Abstract Background: Women living with human immunodefciency virus (HIV) tend to develop cervical cancer at a younger age than women without HIV. The World Health Organization’s (WHO) 2021 guidelines for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention include a conditional recommendation for initiating screen‑ ing at age 25 for women living with HIV (WLWH). This recommendation is based on low-certainty evidence, and WHO calls for additional data. We describe the association of age and HIV status with visual inspection with acetic acid (VIA) positivity and cervical intraepithelial neoplasia grade two or higher (CIN2+) in Botswana. Methods: This was a retrospective cross-sectional study of 5714 participants aged 25 to 49 years who underwent VIA screening in a clinic mainly serving WLWH. VIA-positive women received cryotherapy if eligible or were referred for colposcopy and excisional treatment. Known cervical cancer risk factors, screening outcome, and histological results were extracted from the program database. We compared the proportions and association of VIA positivity and CIN2+ by age and HIV status. Results: The median age was 35 years [IQR 31–39], and 18% of the women were aged 25–29. Ninety percent were WLWH; median CD4 count was 250 cells/µL [IQR 150–428], and 34.2% were on anti-retroviral treatment (ART). VIApositivity was associated with younger age (OR 1.48, CI 1.28, 1.72 for 25–29 years vs. 30–49 years), and HIV-positivity (OR 1.85, CI 1.51, 2.28). CIN2+ was only associated with HIV-positivity (OR 6.12, CI 3.39, 11.10), and proportions of CIN2+ were similar for both age groups in WLWH (69.1% vs. 68.3%). Conclusions: Younger WLWH in Botswana had a signifcant burden of CIN2+. This fnding further supports lowering the screening age for WLWH from 30 to 25. Keywords: Botswana, Cervical pre-cancer, Cervical cancer screening, Colposcopy, Cryotherapy, Loop electrical excision procedure, See-and-treat, Visual inspection after acetic acid

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