Cervical cancer (CC) remains one of the most common malignancies among women in India, with nearly 100,000 women diagnosed annually and over 60,000 preventable deaths annually. With high-risk human papillomavirus (HR-HPV) as the causative agent for CC, one risk factor that places women at high risk for CC is human immunodeficiency virus (HIV), as impaired immune response against Human papillomavirus (HPV) may result in persistent HR-HPV infection, a critical risk factor for progression of HPV-related cervical oncogenesis. Progression of precancerous lesions among women living with HIV (WLH) is also associated with: 1) lack of HPV screening; 2) high levels of depressive symptoms and stigma; and 3) malnutrition, which negatively impacts the activation and proliferation of immune cells. Yet programs that offer WLH with comprehensive services focused on HPV screening and psychological and nutritional support are almost non-existent, and the gap is critical. Nutrition plays an integral role in relationship to HPV/HIV co-infection, as demonstrated by an increased risk of HR-HPV associated with poor nutrition; nutritional deficiencies are likewise linked to cervical intra-epithelial neoplasia. The immunological effect of malnutrition may also be exacerbated among WLH due to elevated energy demands of chronic immune activation; worsened with HPV/HIV co-infection. Further, depressive symptoms (aka depression for brevity) partially mediate the effect of food insecurity on HIV viral suppression. In our completed ASHA-Nutrition R01 study of antiretroviral (ART) adherence, the investigators trained lay community health workers, named Accredited Social Health Activist (ASHA), to improve the health of 600 rural WLH by providing emotional support, skill-building, nutrition education, and/or protein-enriched food supplements. In that study, our intervention, co-delivered by our trained ASHA, and guided by nurses, led to increased CD4+ T cell recovery and improved anthropometric and psychosocial outcomes. The investigators found that ASHA support plus protein supplements and nutritional education were significantly associated with improved CD4 counts and increased lean mass at 18 months (P < 0.001), as well as significant improvements in depression, ART adherence, social support and internalized stigma. In our sub study, CC screening of 598 of these WLH revealed that 13% were found to have abnormal cervical lesions and 4 (1%) had squamous CC. Preliminary evidence also revealed that nutritional supplements may be associated with a 40% reduction in the risk of abnormal cervical lesions (adjusted odds ratio [aOR] = 0.60), with an association between serum albumin and reduced risk of abnormal lesions (aOR= 0.39).

With a focus on secondary prevention of CC, the investigators hope to mitigate the link between HR-HPV persistence and risk of CC as well as improve the health of women co-infected with HPV/HIV (W-Co-V). Our stellar team plans to build upon our prior ASHA-Nutrition intervention, using formative research to refine a nurse-led, ASHA co-delivered, nutrition-enhanced SAKHI HPV intervention, adapted for W-Co-V. This will be followed by a randomized controlled trial (RCT), assessing the efficacy of our refined comprehensive, multifaceted SAKHI HPV intervention, as compared with an enhanced Standard of Care (SOC+) (usual care + 3 sessions [wellness, basic nutrition and HPV/HIV health promotion]) among 348 high-risk co-infected women to prevent CC while remaining engaged in the HIV treatment cascade, and managing nutritional health. Recruited participants will be individually randomized in a 1:1 ratio into the two study arms. Our Primary outcome is HR-HPV persistence (2 positive tests for the same HR-HPV type, separated by 12-18 months). The two aims incorporating RCT interventions are as follows:

Aim 2. To evaluate the efficacy of SAKHI HPV intervention among 348 W-Co-V on the primary outcome (HR-HPV persistence) as compared to the Enhanced Standard of Care (SOC+) program. H2: Compared to the SOC+ participants, SAKHI participants will have lower rates of HR-HPV persistence.

Aim 3. Assess the impact of the SAKHI program secondarily on: 1) HIV indices (HIV viral load; CD4 count); 2) Nutritional index (serum albumin) at 6-, 12-, and 18-months.

In this 5-year parallel-group RCT, the investigators will conduct a RCT to assess the efficacy of our six-month SAKHI HPV intervention, featuring: 1) eight in-depth group education sessions by nurses, OB/GYN and HIV physicians, psychologists, and nutrition experts on HPV/HIV, CC, and nutrition; 2) ASHA supported 1:1 sessions and community referrals; and 3) selected life skills training by expert artisans as compared to an Enhanced Standard of Care (SOC+) program, featuring 3 group sessions: wellness, basic nutrition and HIV/HPV information and referrals. The primary outcome is HR-HPV persistence (consecutive positivity for same HR-HPV type, separated by 12-18 months).

