Age-Specific Distribution and Factors Associated with High-Risk HPV Infection and Cervical Lesions Among HIV-Positive and -Negative Women in Maputo, Mozambique: Findings from the HPV-ISI Study

Abstract

Background/Objective: High-risk Human papillomavirus (hrHPV) is the leading cause of premalignant lesions and cervical cancer (CC), affecting disproportionally women living with HIV. Mozambique is among the countries with a heavy triple-burden of HIV, hrHPV infections and CC which accounts for more than 5300 new cases and 3800 deaths each year. In this study, we assessed the age-specific distribution and factors associated with hrHPV and cervical lesions among HIV-positive and -negative women from HPV-ISI (HPV Innovative Screening Initiative) study in Maputo, Mozambique. Methods: This cross-sectional study included 1248 non-pregnant women aged ≥18 years who attended CC screening at the DREAM Sant’Egídio Health Centre between July 2021 and April 2022. Screening involved visual inspection with acetic acid (VIA) and high-risk HPV DNA testing. Sociodemographic, lifestyle, and reproductive data were collected through a routine questionnaire. Logistic regression assessed associations between risk factors and hrHPV infection or cervical lesions. Age-specific hrHPV prevalence, partial HPV16/18 genotyping, and abnormal cytology rates were further analyzed by HIV status. Results: The mean age of participants was 43.0 ± 8.6 years. Overall hrHPV prevalence was 28.0%, being higher among HIV-positive women (46.8%) than HIV-negative women (23.8%). Non-16/18 hrHPV genotypes predominated across all age groups. VIA positivity was 11.1%, most frequently involving less than 75% of the cervical area and was more common among younger women (30–45 years) and those living with HIV. Increasing age was associated with lower odds of hrHPV infection (OR = 0.98, 95% CI: 0.97–1.00; p = 0.017), as was higher parity (≥3 deliveries vs. nulliparity: OR = 0.58, 95% CI: 0.36–0.94; p = 0.029). Contraceptive use (OR = 1.65, 95% CI: 1.15–2.38; p = 0.007) and a partially or non-visible squamocolumnar junction (SCJ) (OR = 2.88, 95% CI: 1.74–4.79; p < 0.001) were associated with higher odds of VIA positivity. Conclusions: hrHPV infection and cervical lesions were more frequent in younger and HIV-positive women, highlighting the need for strengthened targeted screening within HIV care services in Mozambique.

1. Introduction

Human papillomavirus (HPV) is one of the most common sexually transmitted infection (STI) worldwide [1,2]. Infections with HPV have a high negative impact on women social life in Sub-Saharan Africa, as they are responsible for a significant proportion (ranging from 20% to 26%), of all cancers diagnosed [3], mainly cervical cancer (CC)—the most common female cancer and leading cause of morbidity and mortality in the region [4,5].

Genital infection with HPV is substantial high during the individual’s lifetime, with an estimated risk of 60–84.6% among sexually active women; however, without necessarily developing any symptoms [1,6]. Most (80–90%) of these infections are cleared spontaneously within 12–24 months; some, particularly by oncogenic types—well known as high-risk HPV (hrHPV), persist and induce the development of premalignant lesions and CC over time [5,7,8]. To date, the hrHPV include fifteen genotypes (HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, and 82), classified as oncogenic, and three genotypes (HPV 26, 53, and 66), considered probably carcinogenic [9,10].

The worldwide prevalence of HPV infection in women with no cervical abnormalities is 11–12%, with higher age-standardized rates in sub-Saharan Africa (24%), compared to other region (16–21%) [1,2]. Immunodeficiency is a major determinant of HPV infection and CC risk [11]. Women living with HIV face a disproportionately high burden, including increased acquisition of HPV, higher frequency of multiple infections, and greater likelihood of persistent hrHPV infection, resulting in a six-fold increased risk of premalignant lesions and CC [11,12,13]. On the other hand, the exposure and acquisition of HPV infection relay primarily on sexual lifestyle-related factors, including early age of sexual debut, the number of lifetime sexual partners, history of STIs, and others. In addition to these, other factors such as smoking, diet/malnutrition, parity, use of hormonal contraceptives, alcohol consumption, and concomitant STIs (specially Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma spp., and Herpes virus), have been associated, beyond the acquisition of the infection, with a higher probability of hrHPV persistence, and further development of premalignant lesions and CC [14,15,16]. Additionally, an older age, lower socioeconomic and educational status [17,18,19] have also been associated with an increased risk of disease in HPV-seropositive women.

Mozambique is among the countries with a heavy burden of HPV infection, HIV, and cervical cancer [11,20]. The prevalence of HPV infection among Mozambican women is alarmingly high, with studies indicating significant rates of hrHPV (HPV 16, 18, 31, 33, 35, 45, 51, 52, and 58), either among women with normal cytology [1] or among those diagnosed with cervical precancerous lesions and cancer; varying from 20% to 75.9% [21,22,23,24,25,26]. Every year, more than 5300 cervical cancer new cases and more than 3800 deaths are registered [20], affecting particularly women living with HIV/AIDS [27,28]. It is estimated that in the general population, around 8.6% of Mozambican women of reproductive age (>18 years old) have had a cervical hrHPV infection at some point in their lives, with HPV types 16 and 18 accounting for over 51.0% of invasive CC cases [20,29].

In the overall picture of HPV infection and CC incidence in Mozambique, the key contributing factors include the high rates of HIV infection (between 15.1 and 26.6%) among sexually active women or those of reproductive age [30,31], and the strikingly low availability and uptake of annual cervical cancer screening [28,32]. Meanwhile, although the prevalence and distribution of HPV genotypes in Mozambique have been considerably elucidated, little is known about age-related differences and the sociodemographic, lifestyle, and gynecological factors associated with hrHPV infection and cervical lesions within the context of HIV care in the country.

Knowledge of risk factors, combined with early detection of high-risk HPV infection and precancerous lesions, provides essential information for identifying at-risk populations and preventing CC [7,33,34]. In this study, we present the age-specific distribution and factors associated with high-risk HPV infection and cervical lesions, stratified by HIV status, among Mozambican women. The objective was to identify determinants of hrHPV infection and cervical abnormalities to inform the implementation of HPV-based screening programs in Mozambique [28,35,36].

