Cervical cancer screening adherence following initial HIV testing in Eswatini

Adherence to cervical cancer screening reduces cervical cancer mortality, particularly in settings with high HIV prevalence. We conducted the first nationwide study examining adherence to cervical cancer screening following first HIV testing in Eswatini, a country with the highest HIV prevalence globally.

We analysed data of 18 989 women between 2019 and 2023 who underwent first-time HIV testing, with follow-up for cervical cancer screening until 2024 using Eswatini Client Management Information System. Cervical cancer screening adherence was defined per national guidelines: undergoing screening within one year for HIV-positive testers and within two years for HIV-negative testers. Poisson regression with robust variance assessed crude and adjusted associations between HIV test status and screening adherence and evaluated predictors of screening adherence by HIV test status.

HIV-positive test status was associated with significantly lower screening adherence (adjusted risk ratio = 0.67, 95% CI: 0.65-0.70). When applying the screening guideline for HIV-negative testers to HIV-positive testers, the association was not significant (adjusted risk ratio = 0.98, 95% CI: 0.96-1.01). For women with either HIV test result, older age (≥50 years) and care at mission hospitals or private clinics were linked to lower adherence, whereas urban residence increased adherence. Marriage was associated with higher adherence only among HIV-negative women.

Cervical cancer screening adherence remains suboptimal in Eswatini, particularly among HIV-positive women. Strengthening integration of HIV testing and cervical cancer screening, alongside targeted interventions for low-adherence subgroups, is needed to reduce screening disparities and improve cervical cancer prevention and prognosis.