Cervical Cancer Screening in Women Living with HIV in South Africa: Addressing Health Disparities Through Integrated...

South Africa confronts a syndemic triple burden of HIV, tuberculosis, and cervical cancer. Women living with HIV (WLHIV) carry a three- to six-fold elevated cervical cancer risk-a biological synergy reflected in persistently high mortality despite progressive screening policies. This review synthesises evidence for why policy has not achieved population-level impact and proposes an integrated prevention model anchored in existing HIV infrastructure.

Following PRISMA-ScR guidelines and the Population-Exposure-Outcome (PEO) framework (Population: WLHIV in South Africa; Exposure: cervical cancer screening and HIV integration strategies; Outcome: screening uptake, cascade completion, and mortality), five databases were searched (2015-2025) yielding 36 included sources. A PRISMA flow diagram is provided as Supplementary Figure 1, and a synthesis summary of all included sources is provided as Supplementary Table S1.

South Africa's cervical cancer mortality rose 12% between 2014 and 2018-paradoxically coinciding with high ART coverage. This ART paradox reflects the unintended consequence of extending WLHIV lifespan into cancer-vulnerable age cohorts without commensurate screening provision. WLHIV face approximately three times the cervical cancer incidence of HIV-negative women; HPV positivity is more than double (41.5% vs 17.4%), post-treatment clearance substantially lower (39.0% vs 65.2%), and all-cause mortality 52% higher (aHR 1.52; 95% CI 1.06-2.19). Point-of-care single-visit screen-and-treat achieved same-day thermal ablation in 94.6% of eligible women in a South African primary care demonstration. Three structural cascade failure points-service silos, loss to follow-up, and treatment bottlenecks-explain the persistent policy-to-outcome gap.

An eight-component integrated model is proposed: co-scheduling screening with CCMDD dispensing visits, WBOT cascade navigation, point-of-care HPV self-sampling, single-visit screen-and-treat, and digital cascade monitoring linked to HIV information systems.

Achieving WHO 90-70-90 targets in high-HIV-prevalence settings requires a fourth pillar-HIV-stratified delivery (90-70-90+H)-with WLHIV as a mandatory priority subpopulation. Cervical cancer screening for WLHIV must be reclassified as a standard component of HIV chronic care.