2. Material and Methods

2.1. Study Design, Participants and Ethical Approval

This is a cross-sectional study in which we analyzed data of 1248 women aged over 18 years who were recruited and screened for hrHPV during a larger research project named HPV innovative screening approach (HPV-ISI), conducted at the DREAM Sant’Egidio health centre in Zimpeto, Maputo, Mozambique [26]. The DREAM Sant’Egidio health centre is an HIV-focused primary care facility affiliated with the DREAM program, a health initiative run by the Community of Sant’Egidio across 11 African countries and providing care to over 500,000 patients. The program implements multiple health projects in sub-Saharan Africa and is actively engaged in laboratory research [26,37,38,39,40,41]. At the DREAM Sant’Egidio health centre, cervical cancer (CC) screening is routinely conducted for women from both urban and rural settings, using a combined visual inspection with acetic acid (VIA)-hrHPV testing approach.

The HPV-ISI research project was conducted between July 2021 and May 2022 and evaluated the feasibility of hrHPV DNA testing compared to the VIA screen-and-treat approach (VIA was used as a screen and not as a triage for hrHPV-positive women) [26], preceding the launch of the national pilot program of hrHPV screening, triage and/or treatment in Mozambique, introduced in 2023 [42].

Figure 1 illustrates the flow diagram of women screened and included in the study analysis. The initial dataset comprised 1323 women (participants) aged over 18 years who were voluntarily recruited from DREAM HIV care centers and from referrals originating from other public health facilities within the Maputo region. Participants were not randomly selected, nor were they sampled to obtain similar numbers of HIV-positive [+] and HIV-negative [+] women. Instead, women were consecutively enrolled as they presented for routine services, and the final sample reflects the natural distribution of HIV status among service users during the study period. Of the 1323 women screened for hrHPV, we excluded 75 records due to missing outcome data and incomplete key variables (

Table 1. Participants data and variables analyzed in this study.

Group		Variables
Factors	Sociodemographic	Healthcare referral Center/facility; Age (years; categories 1: ≤29, 30–45, ≥46; categories 2: ≤24, 25–29, 30–35, 36–40, 41–45, 46–50, 51–55, 56–60, ≥61).
	Sexual and lifestyle behavior	Age at first intercourse—sexual debut [years; ≤17 (adolescent), 18–25 (young), ≥26 (adult)]; Use of contraceptives [no/yes (condom use, oral pills, intrauterine device, implant, injectable, other); smoking habit (no/yes).
	Clinical, gynecological and reproductive history	HIV status (negative/positive); Screening or consultations history (1st/Follow-up 1 year/Follow-up 3 year); Pregnancies history (number; nulligravida, 1–2, ≥3); Full-term pregnancies or deliveries history (number; nulliparous, 1–2, ≥3); History of STI or vaginal discharge (yes/no); Close family/relative with history of cervical cancer (yes/no); Gynecological findings [vaginal/uterus related (normal/abnormal—cervicitis, bleeding, condylomas, polyps, others); SCJ related (Totally visible/Partially or not visible)].
Main outcomes	Clinical-laboratory	VIA result [negative/positive (<75%; ≥75% or worse)]; hrHPV result [negative/positive (HPV-16, HPV-18 and Other hrHPV).

HIV—human immunodeficiency virus; STI—sexually transmitted infections; SCJ—squamocolumnar junction; VIA—visual inspection with acetic acid; hrHPV—high-risk human Papillomavirus.

), yielding a final sample of 1248 participants for this analysis. The inclusion criteria were: (1) women aged ≥18 years with documented genital hrHPV and VIA results; and (2) not currently pregnant. The exclusion criteria were: (1) missing data in more than three study variables (Table 1); and (2) indeterminate or invalid hrHPV results. All participants provided written informed consent. Ethical approval was obtained from the Mozambican National Ethics Committee (ref. 688/CNBS/20) and from the Institutional Health Bioethics Committee of the Faculty of Medicine, Eduardo Mondlane University, and Maputo Central Hospital (ref. CIBS FM&HCM/019/2023). All data were anonymized using numerical codes prior to database creation.

2.2. Data Collection, Samples and Screening Tests

In this study, the outcome variables of interest were hrHPV and VIA cervical screening results of the participants. We considered as potential factors, the variables (Table 1) found to be related to testing hrHPV and VIA positive [+] in previous studies or otherwise biologically plausible.

In summary, to obtain the data used in this study, all participants responded to a brief routine structured questionnaire that included questions on sociodemographic information, lifestyle, sexual and reproductive behavior, and clinical data (Table 1). After the brief questionnaire, a cervical sample was collected and placed into a 20 mL Liquid Media (Roche Cell Collection Medium), which was then sent to the local Molecular laboratory for hrHPV-DNA testing. After sampling for HPV testing women were screened with the current national recommendations based on VIA [43]. For all VIA [+] cases, a digital colposcopy (DC) was performed for lesion confirmation. Cryotherapy was subsequently performed on-site if VIA tested positive with lesions < 75% of the cervix, and women with confirmed major lesions were referred for biopsy.

The hrHPV testing was performed using the Cobas HPV DNA test, in the Cobas 4800 system (Roche Molecular Systems, Pleasanton, CA, USA). The Cobas^® 4800 HPV DNA test is a qualitative assay that allows the detection of 14 hrHPV types by polymerase chain reaction (PCR) and nucleic acid hybridization, giving a partial genotyping by separately identifying HPV16 and HPV18, and 12 other hrHPV types (including HPV types 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68) “pooled” in the same channel. The assay utilizes a human beta-globin gene as internal control to assess the quality of the sampling and the efficiency of the PCR amplification. If internal control was not amplified, samples were referred as invalid. Only samples with a valid test result on Cobas 4800 were included in the analysis of this study.

2.3. Statistical Analyses

Data were analyzed using STATA 15.1 (StataCorp LP, College Station, TX, USA, 2017). Descriptive analyses, including means and standard deviations (SD), were performed for continuous variables, and the number and percentages for categorical variables. The detection results of hrHPV by participant’s characteristics were stratified according to HIV status and by VIA results. An independent-samples t test was used to assess the statistical differences in continuous variables across different hrHPV and VIA groups, within each HIV stratum. Chi-square tests assessed the association of categorical variables with hrHPV and VIA results, according to HIV status. Variables with frequency of less than 5 values were evaluated with Fisher’s exact test. Statistically significant (p < 0.05) variables for hrHPV and VIA results were considered for univariate binary logistic regression to estimate crude odds ratios (ORs). Analyses were conducted for the overall sample and stratified by HIV status (HIV-positive and HIV-negative).

