Hysterectomy-corrected incidence of cervical cancer among women with HIV in the United States, 2001-2019

Background: Including hysterectomized women in cervical cancer rates potentially inflates incidence and may misguide prevention programs. We estimated the hysterectomy-corrected incidence rate (IR) of cervical cancer among women with HIV, overall and by histology, age, race and ethnicity. Methods: We used data from the HIV/AIDS Cancer Match Study - a linkage of 14 HIV and cancer registries in the US. We calculated age-standardized IR (ASIR) of cervical cancer and compared the absolute and relative differences between corrected and uncorrected IRs across age, racial/ethnic and histology groups. Data from the Behavioral Risk Factor Surveillance System was used to correct for hysterectomy. A Poisson regression model was used to estimate hysterectomy-corrected and uncorrected incidence rate ratios (IRR) comparing rates in 2005-2009, 2010-2014, and 2015-2019 to 2001-2004, adjusted for race and ethnicity, age, and region. Results: During 2001-2019, there were 958 cervical cancer cases in 2,007,406 total person-years of follow-up (uncorrected ASIR: 47.7 per 100,000) and 1,632,853 person-years of follow-up after hysterectomy correction (ASIR=58.7). The ASIR after hysterectomy correction increased by 28% among Black women (50.3 vs 64.4), 18% among Hispanic women (52.1 vs 61.6), and 19% among White women (31.6 vs 37.6). The uncorrected IRs had a peak at ages 40-49 with a sharp peak and decline in the younger and older age groups while hysterectomy-corrected IRs had relatively flatter patterns with similar estimates for 30-39, 50-59 and 60-84-year-old women. Compared to the ASIRs in 2001-2004, the hysterectomy-corrected ASIRs were lower in subsequent calendar periods: IRR (2005-2009): 0.80, 95%CI:0.66,0.97, IRR (2010-2014): 0.75, 95%CI:0.61,0.91, and IRR (2015-2019): 0.79, 95%CI:0.64,0.97. Conclusions: Hysterectomy correction unmasked substantial underestimation of cervical cancer ASIRs among women with HIV. There was a significant difference between hysterectomy-corrected and uncorrected estimates across age and racial groups, being more pronounced among Black and White women, and women aged ≥50 years due to the cumulatively rising prevalence of hysterectomy with age.