Objective:To evaluate the impact of antiretroviral therapy (ART) duration and CD4+ cell count on risk for high grade cervical dysplasia in women with HIV (WWH) compared to women without HIV in the treat-all era with integrase strand inhibitors (INSTIs).Design:A prospective longitudinal cohort study in Botswana.Methods:From February 2021 to July 2022, baseline HPV self-sampling was offered to women with and without HIV. Those HPV+ underwent biopsy for histopathological diagnosis. Using women without HIV as reference, risk ratios were calculated for HPV, cervical intraepithelial neoplasia (CIN) 2 or worse (CIN2+), and CIN3+, stratified by ART duration and CD4+ cell counts.Results:Of 3000 women enrolled, 2953(98.4\%) underwent HPV testing, which was positive in 823(55.7\%) WWH and in 654(44.3\%) women without HIV. Histopathology was available for analysis in 1291(87.4\%) women (709 WWH, 582 women without HIV). Over 99\% of WWH had an undetectable HIV viral load and 94.4\% were on a dolutegravir-based ART regimen. WWH had a higher risk of HPV {[}risk ratio 1.27, 95\% confidence interval (95\% CI): 1.18-1.37], CIN2+ (risk ratio 1.52, 95\% CI: 1.16-1.98), and CIN3+ (risk ratio 1.75, 95\% CI: 1.25-2.45) compared to women without HIV. There was attenuation of risk for CIN2+ with higher recent CD4+ cell count, and those with higher nadir CD4+ cell count had similar risk to those without HIV (nadir CD4+ >= 500 CIN2+ risk ratio 1.15 {[}95\% CI: 0.56-2.37], CIN3+ risk ratio 1.81 {[}95\% CI: 0.86-3.79]; nadir CD4+ 350-499 CIN2+ risk ratio 1.23 {[}95\% CI: 0.71-2.12], CIN3+ risk ratio 1.34 {[}95\% CI: 0.68-2.64]).Conclusion:Although some attenuation of risk for CIN2+ was observed with higher recent and nadir CD4+ cell counts, WWH continue to have a higher risk of CIN2+/CIN3+ compared to women without HIV. These findings support tailored cervical screening algorithms for WWH.

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