tests include Human Papillomavirus Deoxyribonucleic Acid (HPV DNA), Visual Inspection with Acetic Acid (VIA) or Visual Inspection with Lugol's Iodine (VILI), and the Pap smear/cytology [ 3 , 4 ]. The WHO has set new ambitious targets to eliminate cervical cancer [ 2 , 5 ]. Besides the goal, it was insufficient to eliminate cervical cancer among WLHIV [ 6 ], and a study predicts that new cases are expected to rise by 2050 [ 5 ]. Globally, 99.7% of cervical precancerous and malignant lesions are attributable to HPV [ 7 ]. HIV-positive women are more likely to develop PCCL and invasive cervical cancer. They are 6 times more likely to develop cervical cancer compared to women without HIV [ 2 ]. Cervical cancer incidence and mortality are highest in low- and middle-income countries (LMICs), largely due to lack of access to HPV vaccination, screening, and socioeconomic determinants [ 2 ]. Approximately 85% of WLHIV and cervical cancer cases occur in sub-Saharan Africa (SSA), highlighting the region’s high cervical cancer burden and persistent inequalities [ 5 ]. The most affected regions with the double burden of diseases were Southern and Eastern Africa (SEA). In 2018, HIV prevalence among women with cervical cancer was 63.8% in Southern Africa and 27.4% in Eastern Africa [ 8 ]. Understanding the factors associated with PCCL is critical to create evidence-based interventions to prevent cervical cancer [ 9 ]. Socioeconomic and demographic factors, healthcare access, and behavioral and clinical factors, including poverty, age, education, parity, distances to services, sexual behavior, absence of screening facilities, CD4 count, viral load, STIs, ART use, oral contraceptives, and tobacco use, are listed among the contributing factors for the occurrence of PCCL [ 10 – 25 ]. There have been conflicting results and conclusions from studies that assessed the prevalence and associated factors of the PCCL among WLHIV across SEA countries, ranging from 1.87% in Zimbabwe [ 26 ] to 76.00% in Zambia [ 27 ]. Small, independent studies may yield inconclusive results, but combining data increases precision. Therefore, the objective of this systematic review and meta-analysis (SRMA) was to determine the pooled prevalence of PCCL and identify associated factors. This study will give insight to policymakers, program planners, researchers, clinicians, and other key stakeholders to implement an intervention that prevents cervical cancer and will provide better guidance for future interventions. Methods and materials This SRMA was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines [ 28 ] ( S1 Table ). The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database at ( https://www.crd.york.ac.uk/PROSPERO/view/CRD420251123583 ). Eligibility criteria Inclusion criteria. We included original primary studies, both published and unpublished, in any language reporting data on the PCCL and/or associated factors among WLHIV in Southern and Eastern Africa, from inception through August 15, 2025. Exclusion criteria. Studies that did not report the outcomes of interests, reviews, case studies, letters, protocols, studies without full texts [ 29 , 30 ], and articles that failed to satisfy the quality assessment standards were excluded [ 31 , 32 ]. Information sources and search strategy An inclusive literature search for primary studies on PCCL and associated factors was conducted using the Condition, Context, and Population (CoCoPop) framework across electronic databases, including PubMed/MEDLINE, Embase, Scopus, Google Scholar, ScienceDirect, and Hinari, to retrieve potential studies relevant to the objective of this study. Additionally, the snowballing technique was conducted. Furthermore, manual searches were performed across different repositories to identify grey literature. Search strategies were adapted for each selected database using relevant search terms and combinations of terms in a systematic search syntax using Boolean operators (“AND” and “OR). The literature search was conducted from July 25 to August 15, 2025, and updated in August 2026. The following search syntaxes and phrases were used for searching. Precancerous; “precancerous cervical lesion”; “cervical lesion”; “Cervical Intraepithelial Neoplasia”; “Cervical cancer”; “HIV-positive women”; “HIV Infections”; “HIV-Sero positivity”; “Women living with HIV”; Determinants; Predictors; “Associated Factors”; “Risk Factors”; Barriers; Burundi; Botswana; Comoros; Djibouti; Eritrea; Eswatini; Ethiopia; Kenya; Lesotho; Madagascar; Malawi; Mauritius; Mozambique; Namibia; Rwanda; Seychelles; Somalia; “South Africa”; “South Sudan”; Swaziland; Tanzania; Uganda; Zambia; Zimbabwe; “Eastern Africa”; “Southern Africa.” The details of the electronic data bases, the search strategy, and the corresponding numbers are supplied ( S2 Table ). Selection process All retrieved records were exported into EndNote 20 to remove duplicates and then evaluated for eligibility. The retrieved data