Background: Cervical cancer (CC) screening and treatment of cervical pre-cancer is effective in CC prevention. UNAIDS recommends that all women living with HIV should be offered CC screening and treatment, if needed. Early antiretroviral treatment (ART) and HIV viral suppression (VS) might reduce risk of progression to invasive CC in HIV-positive women. We used the 2015-16 Malawi Population-based HIV Impact Assessment (MPHIA) data to describe CC screening in HIV-positive women in Malawi, a high HIV burden country with highest CC incidence, globally.
Methods: MPHIA is a nationally representative household survey. Consenting females aged 15-64 years were interviewed and tested for HIV using the national rapid test algorithm; positives were confirmed using Geenius? HIV 1/2 Confirmatory Assay (Bio-Rad). ART use was defined as self-reported or presence of detectable ART in blood. Self-reported CC screening data were analyzed by HIV test result and ART status using weighted percentages and 95% confidence intervals (CI) that account for complex survey design.
Results: Among 1,507 HIV-positive women, 295 (16.0%; 95% CI: 13.4% - 18.6%) reported CC screening, compared to 758 of 8,375 (7.4%; 95% CI: 6.3% - 7.7%) HIV-negative women.
Among 1,110/1507 HIV-positive women on ART, 83.0% (95% CI: 80.0% - 86.0%) reported not being screened for CC. Percentage of HIV-positive women on ART who were not screened for CC was greatest in those aged 15-24 years (94.9%) and in women in rural areas (68.4%) (Table 1).
Among women screened for CC, 18/295 (5.3%; 95% CI: 2.3%-8.3%) HIV-positive and 23/758 (3.7%; 95% CI: 2.2%-5.2%) HIV-negative women reported an abnormal result. Of the 41 women with abnormal results, 17 (47.5%; 95% CI: 28.8%-66.3%) reported receiving same day pre-cancer treatment; 11 (30.0%; 95% CI: 12.5% - 47.3%) reported receiving different day treatment and 13 (22.6; 95% CI: 11.0%-34.1%) reported not receiving treatment. No differences were observed in pre-cancer treatment by HIV status.
Conclusions: CC screening in Malawi was low in general and in HIV-positive women, even among those on ART, indicating a missed opportunity. In the HIV test and treat era, strengthening integration of CC screening with HIV services could play a vital role in CC prevention.

VariableUnweighted number of HIV positive women screenedWeighted percent of HIV positive women screened95% CIUnweighted Number of HIV positive women not screenedWeighted percent of HIV positive women not screened95% CIUnweighted denominator of HIV positive women
All HIV+ women on ART23717.014.0 - 20.087383.080.0 - 86.01,110
15-24 years65.10.7 - 9.58394.990.5 - 99.389
25-34 years5512.48.0 - 16.830387.683.2 - 92.0358
35-44 years11121.716.9 - 26.529578.373.5 - 83.1406
45-59 years5122.814.6 - 31.113377.268.9 - 85.4184
60-64 years1412.24.4 - 19.95987.880.1 - 95.573
Urban residence16131.625.1 - 38.035668.462.0 - 74.9517
Rural residence7612.09.8 - 22.251788.077.8 - 90.2593
[Cervical cancer screening in HIV positive women on ART, by age and residence]