3. Results

3.1. Characteristics of Participants

Characteristic of study population (N = 1248) analyzed in this study are shown in

Table 2. Characteristics of study population in the HPV-ISI study (Maputo, Mozambique).

Characteristic Variables	Frequency
	N	%
Health center of provenance		-
DREAM Sant’Egidio	1052	84.3
DREAM Consolata/Criança	46	3.7
DREAM Machava	136	10.9
DREAM Matola-II	11	0.9
Other—external to DREAM	3	0.2
Age (years), mean ± SD	43.0 ± 8.6	–
Age category (years)
≤29	56	4.5
30–45	700	56.1
≥46	492	39.4
Screening type *
First time	924	74
1-year follow-up	272	21.8
3-year follow-up	52	4.2
Age at sexual debut (years), mean ± SD	17.5 ± 2.4	–
Age at sexual debut (years)
≤17 (adolescent)	666	53.4
18–25 (young)	577	46.2
≥26 (adult)	5	0.4
Number of pregnancies, mean ± SD	4.1 ± 2.1	–
Number of pregnancies
Nulligravida	52	4.2
1–2	233	18.7
≥3	963	77.1
Number of deliveries, mean ± SD	3.2 ± 1.9	–
Number of deliveries
Nulliparous	77	6.2
1–2	379	30.4
≥3	792	63.4
Menstrual cycle, n (%)
Normal (regular)	838	67.1
Abnormal (irregular)	410	32.9
Use of contraceptives
No	875	70.1
Yes **	373	29.9
condom	31	2.5
oral pills	117	9.4
IUD	28	2.2
implant	84	6.7
injectable	76	6.1
other type	16	1.3
not declared	21	1.7
Family history of CC
No	1207	96.7
Yes	15	1.2
Don’t know	26	2.1
Smoking (or ever smoked)
No	1164	93.3
Yes	1	0.1
Not declared	83	6.6
Previous STI/Vaginal discharge
No	1149	92.1
Yes	99	7.9
Gynecological findings—vaginal/uterus
Normal	1147	91.9
Abdormal ***	101	8.1
Gynecological findings—SCJ
Totally visible	1153	92.4
Partially/Not visible	95	7.6
VIA result
Negative	1110	88.9
Positive	138	11.1
<75%	125	10.1
≥75%	13	1.0
hrHPV result
Negative	898	72.0
Positive	350	28.0

* VIA (Visual Inspection with Acetic Acid)-based screening; ** Contraceptives types frequently used; *** Includes cervicitis, bleeding, condylomas, polyps, others; IUD—intrauterine device; CC—cervical cancer; SCJ—squamocolumnar junction; STI—Sexually transmitted infections (self-reported—last 3 months).

. The majority (84.3%) were recruited within the study site—DREAM Sant’Egidio health centre, while smaller proportions were referred from DREAM centers, Machava (10.9%), Consolata/Criança (3.7%) and Matola-II (0.9%), and other health facilities external to the DREAM program (0.2%).

The mean age of the participants was 43.0 ± 8.6 years (range: 18–72 years). The age group with the largest proportion of participants was 30–45 years (16.3%), with 41–45 years being the most represented sub-group within this range. Regarding screening history, nearly three-quarters (74%) were screened for the first time, in comparison to other screening types. The mean age at sexual debut was 17.5 ± 2.4 years, with over half (53.4%) reporting initiation at ≤17 years. Most women were multiparous: 77.1% had ≥3 pregnancies and 63.4% had ≥3 deliveries, while nulligravidity and nulliparity were relatively small (4.2% and 6.2%, respectively).

Concerning reproductive and lifestyle characteristics, 32.9% reported irregular menstrual cycles, and 29.9% used contraceptives, mainly oral pills (9.4%), implants (6.7%), and injectables (6.1%). Family history of cervical cancer was uncommon (1.2%), and smoking was virtually absent (0.1%). A small proportion reported prior STIs or vaginal discharge (7.9%). Gynecological examination showed abnormalities in 8.1% of cases, while the SCJ was visible in 92.4%. VIA testing yielded 11.1% positive results, with most lesions involving <75% of the cervix. The prevalence of hrHPV infection was 28%.

3.2. Distribution of hrHPV and VIA Results by Participants Characteristics and According to HIV Status

Table 3. Bivariate association analyses between participants’ characteristics and hrHPV status among all women and stratified by HIV status.