Secondary outcomes include improved: 1) HIV-related indices (HIV viral load and CD4 count); 2) Nutritional indices (serum albumin) measured at 6, 12, and 18 mos.

The investigators will conduct a two-arm parallel-group RCT among 348 W-Co-V who are cared for at the Belgaum District ART centers. Participants from 24 villages in Karnataka will be individually randomized in a 1:1 ratio to the SAKHI and SOC+ study arms prior to enrollment. A cohort of 16 women (8 per group) will be enrolled every month. Primary outcome, HR-HPV persistence (positivity for same HR-HPV type, separated by 12-18 months), will be compared to enhanced standard of care (SOC+) control group that is above and beyond what is typically offered to WLH treated in the health facility. Persistent HR-HPV is a widely used outcome for HPV vaccine and other CC prevention interventions, due to its critical role in HPV-related cervical oncogenesis. Secondary outcomes will focus on improvement in: 1) HIV related indices (HIV viral load and CD4 count); and 2) Nutritional index, serum albumin levels - a marker for protein consumption).

Setting: Karnataka is selected as our key site for the study as rates of HPV have remained second highest in the country. The W-Co-V are being recruited from underserved ART centers in the Bangalore and its surrounding districts. In the next several months, the team will be in Districts outside Bangalore including Tumkur, and Kolar, while additional sites will be conducted in Northern Karnataka to include Belgaum, Athani, Chikooi, Gokak, Raibagh and Saudatti.

The KSAPS (Karnataka State acquired immunodeficiency syndrome (AIDS) Program Society) has approved these sites to participate in our study. To enroll 348 W-Co-V, a total of 4200 WLH will be screened; thus, ongoing screening of our staff will be conducted in all ART centers. First-line ART is offered free by the government to all eligible PLWH and all newly diagnosed are referred to the ART centers. Thus, the investigators anticipate the 6 ART Centers will provide a sufficient number of eligible women.

Screening and Enrollment Procedure: The interviewers are informing the WLH about the study with flyers posted in the lobbies of the ART centers. Interested WLH approach the interviewer, stationed in the lobby, and retreat to a private room for further information. After the study is discussed, and all questions answered, the initial informed consent form (ICF) for screening is signed by the WLH. Immediately thereafter, the interviewer administers a brief 5-minute screening assessing age, prior HPV screening/treatment for HPV, abnormal cytology/CC, and HIV and ART status. Those who found not eligible are thanked for their time, provided the screening compensation and provided any immediately needed referrals in the community. Among those eligible, HPV status is assessed by requesting the women to perform a self-sample vaginal swab collection in the clinic restroom, wherein trained ASHA are available to assist. The samples are collected and sent to a selected lab for processing. At the lab, the samples are processed for presence of oncogenic HPV, and genotyping. If oncogenic type HPV is found, a visual inspection of the cervix with application of acetic acid is scheduled and conducted by our trained nurse. The decision to have the VIA immediately after the self-swab is also an option.

Typically, in India, nurses are trained to do VIAs; a good substitute for CC screening in low resource areas. Results will be provided confidentially to the woman by the nurse under the guidance of protocols developed by our gynecologist. If found to be VIA negative, the W-CoV will be referred to the interviewer for consideration of enrollment into the study, and a second ICF for participating in the RCT will be discussed and signed. Women found to be VIA positive are immediately referred to a gynecologist. Eligible and consenting women will be individually randomized in a 1:1 ratio to either the SAKHI or SOC+ programs prior to study initiation. Once assigned, the PC delivers the assignment to the appropriate study nurse and ASHA. Based on World Health Organization (WHO) guidelines, WLH found to be HPV positive should be rescreened for HPV in the next 12 months, along with VIA. If found to be VIA negative, screening can be resumed every 3 years. The interview staff are not involved in the delivery of the intervention and thus are blinded to condition for all assessments. Providers at the ART centers will also be blinded to study conditions.

