Screening for Cervical Cancer in HIV-Infected Women Receiving Care in the United States:

Timely reminder interventions to improve annual Papanicolaou (Pap) smear rates among HIV-infected women in an outpatient center of southern Nevada: a short report

Current guidelines recommend annual Papanicolaou (Pap) smears for human immunodeficiency virus (HIV)-infected women for cervical cancer screening. Rates for such screening in Nevada are below the national rate. Our cohort includes 485 eligible HIV-infected adult women from an outpatient center in Southern Nevada of which only 12 women had obtained a Pap smear in the past year. An intervention was conducted from June 2015 to September 2015, in which reminders to schedule a Pap smear were sent to the remaining cohort of 473 women via sequential text messaging, followed by phone call attempts. Of all subjects, 94% contacted by text messages and 41% contacted by phone calls were successfully reached. There was an increase in the rate of completed Pap smears from 2.5% (12/485) at baseline to 11.8% (56/473) after interventions (p < 0.0001) in a period of three months. Out of the 68 Pap smear results, 20 (29.4%) were abnormal. Our intervention, utilizing methods of communication such as text messaging and phone calls, markedly increased the rate of completed Pap smear screening in our population.

Levels and determinants of breast and cervical cancer screening uptake in HIV-infected women compared with the general population in France

OBJECTIVES

Cancer is a growing concern for HIV-infected people, and screening plays a major role in alleviating the burden it causes. We sought to investigate the levels and determinants of breast cancer screening (BCS) and cervical cancer screening (CCS) in HIV-infected women as compared with the general population.

METHODS

The Agence Nationale de Recherche sur le Sida et les Hépatites Virales (ANRS)-Vespa2 study was conducted in 2011 in a national representative sample of 3022 HIV-infected hospital out-patients in France. The rates and correlates of BCS and CCS among HIV-infected women were compared with those in the general population using multivariate Poisson regression models.

RESULTS

The BCS rate during the 2 years preceding the survey interview was 80.7% among HIV-infected women vs. 89.1% in the general population (P = 0.146). The CCS rate during the preceding 3 years was 88.1% among HIV-infected women vs. 83.1% in the general population (P = 0.021). During the preceding year, the CCS rate among HIV-infected women was 76.5%. The barriers to BCS and CCS were a low educational level [BCS: adjusted prevalence rate ratio 0.88; 95% confidence interval (CI) 0.80-0.97; CCS: adjusted prevalence rate ratio 0.91; 95% CI 0.83-0.99], not having supplementary health insurance (CCS: adjusted prevalence rate ratio 0.92; 95% CI 0.86-0.98), an irregular gynaecological follow-up (BCS: adjusted prevalence rate ratio 0.77; 95% CI 0.64-0.92; CCS: adjusted prevalence rate ratio 0.72; 95% CI 0.64-0.81) and a low CD4 count (BCS: adjusted prevalence rate ratio 0.83; 95% CI 0.71-0.97; CCS: adjusted prevalence rate ratio 0.78; 95% CI 0.63-0.98). The disparities in CCS uptake in terms of age, employment and gynaecological follow-up were less pronounced among HIV-infected women than in the general population.

CONCLUSIONS

BCS and CCS uptake was not lower among HIV-infected women than in the general population, but CCS was suboptimal. Specificities in the profile of barriers to screening emerged.

Factors influencing cervical cancer screening in women infected with HIV: a review of the literature

The purpose of this article is to review and compare factors that influence cervical cancer screening behavior in HIV-infected women and uninfected women. The research literature revealed that age, ethnicity/race, tobacco use, weight, education, economic issues, and risky behaviors such as substance abuse were factors that influenced cervical cancer screening among all women. HIV viral load and CD4+ T lymphocyte count were serologic factors that affected cervical cancer screening in HIV-infected women. Clinicians can use this information to identify patients at risk for poor Pap test adherence. Future interventions to reduce potential barriers for cervical cancer screening are needed in HIV-infected women.

Cervical pap screening cytological abnormalities among HIV-infected adolescents in the LEGACY cohort

OBJECTIVES

To determine the prevalence of cervical Pap screening (CPAP-S), identify factors associated with CPAP-S, and explore risk factors for abnormal cervical cytology in female adolescents with perinatally and behaviorally acquired HIV infection.

DESIGN

Cross-sectional.

SETTING

LEGACY is a national observational cohort chart review study of 1478 HIV-infected persons (<age 24 years) managed in 22 HIV specialty clinics in the United States.

PARTICIPANTS

Sexually active females aged 13-24 years in the LEGACY cohort.

MAIN OUTCOME MEASURES

CPAP-S and abnormal cervical cytology.

RESULTS

Of 231 sexually active female LEGACY participants 13-24 years of age 49% had documentation of CPAP-S between 2001 and 2006. Fifty-eight percent of 113 cervical tests were abnormal (2% high-grade). In multivariable analysis, perinatal HIV infection and black race were associated with decreased likelihood of CPAP-S (adjusted prevalence ratio [APR] 0.66, 95% CI 0.45-0.96 and APR 0.74, 95% CI 0.56-0.96, respectively). Presence of any sexually transmitted infection (STI) was independently associated with increased likelihood of CPAP-S (APR 1.56, 95% CI 1.21, 2.02). CD4+ T-lymphocyte count <200 cells/mL and previous STI diagnosis were independently associated with increased likelihood of abnormal cervical cytology (APR 2.19, 95% CI 1.26-3.78 and APR 1.94, 95% CI 1.29-2.92, respectively).

