Persistent human papillomavirus after thermal ablation in Malawian women with and without HIV: Implications for risk-based cervical cancer prevention in low- and middle-income countries.

Abstract

Background: Persistent high-risk human papillomavirus (hrHPV) infection can lead to cervical precancer, with women living with HIV (WLWH) at increased risk due to impaired immune clearance. Thermal ablation (TA) is a low-cost treatment for precancerous lesions, but data on hrHPV persistence after TA among WLWH are limited.

Objectives: To evaluate overall and channel-specific hrHPV persistence 12 months after TA among women in Lilongwe, Malawi.

Design: Cross-sectional analysis of Malawian women who received TA during and after the PEER trial (prevention of cervical cancer through two HPV-based screen-and-treat implementation models in Malawi).

Methods: We analyzed 495 hrHPV-positive women (113 WLWH, 382 without HIV) treated with TA. Self-collected cervicovaginal samples were obtained before treatment and at 12 months post-treatment and tested with the GeneXpert HPV assay, which detects hrHPV across five high-risk genotype channels (P1-P5). Channels P3-P5 were grouped as non-16/18/45 hrHPV types (HPV 31, 33, 35, 39, 51, 52, 56, 58, 59, 66, 68). Persistence was defined as the detection of the same channel at both time points. Differences in persistence rates were assessed using Fisher's exact and Welch's t-tests.

Results: At 12 months post-TA, 35.6% of women were persistently hrHPV-positive. Persistence was higher among WLWH (46.0%) than women without HIV (32.0%, p = 0.01). By genotype, persistence was most common for non-16/18/45 types (37.7%), followed by HPV16 (28.9%) and HPV18/45 (18.0%). WLWH had higher persistence of non-16/18/45 types (51.8% versus 33.7% in HIV-negatives, p = 0.003), while persistence of HPV16 (35.0% versus 27.1%, p = 0.58) and HPV18/45 (26.3% versus 14.9%, p = 0.14) did not differ significantly.

Conclusions: Over one-third of women had persistent hrHPV 12 months after TA, with higher rates among WLWH, primarily for non-16/18/45 genotypes. Findings highlight the need for enhanced follow-up and adjunct therapies to improve post-treatment clearance and advance cervical cancer prevention in low-resource settings.