Variables	All			HIV-Positive (+)			HIV-Negative (−)
	hrHPV (+)	hrHPV (−)	p Value	hrHPV (+)	hrHPV (−)	p Value	hrHPV (+)	hrHPV (−)	p Value
Age (years), mean ± SD	42.0 ± 8.9	43.3 ± 8.0	0.013 a	43.3 ± 8.1	42.9 ± 7.4	0.540	39.9 ± 9.9	43.6 ± 9.1	<0.001 a
Age category (years), n (%)
≤29	21 (1.7)	35 (2.8)		5 (0.9)	7 (1.2)		16 (2.4)	28 (4.2)
30–45	206 (16.5)	494 (39.6)	0.067	132 (22.6)	228 (39.0)	0.751	74 (11.1)	266 (40.1)	<0.001 a
≥46	123 (9.9)	369 (29.6)		84 (14.4)	128 (21.9)		39 (5.9)	241 (36.3)
Screening type *, n (%)
First time	259 (20.8)	665 (53.3)	0.038 a	151 (25.9)	229 (39.2)	0.339	108 (16.3)	436 (65.7)	0.561
1-year follow-up	84 (6.7)	188 (15.1)		70 (12.0)	133 (22.8)		14 (2.1)	55 (8.3)
3-year follow-up	7 (0.6)	45 (3.6)		0 (0.0)	1 (0.2)		7 (1.1)	44 (6.6)
Age at sexual debut (years), mean ± SD	17.5 ± 2.7	17.6 ± 2.3	0.512	17.3 ± 2.7	17.4 ± 2.2	0.626	17.7 ± 2.7	17.7 ± 2.4	1.00
Age at sexual debut (years), n (%)
≤17 (adolescent)	197 (15.8)	469 (37.6)		128 (21.9)	202 (34.6)		69 (10.4)	267 (40.2)
18–25 (young)	150 (12.0)	427 (34.2)	0.105	91 (15.6)	160 (27.4)	0.483	59 (8.9)	267 (40.2)	0.401
≥26 (adult)	3 (0.2)	2 (0.2)		2 (0.3)	1 (0.2)		1 (0.2)	1 (0.2)
Number of pregnancies, mean ± SD	4.0 ± 2.2	4.1 ± 2.1	0.456	3.9 ± 2.0	4.0 ± 2.0	0.558	4.2 ± 2.5	4.2 ± 2.1	1.00
Number of pregnancies, n (%)
Nulligravida	23 (1.8)	29 (2.2)	0.038 a	10 (1.7)	10 (1.7)	0.524	12 (1.8)	18 (2.7)	0.013 a
1–2	65 (5.2)	168 (13.5)		47 (8.1)	80 (13.7)		18 (2.7)	88 (13.3)
≥3	263 (21.1)	700 (56.2)		164 (28.2)	271 (46.6)		99 (14.9)	429 (64.6)
Number of deliveries, mean ± SD	3.2 ± 2.0	3.3 ± 1.8	0.393	3.1 ± 1.9	3.1 ± 1.7	1.00	3.3 ± 2.2	3.4 ± 1.8	0.589
Number of deliveries, n (%)
Nulliparous	29 (2.3)	48 (3.8)		15 (2.6)	24 (4.1)		14 (2.1)	24 (3.6)
1–2	115 (9.2)	264 (21.2)	0.046 a	78 (13.4)	115 (19.7)	0.645	37 (5.6)	149 (22.4)	0.017 a
≥3	206 (16.5)	586 (47.0)		128 (21.9)	224 (38.4)		78 (11.7)	362 (54.5)
Menstrual cycle, n (%)
Normal (regular)	239 (19.2)	599 (48.0)	0.639	152 (26.0)	256 (43.8)	0.710	87 (13.1)	343 (51.7)	0.538
Abnormal (irregular)	111 (8.9)	299 (24.0)		69 (11.8)	107 (18.3)		42 (6.3)	192 (28.9)
Use of contraceptives, n (%)
No	244 (19.5)	631 (50.6)	0.891	165 (28.3)	259 (44.3)	0.339	79 (11.9)	372 (56.1)	0.075
Yes **	106 (8.5)	267 (21.4)		56 (9.6)	104 (17.8)		50 (7.5)	163 (24.5)
condom	11 (0.9)	20 (1.6)		8 (1.4)	11 (1.9)		3 (0.5)	9 (1.4)
oral pills	32 (2.6)	85 (6.8)		12 (2.1)	27 (4.6)		20 (3.0)	58 (8.7)
IUD	5 (0.4)	23 (1.8)		1 (0.2)	9 (1.5)		4 (0.6)	14 (2.1)
implant	26 (2.1)	58 (4.6)		19 (2.9)	19 (3.3)		9 (1.4)	39 (5.9)
injectable	23 (1.8)	53 (4.2)		10 (1.7)	26 (4.5)		13 (2.0)	27 (4.1)
other type	4 (0.3)	12 (1.0)		4 (0.7)	6 (1.0)		0 (0.0)	6 (0.9)
not declared	5 (0.4)	16 (1.3)		4 (0.7)	6 (1.0)		1 (0.2)	10 (1.5)
Family history of CC, n (%)
No	337 (27.0)	870 (69.7)	0.389	212 (36.3)	347 (59.4)	0.698	125 (18.8)	523 (78.8)	0.687
Yes	3 (0.2)	12 (1.0)		1 (0.2)	4 (0.7)		2 (0.3)	8 (1.2)
Don’t know	10 (0.8)	16 (1.3)		8 (1.4)	12 (2.1)		2 (0.3)	4 (0.6)
Smoking (or ever smoked), n (%)
No	326 (26.1)	838 (67.1)	0.276	203 (34.8)	333 (57.0)	0.428	123 (18.5)	505 (76.1)	0.829
Yes	1 (0.2)	0 (0.0)		1 (0.2)	0 (0.0)		0 (0.0)	0 (0.0)
Not declared	23 (1.8)	60 (4.8)		17 (2.9)	30 (5.1)		6 (0.9)	30 (4.5)
Previous STI/Vaginal discharge, n (%)
No	318 (25.5)	831 (66.6)	0.351	199 (34.1)	331 (56.7)	0.660	119 (17.9)	500 (75.3)	0.696
Yes	32 (2.6)	67 (5.4)		22 (3.8)	32 (5.5)		10 (1.5)	35 (5.3)
Gynecological findings—vaginal/uterus, n (%)
Normal	311 (24.9)	836 (67.0)	0.020 a	195 (33.4)	330 (56.5)	0.323	116 (17.5)	506 (76.1)	0.067
Abdormal ***	39 (3.1)	62 (5.0)		26 (4.5)	33 (5.7)		13 (2.0)	29 (4.4)
Gynecological findings—SCJ, n (%)
Totally visible	320 (25.6)	833 (66.7)	0.409	201 (34.4)	341 (58.4)	0.189	119 (17.9)	492 (74.1)	1.00
Partially/Not visible	30 (2.4)	65 (5.3)		20 (3.4)	22 (3.8)		10 (1.5)	43 (6.5)

p values were obtained from bivariate association analyses comparing hrHPV-positive and hrHPV-negative women: Student’s t-test was used for continuous variables. Pearson’s Chi-square test was used for categorical variables, and Fisher’s exact test was applied when expected cell counts were <5. Statistically significant (p < 0.05) associations are bolded and indicated by superscript letters (a). * VIA (Visual Inspection with Acetic Acid)-based screening; ** Contraceptives types frequently used; *** Includes cervicitis, bleeding, condylomas, polyps, others; IUD—intrauterine device; CC—cervical cancer; SCJ—squamocolumnar junction; SD—standard deviation; STI—Sexually transmitted infections (self-reported—last 3 months).

and

Table 4. Bivariate association analyses between participants’ characteristics and VIA results among all women and stratified by HIV status.

