Cervical Cancer Screening Expanded Sharply Across Lusaka Clinics
Between 2010 and 2019, cervical cancer screening in Lusaka moved from a limited programmatic service to a far broader public health intervention. Across 11 government health facilities, the Cervical Cancer Prevention Program in Zambia captured 183,165 women and 204,225 screening results using visual inspection with acetic acid and digital cervicography, or VIAC. The scale alone matters. Screening programs only reduce mortality when they reach enough women often enough to identify precancerous disease before symptoms appear, and this cohort shows that reach increased over time rather than stagnating in a narrow pilot phase.
Screening frequency rose 65.7% over the study period, with most visits representing first-time screening rather than repeat attendance. In practical terms, that pattern suggests the program was still drawing in women who had never previously entered cervical cancer prevention services. For a disease that remains the fourth leading cause of cancer-related death among women worldwide, first contact with screening services is often the decisive step in interrupting the pathway from persistent human papillomavirus infection to invasive cancer.
HIV Status Marked a Clear Divide in Screening Positivity
Across the full cohort, 21,326 of 204,225 screens were VIAC-positive, a positivity rate of 10.4%. Treatment followed in 16,244 of those positive cases, or 76.2%, showing that the program reached beyond detection and into care delivery for a substantial share of women with abnormal findings. The positivity burden was not evenly distributed. Women living with HIV accounted for 76,607 screenings, or 37.5% of all tests, and they were far more likely to test positive than women who were HIV-negative.
The adjusted odds ratio for a positive VIAC result in women with HIV was 3.60, with a 95% confidence interval of 2.14 to 6.08. Biology offers a direct explanation. Immunosuppression weakens the host response to persistent oncogenic HPV infection, allowing cervical intraepithelial lesions to develop more readily and potentially progress faster than in women without HIV. In regions with a high HIV burden, cervical cancer prevention and HIV care cannot be separated without losing preventive power.
Younger women living with HIV carried the highest predictive probability of a positive screen. Among those 29 years or younger, the predicted probability reached 18.6%, with a 95% confidence interval of 14.2% to 22.9%.
Younger Women With HIV Concentrated the Highest Screening Yield
The age-specific pattern deserves attention because it complicates simple assumptions about cervical cancer risk. Traditional screening programs often focus on older age groups because invasive disease is more common later in life, but the Lusaka cohort shows that younger women living with HIV may already harbor abnormal cervical findings at a meaningful rate. The predictive probability of positivity in women aged 29 years or younger suggests that the burden of cervical precancer may begin earlier in the setting of HIV, whether through earlier HPV acquisition, impaired viral clearance, or both.
Women younger than 20 years with HIV accounted for a particularly concerning subgroup in the interpretation of the findings. The dataset cannot determine whether these positive screens reflect earlier disease onset or whether some positive results represent misclassification in an age group with a high prevalence of sexually transmitted infections. Both possibilities carry clinical consequences. If disease onset is genuinely earlier, screening strategies may need to begin sooner for women living with HIV. If misclassification contributes substantially, the limitations of visual inspection in very young women become harder to ignore, especially where inflammation and infection can mimic precancerous change.
Sensitisation Strategy Matters as Much as Test Access
The investigators evaluated not only screening results but also patterns of sensitisation strategies by age group. That design choice speaks to a core implementation problem: increasing the number of sites and tests does not automatically solve underuse. Women often face different barriers depending on age, parity, marital status, perceived risk, stigma, and prior contact with HIV services. A single outreach message rarely fits all of those realities.
Customized sensitisation strategies could improve uptake and adherence by speaking more directly to those differences. Younger women may respond to messages that address confidentiality, reproductive planning, and the meaning of an abnormal result. Older women may need reminders that the absence of symptoms does not equal the absence of risk. For women already engaged in HIV care, screening can be paired with routine visits, which may lower the logistical barrier to testing and treatment. In a programmatic setting, those details are not peripheral. They determine whether a screening program becomes a reliable prevention platform or remains an intermittent opportunity.
Treatment Coverage Leaves Room for Improvement
The treatment rate after VIAC positivity, while substantial, was not complete. Of the 21,326 women who screened positive, 16,244 received treatment. The remaining gap represents a real vulnerability in the prevention chain. Screening only prevents cancer when positive findings lead to timely management, and every missed treatment opportunity allows dysplasia to persist, recur, or progress.
The cohort also reflects the strengths and constraints of routine service delivery. Programmatic data capture real-world behavior rather than idealized trial conditions, which gives the findings immediate public health relevance. At the same time, routine data limit the ability to distinguish biologic risk from diagnostic uncertainty. That is especially true when visual inspection is used as the primary screening tool across large clinics and diverse patient populations.
The rise in screening coverage across nearly a decade suggests that organized cervical cancer prevention can gain traction in a high-burden setting. The remaining challenge is precision: reaching the women at greatest risk, testing them at the right age, and ensuring that a positive screen turns into definitive care. For Zambia and similar settings, the path to WHO elimination targets will depend on whether HIV services and cervical cancer prevention are built as one continuum rather than two separate programs.