This study aimed to assess the co-morbidity of cervical cancer and its associated factors among WLHIV in the Awi zone, northwest Ethiopia. The study revealed that the overall prevalence of co-morbidity of CC among WHIV in Awi Zone was 24.9% (21.3–28.1%).This finding is in line with the previous studies in Kenya (26.4%), SSA (25.6%), Tanzania (26.7%), Swaziland (22.9%), India (24.06%) [39–43]. However, the findings of this study were slightly higher than previous studies in Ethiopia, including those conducted at referral hospitals in the Amhara region ([44], Eastern Ethiopia ([37], North-east Ethiopia [45],Northwest Ethiopia [46]. The observed discrepancy might be due to inclusion criteria; the current study included only women who were screened for CC. In addition, it might be due to the scaled-up CC screening as a result of some emphasis given relative to the previous years. The more women’s living with HIV/AIDS were screening for CC, the probability of obtaining positive cases increases. Furthermore, this finding was also found to be higher than some previous studies in Zambia (15%) [47], Nigeria (19%, 19.5% and 12.8%) [48–50],Namibia (17%) [51], and Spain 18% [52]. The sources of heterogeneity in the finding could be due to differences in CC screening techniques as a result of the varied sensitivity and specificity of each screening method [47, 53, 54]. The sources of heterogeneity in the finding could be due to differences in CC screening techniques as a result of the varied sensitivity and specificity of each screening method [55]. Therefore, the varied status of LMICs in HPV vaccine uptake [56] and the high prevalence of high-risk HPV in Ethiopia[57], could be a possible reason for the upward inclination of the finding in the current study. The above finding implies that co-morbidity cervical cancer is a significant public health problem in the study area, and it highlights the need to scale up CCS by expanding the screening service throughout the health facilities for vulnerable communities to uncover the magnitude of the problem. In contrast, the above finding was also found to be lower than results of previous studies in South Africa [58], Zambia52% [54], Cameron (68.18%) [59], and systematic review and meta-analysis study conducted At Africa level [18]. The higher prevalence reported by the other studies could be due to the behavioral and sexual characteristics of the women studied, such as age at first sexual debut and the number of sexual partners. As women have frequent exposure to sexual intercourse with different people, the risk of acquiring HPV increases, leading to CC [60, 61]. Furthermore, it could be partly explained by variation in methods of screening for CC [54], because the more variation in the measurements, the more varied the result the result will be due to the varied specificity and sensitivity of each screening method [47, 53, 54].
In the current study, history of STD was found to be significantly associated with the co-morbidity of cervical cancer (CC). Those women living with HIVB/AIDS who had ever had a history of an STD were almost four (3.97) times more likely to have co-morbidity than those who never had a previous history of STIs. This finding is in harmony with previous studies in referral hospitals in the Amhara region, Northwest Ethiopia [45, 62], Saint Peter specialized hospital in Addis Ababa, Ethiopia [63], and in different African countries like Nigeria and Uganda [42, 50, 64], respectively. The possible explanation could be that HPV infection is more prevalent in STI patients due to its sexually transmitted nature. Co-infection with an STI and HPV amplifies the risk of CC by causing inflammation, which enables HPV persistence and adherence. This severely affects immunocompromised women, making them vulnerable to other opportunistic infections, including CC [65]. These findings suggest that screening for HPV and precancerous cervical lesions (PCCLs) needs to be made available to all women with STIs.
A significant association was also obtained between lifetime numbers of sexual partners and the co-morbidity of CC; the women who had more than one lifetime sexual partner were almost three (2.86) times more likely to have PCCL as compared to those women who had only one lifetime sexual partner. This finding is supported by previous studies in Northeast Ethiopia [45], referral hospitals in Amhara region, northwest Ethiopia [62], in Mekelle, northwest Ethiopia [66]. It also in harmony with studies in SSA[39], and Swaziland [42]. This could be due to the increased number of sexual partners, which increases the chance of acquiring HPV infection. The above finding implies that reducing the co-morbidity of CC among WLHIV is highly determined by emphasizing and undertaking preventive measures against sexually transmitted infection and reducing the number of sexual partners. It would be better to incorporate sexual and reproductive health into health education programs to decrease this co-morbidity.
The odds of developing CC among women who took OC were almost two times (2.19) higher than those of those who did not take OC. This finding is supported by previous studies in Debre Markos comprehensive specialized referral hospital, Adama referral hospital western Kenya, and a systematic review and meta-analysis report, respectively [37, 67–69]. The possible explanation for this might be that prolonged use of oral contraceptives may increase the eversion of the columnar epithelium of the cervix to the ectocervix, which enhances the exposure of the columnar epithelium to HPV infection, the main cause of almost all CC [69]. In addition, women’s who use oral contraceptives might have different sexual behaviors compared to those who do not, such as having more sexual partners or less frequent condom use, which can increase the risk of HPV infection.
The odd’s of developing a comorbidity of cervical cancer is almost four times (3.82) higher among women who had a baseline CD4 cell count of ≤ 200 cells/mm³ compared to their counterparts. This finding is in line with studies conducted in Woldia and Mekelle Comprehensive Specialized Hospital, Northwest Ethiopia [70, 71]. It is also supported by a study in Tanzania [72], and systematic review and meta-analysis studies in Africa and globally [39, 73–75]. This can possibly be explained by the fact that as CD4 counts decline, women's immunity weakens, reducing their ability to clear HPV infections compared to HIV-negative women[73]. HIV-induced immunosuppression playing a significant role in preventing the effective clearance of HPV and controlling its manifestation, hence increasing the chance of acquiring opportunistic infections such as cervical cancer [43, 73]. The above finding suggests that reducing vulnerability to the comorbidity of cervical cancer is highly dependent on maintaining women’s immune status. Hence, it may be beneficial to initiate a cotrimoxazole preventive therapy (CPT) booster dose for those with low CD4 counts.
Furthermore, adherence to ART drugs also has a significant association with the comorbidity of HIV and cervical cancer. In this study, the odds of developing the co-morbidity of cervical cancer among women living with HIV who have poor and fair adherence status were almost three times (2.81 and 3.25, respectively) more likely compared to those who have good adherence.. The possibly explanation could be being on ART with good adherence boosts women’s immunity and reduces the tendency to develop PCCL. It could be also explained by the fact that HAART lowers HPV acquisition, and increases clearance via immune reconstitution, decrease risk of the progession precancerous lesion to cervical cancer [74, 76]. The above finding implies that preventing co-morbidity of CC is highly determined by increase the ART drug adherence level of women’s living with HIV/AIDS
4.1 Limitation of the study
The limitations of this study include that variables such as age at first sexual intercourse and number of sexual partners were retrospectively reported by participants over many years. Therefore, the information provided may be subject to recall bias and social desirability bias. Additionally, visually apparent cervical cancer lesions (PCCL) could have been missed using the VIA screening method due to its limited sensitivity, potentially underestimating the magnitude of the outcome. Moreover, the inherent subjectivity of visual screening methods could influence the study's findings in either direction, leading to potential overestimation or underestimation to some extent.