Variables	All			HIV-Positive (+)			HIV-Negative (−)
	VIA (+)	VIA (−)	p Value	VIA (+)	VIA (−)	p Value	VIA (+)	VIA (−)	p Value
Age (years), mean ± SD	38.9 ± 7.9	43.5 ± 8.5	<0.001 a	39.6 ± 8.1	43.6 ± 7.5	<0.001 a	38.1 ± 7.8	43.4 ± 9.3	<0.001 a
Age category (years), n (%)
≤29	14 (1.1)	42 (3.4)		7 (1.2)	5 (0.9)		7 (1.1)	37 (5.6)
30–45	95 (7.6)	605 (48.5)	<0.001 a	49 (8.4)	311 (53.3)	<0.001 a	46 (6.9)	294 (44.3)	<0.001 a
≥46	29 (2.3)	463 (37.1)		17 (2.9)	195 (33.4)		12 (1.8)	268 (40.4)
Screening type, n (%)
First time	112 (9.0)	812 (65.1)	0.075	54 (9.4)	326 (55.8)	0.224	58 (8.7)	486 (73.2)	0.227
1-year follow-up	24 (1.9)	248 (19.9)		19 (3.3)	184 (31.5)		5 (0.9)	64 (9.6)
3-year follow-up	2 (0.2)	50 (4.0)		0 (0.0)	1 (0.2)		2 (0.3)	49 (7.4)
Age at sexual debut (years), mean ± SD	17.3 ± 2.7	17.6 ± 2.4	0.213	17.2 ± 1.6	17.4 ± 2.5	0.507	17.3 ± 3.5	17.7 ± 2.3	0.210
Age at sexual debut (years), n (%)
≤17 (adolescent)	81 (6.5)	585 (46.9)		40 (6.8)	290 (49.7)		41 (6.2)	295 (44.4)
18–25 (young)	56 (4.5)	521 (41.7)	0.316	33 (5.7)	218 (37.3)	0.753	23 (3.5)	303 (45.6)	0.013 a
≥26 (adult)	1 (0.1)	4 (0.3)		0 (0.0)	3 (0.5)		1 (0.2)	1 (0.2)
Number of pregnancies, mean ± SD	3.8 ± 1.8	4.1 ± 2.1	0.070	3.7 ± 1.7	4.0 ± 2.0	0.223	4.0 ± 2.0	4.2 ± 2.2	0.483
Number of pregnancies, n (%)
Nulligravida	4 (0.3)	46 (3.7)	0.778	2 (0.3)	18 (3.1)	0.902	2 (0.3)	28 (4.2)	0.723
1–2	26 (2.1)	207 (16.6)		17 (2.9)	110 (18.9)		9 (1.4)	97 (14.2)
≥3	108 (8.7)	855 (68.6)		54 (9.3)	381 (65.5)		54 (8.1)	474 (71.4)
Number of deliveries, mean ± SD	3.0 ± 1.7	3.3 ± 1.8	0.052	2.9 ± 1.7	3.1 ± 1.8	0.372	3.1 ± 1.7	3.4 ± 1.9	0.223
Number of deliveries, n (%)
Nulliparous	8 (0.6)	69 (5.5)		4 (0.7)	35 (6.0)		4 (0.6)	34 (5.1)
1–2	55 (4.4)	324 (26.0)	0.036 a	33 (5.7)	160 (27.4)	0.062	22 (3.3)	164 (24.7)	0.515
≥3	75 (6.0)	717 (57.5)		36 (6.2)	316 (54.1)		39 (5.9)	401 (60.4)
Menstrual cycle, n (%)
Normal (regular)	89 (7.1)	749 (60.0)	0.502	52 (8.9)	356 (61.0)	0.892	37 (5.6)	393 (59.2)	0.173
Abnormal (irregular)	49 (3.9)	361 (28.9)		21 (3.6)	155 (26.5)		28 (4.2)	206 (31.0)
Use of contraceptives, n (%)
No	83 (6.7)	792 (63.4)	0.008 a	49 (8.4)	375 (64.2)	0.264	34 (5.1)	417 (62.8)	0.007 a
Yes *	55 (4.4)	318 (25.5)		24 (4.1)	136 (23.3)		31 (4.7)	182 (27.4)
condom	2 (0.2)	29 (2.3)		0 (0.0)	19 (3.3)		2 (0.3)	10 (1.5)
oral pills	18 (1.4)	99 (7.9)		6 (1.0)	33 (5.7)		12 (1.8)	66 (9.9)
IUD	5 (0.4)	23 (1.8)		1 (0.2)	9 (1.5)		4 (0.6)	14 (2.1)
implant	14 (1.1)	70 (5.6)		5 (0.9)	31 (5.3)		9 (1.4)	39 (5.9)
injectable	11 (0.9)	65 (5.2)		7 (1.2)	29 (5.0)		4 (0.6)	36 (5.4)
other type	2 (0.2)	14 (1.1)		2 (0.3)	8 (1.4)		0 (0.0)	6 (0.9)
not declared	3 (0.2)	18 (1.4)		3 (0.5)	7 (1.2)		0 (0.0)	11 (1.7)
Family history of CC, n (%)
No	134 (10.7)	1073 (86.0)	0.307	70 (12.0)	489 (83.7)	0.661	64 (9.6)	584 (88.0)	0.494
Yes	0 (0.0)	15 (1.2)		0 (0.0)	5 (0.9)		0 (0.0)	10 (1.5)
Don’t know	4 (0.3)	22 (1.8)		3 (0.5)	17 (2.9)		1 (0.2)	5 (0.8)
Smoking (or ever smoked), n (%)
No	129 (10.3)	1035 (82.9)	0.216	68 (11.6)	468 (80.1)	0.857	61 (9.2)	567 (85.4)	0.772
Yes	1 (0.1)	1 (0.2)		0 (0.0)	1 (0.2)		0 (0.0)	0 (0.0)
Not declared	9 (0.7)	74 (5.9)		5 (0.9)	42 (7.2)		4 (0.6)	32 (4.8)
Previous STI/Vaginal discharge, n (%)
No	124 (9.9)	1025 (82.1)	0.190	66 (11.3)	464 (79.5)	0.831	58 (8.7)	561 (84.5)	0.315
Yes	14 (1.1)	85 (6.4)		7 (1.2)	47 (8.0)		7 (1.1)	38 (5.7)
Gynecological findings—vaginal/uterus, n (%)
Normal	123 (9.9)	1024 (82.0)	0.244	64 (11.0)	461 (78.9)	0.532	59 (8.9)	563 (84.8)	0.287
Abdormal **	15 (1.2)	86 (6.9)		9 (1.5)	50 (8.6)		6 (0.9)	36 (5.4)
Gynecological findings—SCJ, n (%)
Totally visible	115 (9.2)	1038 (83.2)	<0.001 a	58 (9.9)	484 (82.9)	<0.001 a	57 (8.6)	554 (83.4)	0.223
Partially/Not visible	13 (1.8)	72 (5.8)		15 (2.6)	27 (4.6)		8 (1.2)	45 (6.8)

