Precancerous Cervical Lesions in HIV‐Positive Women: Caution Needed in Interpreting Low Prevalence Estimates

We read with great interest the study by Tesfahun et al. on the prevalence of precancerous cervical lesions (PCCL) among HIV-positive women in Ethiopia [1]. Cervical cancer prevention in women living with HIV remains a critical issue, and the authors are to be commended for addressing this gap. However, several methodological and interpretive limitations call for a cautious appraisal of their findings. The reported prevalence of PCCL in HIV-positive women 5.4 percent was unexpectedly lower than in HIV-negative women 10.7 percent [1]. This finding diverges from much of the regional and global literature. For example, a multicenter study in Addis Ababa documented a 16.6 percent prevalence of PCCL among HIV-positive women [2], while a systematic review of Ethiopian cohorts reported a pooled prevalence of approximately 15 percent [3]. Similarly, Ugandan data demonstrated 23 percent of HIV-positive women had premalignant cervical changes, compared with 12 percent among HIV-negative counterparts [4]. Such discrepancies raise questions about sampling strategies and the representativeness of the study population. Tesfahun et al. selected equal numbers of HIV-positive and HIV-negative women from a single region, but it is unclear whether this reflected the actual population distribution. This design may have inadvertently introduced selection bias. Another limitation is the exclusive reliance on visual inspection with acetic acid (VIA) as the diagnostic tool. While VIA is pragmatic in low resource settings, its sensitivity and specificity are suboptimal, and results are vulnerable to interobserver variability [5]. The absence of histological confirmation weakens the validity of the prevalence estimates. Moreover, the study did not evaluate several key risk factors such as parity, smoking, or immunologic status (CD4 count, viral load, ART duration) which are well-established determinants of cervical dysplasia [2, 3, 6]. Without adjusting for these variables, residual confounding is inevitable. Statistical power is another concern. Only 42 cases of PCCL were detected in total, yielding wide confidence intervals for adjusted odds ratios. For example, the association between multiple sexual partners and PCCL produced extremely wide intervals, suggesting instability of the estimates [1]. With such limited event numbers, even minor data irregularities could have significantly influenced the conclusions. The facility-based, cross-sectional design further limits external validity. Ethiopia is highly diverse in terms of HIV prevalence, HPV vaccine uptake, and healthcare access. Findings from a single region should not be generalized to the national level, especially when they diverge from multicenter and meta-analytic evidence [2, 3]. Despite these weaknesses, the study contributes important insights. The comparative approach between HIV-positive and HIV-negative women is rarely employed in this context, and identifying behavioral risk factors such as sexually transmitted infections and multiple partnerships aligns with prior evidence [3, 6]. The emphasis on screening within ART clinics also reflects an important operational strategy. Looking forward, several steps are needed to strengthen research and practice. Future studies should adopt multicenter or population-based sampling strategies, integrate more accurate diagnostic methods such as HPV DNA testing or cytology, and account for immunologic and behavioral risk factors. Given the reports of postmenopausal bleeding and higher lesion prevalence in immunocompromised women, surveillance should be intensified among older HIV-positive women [5, 6]. In line with WHO's global elimination targets, ensuring at least 70 percent of women are screened with high-performance tests by age 45 remains essential [7]. Integration of HPV vaccination expanded screening coverage, and linkage of ART clinic data with national cancer registries would significantly advance Ethiopia's cervical cancer prevention agenda. Hun and colleagues have provided some valuable early data on this topic. However, we should interpret their findings very carefully, since the study has certain methodological and contextual limitations. In fact, other evidence from around the world and in Ethiopia suggests that women living with HIV face an even greater burden of PCCL than Hun et al.'s study reports. It's clear that we now need larger, more rigorous research studies that dig into the underlying mechanisms so that policymakers and healthcare providers in Ethiopia (and beyond) have solid evidence to guide effective policies and clinical interventions. Ibadullah Tahir: conceptualization, investigation, visualization, methodology, validation, formal analysis, supervision, resources, writing – original draft, writing – review and editing. Hunain Shahbaz: writing – review and editing, resources, supervision. Aimal Khattak: visualization and supervision. The authors have nothing to report.