CONCLUSIONS

Among sexually active HIV-infected adolescent females, prevalence of CPAP-S was low and cytology was abnormal in more than half of Pap smears. Perinatally HIV-infected, sexually active females were less likely to undergo CPAP-S than their behaviorally HIV-infected counterparts. Interventions targeted at HIV-infected adolescents and care providers are needed to improve CPAP-S in HIV-infected young women, especially those with perinatally acquired HIV infection.

Frequency of Gynecologic Follow-Up and Cervical Cancer Screening in the Swiss HIV Cohort Study

BACKGROUND

According to current recommendations, HIV-infected women should have at least 1 gynecologic examination per year.

OBJECTIVES

To analyze factors associated with frequency of gynecologic follow-up and cervical cancer screening among HIV-infected women followed in the Swiss HIV Cohort Study (SHCS).

METHODS

Half-yearly questionnaires between April 2001 and December 2004. At every follow-up visit, the women were asked if they had had a gynecologic examination and a cervical smear since their last visit. Longitudinal models were fitted with these variables as outcomes.

RESULTS

A total of 2186 women were included in the analysis. Of the 1146 women with complete follow-up in the SHCS, 35.3% had a gynecologic examination in each time period, whereas 7.4% had never gone to a gynecologist. Factors associated with a poor gynecologic follow-up were older age, nonwhite ethnicity, less education, underweight, obesity, being sexually inactive, intravenous drug use, smoking, having a private infectious disease specialist as a care provider, HIV viral load <400 copies/mL, and no previous cervical dysplasia. No association was seen for living alone, CD4 cell count, and positive serology for syphilis.

CONCLUSIONS

Gynecologic care among well-followed HIV-positive women is poor and needs to be improved.

[Risk factors for incident cervical intraepithelial neoplasia (CIN) among HIV-infected women: a prospective study]

OBJECTIVES

To study risk factors for incident cervical intraepithelial neoplasia (CIN) among HIV-infected women.

PATIENTS AND METHODS

Prospective study of a population of 97 HIV-infected women with normal Pap smear at inclusion.

RESULTS

Fourteen CIN (diagnosed by colposcopy and confirmed with biopsy) were observed within a median follow-up of 38 months (13 CIN 1, one CIN 2). The incidence of cervical lesions was estimated to be 2%, 7% and 10% respectively at one year, two and three years after inclusion, The time to occurrence was very variable (ranging from 7 months to 6 years) among our patients. No known risk factors, in particular neither the CD4 cell count nor antiretroviral treatment, were identified to be associated with occurrence of CIN in our study population.

CONCLUSION

Regardless of their immune status and HIV treatments, extensive and prolonged gynaecological follow up of HIV-infected women remains necessary.

Cervical screening in HIV-positive women: characteristics of those who default and attitudes towards screening

OBJECTIVES

To determine the characteristics of HIV-positive women who undergo cervical screening and to identify negative attitudes and experiences of these women to screening and the factors associated with these.

METHODS

We compared the Royal Free Cohort data from 59 newly diagnosed HIV-infected women, 31 of whom did and 28 of whom did not attend for cervical screening in 2001, and from 227 women under active cervical screening follow-up (at least one cervical screen since June 2001) and 88 HIV-infected women lost to follow-up (not screened since January 2001). Attitudes to screening were investigated with the aid of a questionnaire given to all women attending clinic who had had a previous colposcopy.

RESULTS

Of the 59 newly HIV diagnosed women, 31 (53%) underwent cervical screening. These 31 women were more likely to be heterosexual (100 vs 89%, P=0.05), to have lower median viral loads (< 50 vs 3210 HIV-1 RNA copies/mL) and to be receiving antiretrovirals (ARVs) (74 vs 54%, P=0.1) than those not screened. Of the 315 women who had at least one screen, 72% returned for further follow-up. There were no differences in age or ethnicity between these groups. Those under active follow-up had a higher CD4 count (P=0.04) and lower viral load (P=0.0001) at their last visit. They were also more likely to be on highly active antiretroviral therapy (HAART) (68 vs 52%, P=0.006). A total of 78 of 104 questionnaires (75%) were returned. Women participating in the questionnaire study were mainly of back ethnicity (68%), did not speak English as their first language (59%) and were taking ARVs (76%). Most agreed that regular smears and colposcopy were valuable. Women of white ethnicity, and those speaking English as a first language, were more likely to dislike colposcopy compared with those of nonwhite ethnicity (87 vs 25%, respectively, P=0.0007) and not speaking English as a first language (74 vs 26%, respectively, P=0.002). Those of white ethnicity were more likely to find smears and colposcopy painful (60 and 73%) compared with those of black ethnicity (46 and 51%, P=0.47 and 0.28, respectively).

CONCLUSIONS

Our results suggest that women on HAART with better disease control, older women, and those of black African ethnicity are more likely to take up cervical screening. Cervical screening experience varies by ethnicity and language.

Cervical neoplasia and the HIV-infected patient

HPV infection and cervical dysplasia occur more frequently in HIV-infected women. All HIV-infected women should be screened at least annually for cervical cancer with cervical cytology. All patients with any abnormality in the Pap smear should be referred for colposcopic evaluation. Patients with documented high-grade dysplasia should be treated. All patients must be observed closely after treatment for recurrence. Treatment with agents such as imiquimod or 5-FU may help to decrease recurrence rates. Patients who are diagnosed with cervical cancer should be treated with surgery or concurrent chemotherapy and radiation as determined by extent of disease and health status. It appears that HAART may have a positive impact on cervical dysplasia and cancer. Thus, all HIV-infected patients should be managed optimally on HAART. Hopefully, as patients live longer and healthier on HAART, they will be more compliant with cervical cancer screening, and cervical cancer will become an increasingly rare disease.