p values were obtained from bivariate association analyses comparing hrHPV-positive and hrHPV-negative women: Student’s t-test was used for continuous variables. Pearson’s Chi-square test was used for categorical variables, and Fisher’s exact test was applied when expected cell counts were <5. Statistically significant (p < 0.05) associations are indicated by superscript letters (a). * Contraceptives types frequently used; ** Includes cervicitis, bleeding, condylomas, polyps, others; VIA—Visual Inspection with Acetic Acid; IUD—intrauterine device; CC—cervical cancer; SCJ—squamocolumnar junction; SD—standard deviation; STI—Sexually transmitted infections (self-reported—last 3 months).

summarize the bivariate association analyses comparing sociodemographic, reproductive, behavioral, and clinical characteristics according to hrHPV status and VIA results, stratified by HIV status: HIV-positive [+] and HIV-negative [−]. Women with hrHPV positivity [+] (Table 3) were slightly younger than those who tested negative [−] (mean age 42.0 vs. 43.3 years, p = 0.013), a difference that was particularly evident among HIV [−] women (p < 0.001). Stratification by age groups showed higher hrHPV prevalence among women aged 30–45 years (16.5%) and ≥46 years (9.9%), compared to those ≤29 years (1.7%). Screening history also influenced hrHPV detection, with first-time attendees more frequently hrHPV [+] than those at follow-up (p = 0.038).

Reproductive history revealed significant associations. Women with hrHPV [+] were more likely to be nulligravida (p = 0.038) or have had one to two deliveries (p = 0.046), particularly among HIV [−] participants (p = 0.013 and p = 0.017, respectively). In contrast, age at sexual debut, number of pregnancies, contraceptive use, menstrual regularity, and family history of cervical cancer did not show significant associations with hrHPV. Finally, gynecological abnormalities of the vagina or uterus were more common in hrHPV [+] women (3.1% vs. 5.0%, p = 0.020), while visibility of the squamocolumnar junction and prior STI history were not significantly related (Table 3).

Regarding the VIA results, women with VIA-positive [+] results were significantly younger than VIA-negative [−] women (mean age 38.9 vs. 43.5 years, p < 0.001). This trend was consistent across both HIV [+] and HIV [−] groups. The highest VIA [+] was observed among women aged 30–45 years, while those ≥46 years were more often VIA [−] (p < 0.001). Screening type showed no significant differences, although most VIA [+] cases were detected during first-time screening (Table 4).

Reproductive factors showed mixed associations. VIA [+] women had slightly fewer pregnancies and deliveries on average, but only parity was marginally associated, with nulliparous women less likely to test VIA [+] (p = 0.036). Age at sexual debut, family history of CC, and reported STI/vaginal discharge were not significantly related to VIA results (Table 4). Contraceptive use showed an interesting pattern: women not using contraceptives had higher VIA [+] compared to users, particularly among HIV [−] women (p = 0.007). Menstrual cycle regularity, smoking history, and gynecological findings of the vagina/uterus were not significant predictors. However, visibility of the SCJ was strongly associated with VIA results, especially among HIV [+] women (p < 0.001).

3.3. Overall Prevalence of hrHPV Types According to HIV Status and Its Age-Specific Distribution

Figure 2 and Figure 3 show the distribution of hrHPV types (HPV-16, HPV-18, and non-16/18 types) in single and multiple infections according to HIV status and age groups, respectively. Among HIV [−] women, hrHPV types other than HPV-16/18 were most common (17.0%), mainly as single infections (14.2%) and less as multiple (2.8%). HPV-16 and HPV-18 were less frequent, up to 3.6% and 2.0%, respectively. In HIV [+] women, hrHPV prevalence was higher, especially non-16/18 types (31.8%), with 23.8% single and 8.0% multiple infections. HPV-16 (9.4%) and HPV-18 (5.6%) were also more frequent than in HIV [−] (Figure 2).

The distribution of hrHPV types across different age groups (Figure 3), shows peaks among women aged 30–45 years, particularly at 41–45 years. Single infections predominated across all age groups. Non-16/18 hrHPV types accounted for most infections, both single and multiple, whereas HPV-16 and HPV-18 were less frequent and mainly detected as single infections. Multiple hrHPV infections were more common in women aged 30–45 years and declined with increasing age. HrHPV detection was markedly lower in women aged ≥ 56 years.

3.4. Overall Prevalence of Cervical Lesions According to HIV Status and Its Age-Specific Distribution

Figure 4 shows the distribution of cervical lesions—frequency of VIA-positive [+] lesions (<75% and ≥75% of the cervix) across age groups, stratified by HIV status. Among HIV [−] women, VIA [+] < 75% were identified in 59 cases (8.9% of the total), with the highest frequency in the 30–35-year age group (17 cases, 2.6%). Larger lesions (≥75%) were rare, occurring in only 6 cases (0.9%). In HIV [+] women, VIA [+] < 75% were slightly more frequent (66 cases, 11.3%), with a peak in the 36–40-year age group (26 cases, 4.5%). Larger lesions (≥75%) were also more common among HIV [+] women (7 cases, 1.2%) compared with HIV [−] women. Overall, VIA positivity was concentrated among women aged 30–45 years, with both lesion types (<75% and ≥75% of the cervix) more frequent in HIV [+] participants, highlighting the combined influence of age and HIV status on cervical lesion burden.

3.5. Factors Associated with hrHPV Prevalence and Cervical Lesions

A logistic regression analysis evaluating factors associated with hrHPV infection, stratified by HIV status, showed that increasing age was associated with lower odds of hrHPV infection (OR = 0.98, p = 0.017), corresponding to an approximately 2% decrease in the odds of hrHPV per additional year of age. This association was more pronounced among HIV [−] (OR = 0.96, p < 0.001), indicating lower odds of hrHPV with increasing age, and was not statistically significant among HIV [+] women. Compared with women aged ≤29 years, those aged ≥46 years had significantly lower odds of hrHPV infection overall (OR = 0.56, p = 0.046) and among HIV [−] women (OR = 0.28, p < 0.001).