Study Procedure: The investigators will recruit and enroll 348 eligible women living with HIV who test positive for HPV (WLHIV-HPV+) into one of two study arms: the SAKHI intervention arm or the Enhanced Standard of Care (SOC+) control arm. Participants will be recruited from ART centers across Karnataka, including KC General Hospital, Chikkaballapur, Kolar, Tumkur, Ramanagara, and Belagavi. Recruitment will occur in small groups of approximately 8 women per arm to facilitate intervention delivery and group-based activities. Following screening and informed consent procedures, eligible participants complete HPV self-swab testing and VIA screening. Women who are HPV-positive and VIA-negative proceed to baseline enrollment and randomization. Follow-up assessments occur at baseline, 6 months, 12 months, and 18 months.

At baseline and follow-up assessments, blinded interviewers administer questionnaire-based assessments using REDCap on tablet computers. Assessments include demographic information, HIV and HPV treatment barriers, stigma, emotional well-being, food security, substance use, physical activity, ART adherence, and psychosocial functioning. Dietary assessments are conducted using a two-day 24-hour dietary recall through the NINA-DISH application. Blood samples are collected to assess nutrition markers, Serum Albumin, Iron, Vitamin B12, Vitamin A, Vitamin D, CD4 count, and HIV viral load. Bioelectrical Impedance Analysis (BIA) and Body Mass Index (BMI) assessments are conducted during assessment visits. In addition to scheduled assessments, peer counselors maintain regular contact with participants through weekly visits, ongoing support, group sessions, and referral coordination as outlined in the intervention protocol. Group sessions focus on HPV education, HIV wellness, nutrition, mental health, resilience, behavioral activation, self-care, and employability skill-building. For implementation of the intervention, seven peer counselors have been trained, with five assigned to the SAKHI intervention arm and two assigned to the SOC+ arm. Peer counselors have undergone rigorous training conducted by the study investigators, project coordinator, and co-investigators. Training includes protocol orientation, mock sessions, counseling techniques, module-guided intervention delivery, confidentiality procedures, documentation practices, and mobile phone-based field reporting. Quarterly quality assurance assessments and booster training are conducted to maintain intervention fidelity and data quality. To minimize self-selection bias and improve participant comfort, interviewers and peer counselors receive training on confidentiality, stigma reduction, culturally sensitive communication, and disclosure avoidance. Recruitment will occur across multiple ART centers and at varying times to ensure representation of a broad and diverse participant population.

SAKHI Intervention: After completing their training, peer counselors are assigned to participants within the SAKHI intervention or SOC+ control arms to provide individualized support and follow-up, with each peer counselor effectively managing approximately 6-7 participants to ensure continuity and quality of engagement. To minimize contamination, we allot randomized participant lists and organize peer counselors into two working teams to support participant engagement in a structured manner with protocol-driven, with arm-specific modules, schedules, and content implemented according to participant assignment. The peer counselors are supervised by the nurse supervisor, the Project Coordinator, and investigators. Peer counselors maintain regular weekly contact with SAKHI participants and once every alternative month over the six month intervention period to assess participant needs, provide support, reinforce intervention content, monitor participation, and document activities according to the study protocol.

Based on initial interactions with participants, peer counselors and supervising staff identify barriers to intervention participation, follow-up care, ART adherence, screening attendance, and overall engagement. This information helps tailor support strategies to individual participant needs while ensuring that all core intervention components are consistently delivered.

The SAKHI intervention includes:

1. Six monthly group sessions led by trained intervention staff and supported by experts such as physicians, nutritionists, psychologists, and counselors. Sessions cover topics including HPV and cervical cancer education, HIV wellness, nutrition, mental health, resilience, behavioral activation, self-care, and skill-building.
2. Weekly individual peer counselor support and follow-up visits.
3. Referral to grant-supported employability and life skills training programs, including sewing, embroidery, computer training, and other participant-identified skill programs delivered by trained experts.

The specific classes relevant to our targeted W-Co-V were assessed in our CAB/focus group discussions, and include selling vegetables, sewing, weaving, embroidery, etc. These classes will provide economic sustainability, as accomplished by 80% of the WLH in our ASHA-Nutrition study. In the 8 group sessions, based on the comprehensive health seeking and coping paradigm (CHSCP), the nurse and content experts in Nursing, Medicine, Psychology and Nutrition address distinct barriers to ongoing engagement in care by educating the cohort about health promotion, HPV/HIV, coping with stigma, improving depressive symptoms, seeking trusted support, and keeping mentally healthy. The peer counselors who care for these women also attend, listen to the program, and support the team. The assigned peer counselors contact the women weekly and focus on providing 1:1 support to the W-Co-V in accessing and/or adhering to ART as well as reinforcing education received in group sessions, assisting with transportation, offering to accompany them to appointments, providing counseling, promote healthy lifestyle choices, and links with community resources. This weekly peer counselors support will occur over the six-month intervention. Records of time spent will be carefully monitored on the tablets. As lack of job skills has been previously identified as a source of stress, the peer counselors will assess job skills of interest for each woman and arrange selected training sessions weekly over the six-month period with skilled artisans.

