PROJECT SUMMARY/ABSTRACT Cervical cancer is the fourth most common and third most fatal cancer among women worldwide. Cervical cancer is an AIDS-defining illness and the most common cancer among women living with HIV (WLWH) globally. Overall, WLWH have a higher risk of HPV acquisition, lower risk of HPV clearance, higher incidence of high grade lesions (HGSIL), reduced regression from HGSIL to normal, and higher incidence of cervical cancer compared to women without HIV. However, little is known about the biological mechanism of cervical pre-cancer. It is estimated that there are 250,000-1 million new cases of cervical pre-cancer each year in the U.S. requiring treatment for these pre-cancerous lesions. Even with the WHO’s 90-70-90 cervical cancer elimination strategy, where they expect to treat 90% of the pre-cancer women, the unwanted effects of invasive treatment should not be overlooked. Not all pre-cancers progress to cancer and identifying biomarkers associated with progression could help with treatment algorithms (specifically in HIV). One compelling hypothesis is that additional molecular events besides human papillomavirus (HPV) are required for cervical pre-cancer development as well as progression to high grade lesions and biological aging is a likely event at the molecular level. Several studies suggest that HIV induces alterations of the host biology and in doing so these alterations can accelerate biological aging. HIV-related aging potentially results in impairing the immune system so that it can no longer control the risk for cancer. Immune cell profiles using methylation-derived neutrophil-to-lymphocyte (NLR) and leukocyte-to-monocyte ratio (LMR) have been shown to be associated with risk of different cancers, including HPV-driven oropharyngeal cancer; however, there are no reports of studies in pre-cancer, which is a pre-cursor to cancers that will have impactful prevention strategies. In the proposed study, we will examine the association of two biomarkers of aging (aging-related inflammation and DNA methylation) with cervical pre-cancer in WLWH and compare with HIV-negative women in two races (Black and White). To achieve the goal, we will utilize tissues from: a) “coexisting” normal and pre-cancer lesions from each individual and b) pre-cancer progression lesion samples collected longitudinally from the same individual from two different time-points. This design allows validation of results using two different study designs. We will focus on the different neoplastic tissues and utilize cell isolation techniques and nucleotide processing technologies that allow comprehensive methylation assays to derive two biomarkers of aging, immune-cell profile (Aim 1) and biological age (Aim 2), using state-of-the-art computational algorithms. This innovative study will bridge the gap in translating molecular knowledge of cervical pre-cancer progression and potentially provide insights into development of aging biomarkers. There is potenti...