Similarly, higher parity was associated with lower odds of hrHPV infection. Women with ≥3 pregnancies (OR = 0.48, p = 0.012) or ≥3 deliveries (OR = 0.58, p = 0.029) had lower odds of hrHPV infection, particularly among HIV [−] women. No statistically significant associations between age or parity and hrHPV infection were observed among HIV [+] women (

Table 5. Logistic regression analysis for the association between hrHPV results with predictor variables, according to HIV status.

Predictor Variables	All		HIV-Positive (+)		HIV-Negative (−)
	OR (95% CI)	p Value	OR (95% CI)	p Value	OR (95% CI)	p Value
Age (years)	0.98 (0.97–1.00)	0.017	1.01 (0.98–1.03)	0.662	0.96 (0.94–0.98)	<0.001
Age category (years)
≤29			Reference
30–45	0.70 (0.40–1.22)	0.207	0.81 (0.25–2.60)	0.724	0.49 (0.25–0.95)	0.034
≥46	0.56 (0.31–0.99)	0.046	0.92 (0.22–2.25)	0.888	0.28 (0.14–0.57)	<0.001
Screening type
First time			Reference
1-year follow-up	1.15 (0.85–1.54)	0.361	0.80 (0.56–1.14)	0.213	1.03 (0.55–1.92)	0.932
3-year follow-up	0.40 (0.18–0.90)	0.026	n/a	n/a	0.64 (0.28–1.46)	0.293
Number of pregnancies
Nulligravida			Reference
1–2	0.49 (0.26–0.92)	0.027	0.58 (0.23–1.52)	0.271	0.31 (0.13–0.75)	0.009
≥3	0.48 (0.27–0.85)	0.012	0.61 (0.25–1.49)	0.273	0.35 (0.16–0.74)	0.006
Number of deliveries
Nulliparous			Reference
1–2	0.72 (0.43–1.20)	0.209	1.09 (0.54–2.20)	0.820	0.43 (0.20–0.90)	0.026
≥3	0.58 (0.36–0.94)	0.029	0.91 (0.46–1.81)	0.796	0.37 (0.18–0.75)	0.005

hrHPV-negative as reference; OR—Odds ratio; CI—Confidence Interval; n/a—not applicable (not possible to estimate).

).

Regarding factors associated with cervical lesions, logistic regression analysis (

Table 6. Logistic regression analysis for the association between VIA results with predictor variables, according to HIV status.

Predictor Variables	All		HIV-Positive (+)		HIV-Negative (−)
	OR (95% CI)	p Value	OR (95% CI)	p Value	OR (95% CI)	p Value
Age (years)	0.94 (0.92–0.96)	<0.001	0.93 (0.90–0.96)	<0.001	0.94 (0.91–0.97)	<0.001
Age category (years)
≤29			Reference
30–45	0.47 (0.25–0.90)	0.022	0.11 (0.03–0.37)	<0.001	0.83 (0.35–1.97)	0.667
≥46	0.19 (0.09–0.38)	<0.001	0.06 (0.02–0.22)	<0.001	0.24 (0.09–0.64)	0.004
Number of deliveries
Nulliparous			Reference
1–2	1.46 (0.67–3.21)	0.342	1.80 (0.60–5.42)	0.293	1.14 (0.37–3.52)	0.820
≥3	0.90 (0.42–1.95)	0.793	1.00 (0.34–2.97)	0.995	0.83 (0.28–2.45)	0.731
Use of contraceptives
No			Reference
Yes	1.65 (1.15–2.38)	0.007	1.35 (0.80–2.29)	0.263	2.09 (1.25–3.50)	0.005
Gynecological findings–SCJ
Totally visible			Reference
Partially/Not visible	2.88 (1.74–4.79)	<0.001	4.64 (2.33–9.22)	<0.001	1.73 (0.78–3.85)	0.180

VIA-negative as reference; OR—Odds ratio; CI—Confidence Interval; SCJ—squamocolumnar junction.

) showed that increasing age was associated with lower odds of VIA positivity. Each additional year of age was associated with reduced odds of a VIA-positive result (OR = 0.94, p < 0.001). Compared with women aged ≤ 29 years, those aged 30–45 years and ≥46 years had substantially lower odds of VIA positivity, particularly among HIV [+] women (OR = 0.11 and OR = 0.06, respectively; both p < 0.001). Number of deliveries was not significantly associated with VIA positivity.

Contraceptive use was associated with higher odds of VIA positivity overall (OR = 1.65, p = 0.007), with a stronger association observed among HIV [−] women (OR = 2.09, p = 0.005). In addition, a partially or non-visible squamocolumnar junction (SCJ) was strongly associated with higher odds of VIA positivity, especially among HIV [+] women (OR = 4.64, p < 0.001) (Table 6).

4. Discussion

Cervical cancer (CC) ranks as the most frequent cancer in Mozambique among women of all ages in 2022, accounting for about 20.5% of female cancer cases, according to GLOBOCAN estimates [44,45]. It also remains the leading cause of cancer mortality among Mozambican women [20,45]. High-risk (hr) HPV (persistent) infection is well known as prerequisite factor for the modification of the squamous epithelium and progression to premalignant lesions and CC over time [5,7,8].

This study provides important insights into the epidemiology of hrHPV infection and cervical premalignant lesions among women in Mozambique, with particular focus on its age-specific distribution and the associated risk factors, by HIV status. Our findings highlight critical epidemiological patterns that can inform prevention strategies, including screening, integration with HIV services and vaccination.

The mean age of participants (43.0 ± 8.6 years) reflects the typical profile of women attending screening in Mozambique and other sub-Saharan African and worldwide countries, where uptake peaks in mid-adult life [35,46,47,48]. Nearly three-quarters of women were undergoing screening for the first time, pointing to major gaps in awareness and access. This is consistent with earlier studies in Maputo and Nampula, where first-time screening rates exceeded 60% [22,23]. Such low coverage continues to undermine timely prevention [46,47].