were screened independently by two authors (GGA and MNA) according to the review's eligibility criteria. The evaluation process was conducted at three stages: title, abstract, and full-text. The full texts of potentially eligible abstracts were downloaded and examined to verify whether they fulfilled the inclusion criteria. Any disagreement was resolved through discussion with a third reviewer (AMB). Data extraction Data extraction was carried out separately by two reviewers (GGA and NDB) utilizing a prearranged Microsoft Excel. The extracted data items include the first author's name, year of publication, study country, sample size, response rate, and variables related to PCCL and OR with 95% CIs. Study quality and risk of bias assessment The quality of the included studies was independently assessed by three authors (GGA, BTG, and MNA). Disagreements in the assessment and scoring were solved through discussion and consensus. The quality of studies was assessed using the Newcastle‒Ottawa Scale (NOS). The tool was adapted for the purpose of this study. It included 3 categorical criteria comprising selection (maximum 5 scores), comparability (maximum 2 scores), and outcome (maximum 3 scores) with a total maximum score of 10 points. The quality of the included studies was rated according to the following scale: Very good studies: 9–10 points; good studies: 7–8 points; satisfactory studies: 5–6 points; unsatisfactory studies: 0–4 points. Studies with satisfactory to very good quality were included ( S3 Table ) [ 33 , 34 ]. Effect measures The primary outcome of interest for this review was the pooled prevalence of PCCL, estimated as the total number of WLHIV with lesions divided by the total number of WLHIV taking part in the study multiplied by 100%. The secondary outcomes were factors associated with PCCL. We assessed the association between precancerous lesions of the cervix and its determinants in the form of the log odds ratio. For determinants, the odds ratio was calculated based on binary outcomes from the primary studies. Data synthesis and analysis The extracted data were imported into STATA 17 software for comprehensive analysis. The analyzed data were presented as texts, tables, and figures. The margin of error for the prevalence in each study was calculated using a binomial probability model. The combined prevalence from the studies was evaluated for heterogeneity using the I 2 statistic. The proportions of 25%, 50%, and 75% were defined as low, moderate, and high heterogeneity, respectively [ 35 ]. We performed a meta-analysis to estimate the pooled prevalence of PCCL. Subgroup analyses were conducted for geographical area, year of publication, and screening methods. Similarly, a leave-one-out sensitivity analysis was performed to evaluate the robustness of the synthesized results. Publication bias was assessed visually by funnel plots and quantitatively by the Egger regression model. For the variables associated with PCCL, the OR along with its 95% CIs and p < 0.05 was used as the significance threshold. Operational definitions Cervical intraepithelial neoplasia: a histological diagnosis made upon analysis of cervical tissue obtained by biopsy or surgical excision. The condition is graded as CIN 1, 2, or 3, according to the thickness of the abnormal epithelium (1/3, 2/3, or the entire thickness). Squamous intraepithelial lesion: an abnormal result derived from cervical cytological screening or Pap smear testing. Low-grade squamous intraepithelial lesions (LSIL/CIN-1) are defined by early changes in size, shape, and number of abnormal cells formed on the surface of the cervix and may be referred to as mild dysplasia, LSIL, or CIN-1. High-grade squamous intraepithelial lesions (HSIL/CIN-2/CIN-3/CIS) are defined by a large number of precancerous cells on the surface of the cervix that are distinctly different from normal cells. They have the potential to become cancerous cells and invade deeper tissues of the cervix. These lesions may be referred to as moderate or severe dysplasia, HSIL, CIN-2, CIN-3, or cervical carcinoma in situ (CIS). Carcinoma in situ (CIS): pervasive malignancy limited to the epithelium without invasion of the basement membrane. Invasive cervical cancer: a malignant tumor that has spread from the cervix to the tissue deeper in the cervix or to other parts of the body. Invasive cervical cancer stages range from stage I (cancer is in the cervix or uterus only) to stage IV (the cancer has spread to distant organs, such as the liver). Ethical statements The study utilized publicly available primary studies. No new original data involving human participants was gathered. Consequently, ethical approval was not necessary for this study. Results Identification and selection of the studies A total of 2070 studies were identified through database searches and from manual sources. After removing 542 duplicates, 1528 articles were screened by title and abstract; 1433 were subsequently