Objective: To evaluate the impact of ART duration and CD4 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: Prospective longitudinal cohort study in Botswana.

Methods: From February 2021 to August 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 (RRs) 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 detectable HIV viral load and 94.4% were on a dolutegravir-based ART regimen. WWH had a higher risk of HPV (RR1.27,95%CI:1.18,1.37), CIN2+ (RR1.52,95%CI:1.16,1.98) and CIN3+ (RR1.75,95%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 count had similar risk to those without HIV (nadir CD4≥500 CIN2+ RR1.15[95%CI:0.56,2.37], CIN3+ RR1.81[95% CI:0.86,3.79]; nadir CD4 350-499 CIN2+ RR1.23[95% CI:0.71,2.12], CIN3+ RR1.34[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.