The overall hrHPV prevalence of 28% aligns with prior studies from Mozambique, which reported values between 20% and 75.9% depending on HIV status and age [21,22,23,24,25,49]. Comparable prevalence has been described in sub-Saharan African countries [13], including Nigeria, Rwanda, and Burkina Faso [50,51,52]. Unlike high-income settings, where hrHPV prevalence declines after age 30 [53,54], our data show higher positivity in older ages, particularly 30–45 and ≥46 years. This supports evidence that HPV is more frequent in African women, influenced by HIV, reproductive history, and limited access to continuous screening [54,55,56].

HIV was strongly associated with hrHPV infection. HIV-positive [+] women had higher hrHPV prevalence (31.8%) and more frequent multiple infections than HIV-negative [−] counterparts. The crude odds of hrHPV infection were higher in HIV-positive women (OR = 1.99; 95% CI: 1.0–3.9), although this association did not reach statistical significance (p = 0.082). These findings are consistent with systematic reviews in Sub-Saharan Africa reporting higher pooled prevalence of any HPV or hrHPV/multiple infections among HIV [+] women, compared to HIV [−] women; OR = 4.68 (0.71–30.76) [13] and, OR = 3.22 (3.00–3.42) and OR = 3.71 (2.39–5.75), p < 0.001, respectively [12]. Other studies from Mozambique, Zimbabwe, and Kenya also reported that HIV coinfection was linked to broader hrHPV type distribution and reduced viral clearance [56,57,58].

Although HPV-16 and 18 remain oncogenically important, non-16/18 hrHPV types predominated in both groups, especially among HIV [+] women, and were concentrated in women of reproductive and early peri-menopausal age. These patterns mirror findings from African cohorts [13], including Maputo–Mozambique [14,21,23,58] and Burkina Faso [52], underscoring the need for screening and vaccination strategies beyond HPV-16/18. Vaccines targeting only HPV-16/18 may provide partial/limited preventive protection to CC, whereas the nonavalent vaccine could offer broader coverage, although access remains limited. The borderline difference in hrHPV prevalence between HIV [+] and HIV [−] women may reflect sample size constraints and suggests that additional factors—such as reproductive history, genital tract inflammation, and sexual behavior—play an important role in infection risk.

Among the factors assessed, age was associated with hrHPV infection. Logistic regression indicated that each additional year of age slightly reduced the odds of hrHPV, with a stronger effect observed in HIV-negative women. This aligns with findings from several sub-Saharan African countries [13], including South Africa and Nigeria [50,59], where hrHPV declined after midlife, likely reflecting cumulative immune clearance. Conversely, HIV [+] women may sustain hrHPV well into older ages due to immunosuppression and coinfections, underlining the need for differentiated screening strategies.

Reproductive history also influenced hrHPV prevalence. Nulligravida women and those with 1–2 deliveries had higher hrHPV positivity, whereas women with three or more deliveries showed lower odds of infection. This partly contrasts with global data linking high parity to CC [60]. Similar paradoxical findings in Rwanda [51] and Brazil [61] suggest that immune adaptations during multiple pregnancies may enhance viral clearance. Understanding these mechanisms will require more detailed longitudinal studies.

VIA results add further perspective. Overall, 11.1% of women were VIA-positive [+], with slightly higher prevalence among HIV [+] women (11.3% vs. 8.9%). Larger lesions (≥75% of the cervix) were also more frequent in HIV [+] women. These findings are consistent with reports from other African countries, where HIV infection is recognized as an important factor associated with VIA positivity [56] and CC, with an attributable fraction of 20.4% (vs. 1.3% and 1.1%, respectively, in the rest of the world) [60]. Yet, logistic regression revealed that contraceptive use was associated with higher odds of VIA positivity, particularly among HIV [−] women, while parity and prior STI history were not significant predictors. This contrasts with studies from Nigeria and Burkina Faso, where contraceptive use was not significantly associated with hrHPV infection [52,55], and with an Ethiopian study identifying high parity and a history of STIs as associated with VIA positivity (adjusted OR = 2.1, 95% CI: 1.3–4.0; adjusted OR = 1.9, 95% CI: 1.1–3.5, respectively) [62]. Possible explanations include hormonal influences on cervical epithelium or residual confounding by sexual behavior in our sample. Importantly, VIA positivity was strongly associated with poor SCJ visibility, especially in HIV [+] women, confirming that VIA performance declines when the transformation zone is not fully visible [14,63]. This reinforces WHO recommendations to prioritize HPV DNA testing, with VIA limited to triage where feasible.

Our findings on HPV type distribution highlight a regional pattern. HPV-16 and 18 were detected in 9.4% and 5.6% of HIV [+] women, respectively, compared with 3.6% and 2.0% in HIV [−] women. Although modest, these rates are clinically relevant, as HPV-16 and 18 account for most CC cases globally [14]. However, the predominance of other hrHPV types indicates that current vaccines alone will not eliminate CC in Mozambique. Expanded use of the nonavalent vaccine could further increase coverage against the spectrum of circulating hrHPV types.

Behavioral characteristics also influenced observed associations. The mean sexual debut age (17.5 years) and high multiparity reflect sociocultural patterns consistent with other studies from Africa and Mozambique [13,21,22,50]. Earlier sexual debut increases lifetime exposure to HPV [1], while genital tract abnormalities were more frequent in hrHPV-positive women, suggesting that local inflammation and STIs may facilitate persistence [41,64]. Notably, smoking—a key risk factor in other regions [48,65]—was virtually absent in our cohort, limiting its contribution. This underscores the context-specific nature of HPV epidemiology in Africa.

This study contributes to understanding the interplay of HIV, hrHPV, and cervical lesions in a high-burden setting. While our cross-sectional design limits causal inference, the findings reinforce that HIV [+] women are disproportionately affected by hrHPV and cervical abnormalities, especially from non-16/18 types. VIA alone may be inadequate for this group, given anatomical and immunological challenges. Broader vaccine coverage, HPV testing, and integrated HIV–HPV strategies are urgently needed. If scaled up effectively, these interventions could accelerate progress toward WHO’s CC elimination targets in Mozambique and similar settings.

5. Conclusions

This study revealed a 28% prevalence of high-risk HPV (hrHPV) among women in Maputo, with higher rates and multiple infections in HIV-positive [+] participants. Non-16/18 hrHPV types predominated across all ages, particularly among women aged 30–45 years. Younger age, lower parity, and HIV infection were key factors associated with hrHPV positivity, while older age and higher parity showed protective effects. VIA-positive [+] lesions were more frequent in younger and HIV [+] women.