excluded due to being unrelated to the title and abstract contents. Then 95 full-text articles were assessed for eligibility, but 51 were excluded with reason through the critical review process ( S4 Table ). Finally, 44 articles met the inclusion criteria for determining the pooled prevalence of PCCL and its associated factors and included ( Fig 1 ). Download: PNG larger image TIFF original image Fig 1. A PRISMA flow diagram illustrating study selection for the pooled prevalence of PCCL and its associated factors among WLHIV in Southern and Eastern Africa, 2025. https://doi.org/10.1371/journal.pone.0361185.g001 Study characteristics This study included 44 articles involving a total of 47,009 participants, with the sample size and response rate ranging from 49 to 16,869 and 84.05% to 100%, respectively. Regarding the distribution of studies, fifteen were conducted in Ethiopia [ 11 , 13 – 15 , 21 , 22 , 25 , 36 – 43 ], ten in Kenya [ 1 , 19 , 44 – 51 ], four each in Uganda [ 17 , 52 – 54 ] and Tanzania [ 12 , 23 , 55 , 56 ], three in South Africa [ 24 , 57 , 58 ], two each in Namibia [ 59 , 60 ] and Zambia [ 27 , 61 ], and one each in Rwanda [ 62 ], Botswana [ 63 ], Eswatinia [ 18 ], and Zimbabwe [ 26 ]. Moreover, 33 studies were conducted using a cross-sectional design, 4 using a cohort design, 2 using a case-control design, 1 using a randomized control trial, and the remaining 4 were not reported on study design. Regarding the screening methods, 26 were conducted using VIA/VILI, 15 using Pap smear/cytology, and 3 using HPV DNA ( Table 1 ). Download: PNG larger image TIFF original image Table 1. Descriptive characteristics of the included studies for premalignant cervical lesions and associated factors, 2025. https://doi.org/10.1371/journal.pone.0361185.t001 Prevalence of precancerous cervical lesions This review revealed that the prevalence of PCCL among WLHIV in Eastern and Southern Africa varies from 1.87% (95% CI: 0.39, 3.51) to 76.00% (95% CI: 69.17, 82.83). The pooled prevalence of PCCL was 22.25% (95% CI: 19.57, 24.93), I 2 = 98.43%, p < 0.001 ( Fig 2 ). Of the pooled prevalence of PCCL, low-grade squamous intraepithelial lesions (CIN 1) accounted for the majority of PCCL (66%), while high-grade squamous intraepithelial lesions (CIN 2 and CIN 3) accounted for the remaining 34%. Download: PNG larger image TIFF original image Fig 2. The prevalence of PCCL for each study and the pooled prevalence among WLHIV in Southern and Eastern Africa, 2025. https://doi.org/10.1371/journal.pone.0361185.g002 Handling heterogeneity Due to the heterogeneity observed, a random-effects meta-analysis model was employed to account for variability among the studies and provide a more reliable estimate. To explore potential causes of this heterogeneity, a subgroup analysis was carried out based on the geographical region of the studies, the year of publication, and the methods used for screening. Additionally, a sensitivity analysis was conducted. The subgroup analysis of PCCL by geographical region was high among the studies conducted in Southern Africa, which was 31.08%. The lowest was observed in Eastern Africa, which was 20.66% ( Fig 3 ). The reason for the difference between Southern and Eastern Africa is that Southern Africa has the highest HIV rates in the world. The difference in HIV infection rates increases PCCL by causing widespread immune system damage, which allows HPV to persist and facilitates the direct molecular actions of HIV proteins that accelerate cellular transformation. Download: PNG larger image TIFF original image Fig 3. Subgroup analysis by the geographical region for PCCL and its associated factors among WLHIV, 2025. https://doi.org/10.1371/journal.pone.0361185.g003 A subgroup analysis by the study year of publication showed that studies published before 2019 reported a higher overall rate of PCCL, which was 28.08%. In contrast, studies published from 2020 to 2022 revealed a lower overall PCCL, which was 13.22% ( Fig 4 ). The number of women screened before 2019, from 2020 to 2022, and post 2022 were 12052, 7668, and 27289, respectively. The lowest overall prevalence of PCCL and the lowest number of women screened occurred from 2020 to 2022. The reason behind it is due to the COVID-19 pandemic. The COVID-19 pandemic led to a significant decline in cervical cancer screenings, as clinics closed, healthcare resources diverted, and patients avoided care. It led to non-adherence to screening, which disproportionately affected under-represented populations (WLHIV) in lower socioeconomic regions (SEA). As a result, the occurrence of PCCL became lower. From 2023 to 2025, the prevalence of PCCL and the number of women screened increase to 19.67% and 27,289, respectively. The prevalence is adjusted once the pandemic has passed. Download: PNG larger image TIFF original image Fig 4. Subgroup analysis by the study year of publication for PCCL and associated
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