Impact of the 2013 WHO guidelines for screening and treatment of cervical precancerous lesions on women’s screening rates, by HIV-status, in East and Southern Africa: A regression discontinuity design analysis

Introduction In 2013, the World Health Organization (WHO) issued guidelines for cervical pre-cancer screening. It recommended screening women aged 30–49, and younger women once they tested HIV-positive. Subsequent WHO guidelines recommended screening women living with HIV (WLHIV) starting at age 25. However, the impact of 2013 guidelines and age to start screening on screening has not been studied. Methods We used a regression discontinuity design (RDD) analysis of population-based data to assess the impact of the 2013 WHO guidelines on the screening rates for women according to HIV status and age group in Ethiopia, Malawi, Rwanda, Tanzania, Zambia, and Zimbabwe. The outcome was self-reported ever having been screened for cervical pre-cancer between 2008 and 2018. We compared the screening rates according to HIV status and age group, before and after age 25 years. And before and after 2014, the year countries adopted the 2013 guidelines. We then used a data-driven optimal bandwidth selection procedure to estimate the guidelines’ average treatment effect (ATE), with a local polynomial regression discontinuity and robust bias-corrected confidence intervals. We validated the RDD methodology overall and for women with a significant ATE at the country-level analysis. Results We included 73179 women: 6680 (9.1%) living with HIV, 4328 (5.9%) with unknown HIV status, and 62171 (85.0) with a negative HIV status. 5726 (7.9%) reported having ever been screened; 4022 (6.5%) with unknown HIV status, 525 (12.1%) with a negative HIV status and 1179 (17.7%) living with HIV. Adolescent girls and young women living with HIV (AGYWLHIV) aged 15–24 reported screening less often (917 (13.7%)) than their peers with unknown (1677 (38.8%)) or positive HIV status (27278 (43.9%)) (P<0.001), or older women. The ATE of screening was 0 for women with unknown or positive HIV status, for whom the RDD was valid. Conclusion We found no evidence the 2013 WHO guidelines increased or reduced women’s cervical pre- cancer screening. However, AGYWLHIV reported screening less often. Policy makers should lower the age to start screening WLHIV from 25 to 15 to screen more AGYWLHIV. Studies are required to examine the impact of the guidelines on cervical pre-cancer screening in more countries. ### Competing Interest Statement The authors declare no competing interests. ### Funding Statement Olivia Keiser was supported by the Swiss National Science Foundation (grant no 202660). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study did not require ethical review because the personal details in the data are de-identified, and the data is publicly available. It can be accessed with a request at I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data is publicly available. It can be accessed with a request at