The 8 (1.5 hours) group sessions will be held bimonthly over the first four months in a space the research team will rent that is central to all villages, based on the needs identified by prior WLH, and updated by the planned community advisory board (CAB), focus group (FG) meetings, and needs assessment. In months 5 and 6 of the program, the peer counselors will hold role play sessions once a month where the cohort will come together, and role play what they have learned in group sessions and how they are implementing it. Module 1 (sessions 1 & 2) begins with relaxation/grounding exercises, provide general information on HPV on how it spreads, recognizing the link between HPV and cervical cancer, the importance of seeking support from peer counselors, healthcare providers and trusted family/friends; importance of routine HPV screening, and know about the HPV vaccine and where to access care. Module 2 (sessions 3 & 4) focuses on caring for self and family, and begin with relaxation/ grounding exercises, discussions on HIV and how the virus is transmitted; and how the immune system is activated; and information about ART. There also is the beginning of Life Skills offered by experts on ways to enhance coping, including legal and spiritual; and beginning life skills vocational classes. Finally, a discussion about HIV and cervical cancer and information on alcohol and drug use. In Module 3 (sessions 5 & 6), the focus will be on emotional health and well-being. Participants will learn more in depth about relaxation techniques, and skills building, strategies to improve coping, stigma and problem solving, all of which will build resilience. They will learn to set goals and commit to uplifting activities; and continued life skills. They will also receive a handout of local mental health resources. Module 4 (sessions 7 & 8) will focus on providing education about which foods are the least expensive, easily accessible, and highly nutritious and immune supportive; and sharing recipes and enjoying cooking classes. Our nutrition experts will guide food selections using the Dietary Guidelines for Indians and food availability in the local region. Finally, ASHA will provide monthly food supplements that will consist of high protein foods (i.e. Dal lentils), while attending to minimal saturated fat, fiber (soluble fiber), and the cholesterol content of the foods. Food will be distributed based on family size with enough food for each family member to ensure the participant receives the intervention. In addition, to accommodate women who are unable to make group-assigned classes, additional flexible dates will be offered. If successful, this intervention can be easily scaled up by integrating ASHA training into the current Health Mission of India strategies.

Enhanced Standard of Care (SOC+): In India, screening services are lacking at most ART centers. Since it would be unethical to withhold potentially lifesaving information about HPV, the investigators offer an enhanced standard of care to include usual care + three (1.5 hour) group sessions on wellness, basic nutrition, coping with mental health issues, importance of HPV screening and treatment as needed, and ART adherence, and similarly delivered by the nurse and content experts over the six-month intervention. Women assigned to the SOC+ program are HPV screened at baseline as well and l meet as a group three times to meet their distinct SOC+ nurse and peer counselor at the research site. The SOC+ nurse and peer counselor, who follow distinct program protocols, provide information on resources in the community, including nutritious and low-cost foods, as well as referral to ART and other services as needed, and remind the participants by phone of upcoming appointments. However, peer counselors do not visit the women in their homes, nor do they receive the other modules or food supplements. Each of the SOC+ peer counselors follow their cohort of 8 participants every month over the six-month period. The SOC+ nurse guide their peer counselor and answer medical questions for their participants.

Inclusion Criteria:

1. WLH, 25 - 50 years of age; based on HIV-based guidelines;
2. Receiving ART for > 12 months to ensure medication stabilization, and ensure any impact on the cervical cancer outcomes will not be attributed solely to recent ART initiation, as validated by an ART card given to all ART patients;
3. Screened as HPV positive by RT-PCR (Reverse Transcription Polymerase Chain Reaction) for oncogenic genes; and assessed to be VIA negative;
4. Have not participated in Phase I Formative Study.

Exclusion Criteria:

1. Pregnant or lactating women due to hormonal and dietary guideline differences;
2. Women older than age 50. These women will be immediately referred to a gynecology specialist.

The data will be all collected in India and Indian law prohibits sharing of individual participants' research data data with other investigators.