Background: Dolutegravir-based antiretroviral therapy (ART) has optimized viral suppression for women living with HIV (WLWH) in low- and middle-income countries (LMICs). However, it is unclear if this biomedical success has translated into equitable delivery of curative chemoradiation (CRT) for locally advanced cervical cancer.This is the first systematic review to examine stratified chemoradiation outcomes in the dolutegravir/universal test-and-treat era.
Methods: We searched across Pubmed , Embase, Scopus, Ajol, Web of science and grey literature,in January 2026 for English-language studies(2018-2025) on CRT outcomes of locally advanced cervical cancer in LMICs by HIV status. Quality was assessed using ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions). Key outcomes included CRT completion, grade ≥3 toxicity, and early response.
Rayyan was used for screening. findings were synthesized narratively as meta-analysis was infeasible.
Results: Despite viral suppression in >85% of WLWH in included studies (median CD4: 412 cells/µL), WLWH had up to 80% lower odds of completing guideline-concordant CRT. Adjusted analyses from two studies showed pooled odds ratios (OR) of 0.42 (95% CI: 0.18–0.96) and 0.20 (95% CI: 0.11–0.37), with completion rates as low as 28.9% in WLWH compared to 51.0% in women without HIV. Non-completion was primarily driven by failure to receive brachytherapy. One study found higher grade ≥3 ototoxicity in WLWH (16.3% vs. 10.8%; p=0.023). While early clinical response (3–6 months) was similar (adjusted OR 0.91, 95% CI: 0.40–2.08), 12-month locoregional control was lower in WLWH (60.5% vs. 77.6%). Critical HIV-specific data (ART duration, viral load) were frequently missing.
Conclusion: In the universal ART era, WLWH remains at high risk of incomplete curative treatment despite virological control. This "Implementation Gap" suggests that structural barriers to brachytherapy and increased toxicities,rather than tumor biology,drive disparities. Integrated care models addressing logistical and socioeconomic barriers are urgently needed to achieve equitable cancer outcomes in LMICs.