Cervical cancer screening among HIV-infected women in an urban, United States safety-net healthcare system

Cervical Pap screening among women living with HIV in Puerto Rico and the United States - Medical Monitoring Project, 2018-2021

Our objective was to determine the prevalence of cervical Pap screening among women living with HIV (WLWH) in Puerto Rico (P.R.) and other selected United States (U.S.) jurisdictions. Additionally, we sought to compare selected characteristics of WLWH who underwent cervical Pap screening between P.R. and the other U.S. jurisdictions. We analyzed data from the 2018-2021 cycles of CDC's Medical Monitoring Project (MMP), a national surveillance system among adults with HIV residing in P.R. (n = 218) and 22 other MMP jurisdictions (n = 3,653). Weighted percentages and 95 % confidence intervals (CIs) for selected characteristics were estimated. Prevalence ratios with predicted marginal means were calculated. An estimated 91.6 % and 84.6 % of WLWH underwent cervical Pap screening in P.R. and the other 22 MMP jurisdictions, respectively (Prevalence Ratio = 1.08, 95% CI = 1.03-1.13). Among WLWH who underwent cervical Pap screening, those in P.R. were more likely to be 50+ years of age, have a household annual income below $20,000, engage in binge drinking, never smoke, and have Medicaid/other public insurance than those in the other 22 MMP jurisdictions (p < 0.05). No differences were found between P.R. and the other 22 MMP jurisdictions in the percentage reporting higher than the median HIV-stigma score, experiencing HIV health care discrimination, and having ≥ 1 sexual partner in the past 12 months. Although cervical Pap screening rates among WLWH were higher in P.R. than in the other 22 MMP jurisdictions, both surpass the Healthy People 2030 target. Future research should assess adherence and compliance with updated cervical cancer screening guidelines.

An Epidemiological Study of Cervical Cancer Trends among Women with Human Immunodeficiency Virus

The purpose of this study was to examine cervical cancer among women with Human Immunodeficiency Virus (HIV) and to discuss targeted strategies to reduce the risk of developing cervical cancer. This study used retrospective data from surveillance reports collected between January 2001 and December 2012. Women with HIV/Acquired Immunodeficiency Syndrome (AIDS) were linked through a crosswalk file to Florida's cancer registry database to determine which women developed cervical cancer during this period. We examined the cervical cancer trends using age-adjusted cervical cancer rates to examine the changes over time; the geographic variations in cervical cancer and HIV across service areas using a Geographic Information System (GIS); and finally, the cervical cancer rates among women with HIV compared with the cervical cancer rates in the general population. The results show that, over time, the cervical cancer rates in women with HIV/AIDS decreased; however, we detected increases in the cervical cancer rates among women in the general population. The findings of this study show that more work is required to address cervical cancer. This growing burden of cervical cancer implies that targeted interventions are imperative to improving the health status of women with cervical cancer. If properly addressed, the potential to reduce and prevent cervical cancer is achievable.

Community cervical cancer screening and precancer risk in women living with HIV in Jos Nigeria

BACKGROUND

High HIV prevalence, and lack of organized screening for the indigent population receiving care and treatment within HIV clinics in low-resource settings increases cervical cancer incidence. We sought to determine predictors of cervical precancer in women living with HIV and receiving cervical cancer screening in Jos, Nigeria.

METHODS

A cross-sectional study of women living with HIV and receiving care and treatment in adult HIV/AIDS clinics in Jos-Metropolis, Nigeria between June 2020 and April 2023. Ethical approvals were obtained from the ethics committee in Jos, Nigeria and Northwestern University IRB, USA. Informed consent was obtained from eligible participants, and data on socio-demographics, cancer risk factors, and cytology reports were collected. The outcome variables were cervical precancer lesions. The independent variables were prior Pap smear status, socio-demographics, income, educational, and other reproductive health factors. Descriptive statistics was done to obtain means ± sd, frequencies, and percentages for the variables. Univariate and bivariate analyses were done to determine predictors of cervical dysplasia. Analyses were performed using R software.

RESULTS

Of 957 women screened, 570 were living with HIV and 566 women had cytology report and were included in the final analysis. The mean age was 45.08 ± 8.89 years and 81.6% had no prior evidence of Pap test (under-screened). Prevalence of cervical dysplasia was 24% (mild and severe dysplasia were 12.9% and 11.1%, respectively). Age above 45 years (aOR = 3.48, p = 0.009), postmenopausal status (aOR = 7.69, p = 0.000), and women with no history of prior IUCD use (aOR = 5.94, p = 0.0001), were predictors for severe dysplasia. Women who had history of STI (aOR = 0.17, p = 0.000), prior use of IUCD (aOR = 0.32, p = 0.004), prior use of condom (aOR = 2.50, p = 0.003) and had co-morbidities (aOR = 0.46, p = 0.009) were more likely to have had a Pap test in the past.

CONCLUSIONS

The majority of indigent women receiving care at HIV clinics had their first Pap test screening, and lack of organized screening among older and post-menopausal women with HIV, puts women at a higher risk of developing severe cervical precancer lesions.

Roles and mechanisms of exosomal microRNAs in viral infections

Exosomes are small extracellular vesicles with a diameter of 30-150 nm that originate from endosomes and fuse with the plasma membrane. They are secreted by almost all kinds of cells and can stably transfer different kinds of cargo from donor to recipient cells, thereby altering cellular functions for assisting cell-to-cell communication. Exosomes derived from virus-infected cells during viral infections are likely to contain different microRNAs (miRNAs) that can be transferred to recipient cells. Exosomes can either promote or suppress viral infections and therefore play a dual role in viral infection. In this review, we summarize the current knowledge about the role of exosomal miRNAs during infection by six important viruses (hepatitis C virus, enterovirus A71, Epstein-Barr virus, human immunodeficiency virus, severe acute respiratory syndrome coronavirus 2, and Zika virus), each of which causes a significant global public health problem. We describe how these exosomal miRNAs, including both donor-cell-derived and virus-encoded miRNAs, modulate the functions of the recipient cell. Lastly, we briefly discuss their potential value for the diagnosis and treatment of viral infections.

Utilizing first void urine for high-risk HPV testing for cervical cancer screening in HIV-positive women in Katete, Zambia

BACKGROUND

The World Health Organization targets to screen 70% of women worldwide twice for cervical cancer by the year 2030, first by age of 35, and again by the age of 45. However, with the current low screening coverage in many developing countries, this may not be achieved because the invasive sampling method is unacceptable to some. In Zambia, for instance, despite the availability of free cervical cancer screening through the establishment of the Cervical Cancer Prevention Programme, some women are still reluctant to go for screening. First void urine sampling is non-invasive and thus has the potential to increase screening coverage. We aimed to determine the performance of first void urine for high-risk human papillomavirus DNA detection, the prevalence of high-risk HPV, and the acceptability of first void urine sampling.

MATERIALS AND METHOD

A comparative cross-sectional study was conducted among 100 HIV- infected women at St Francis' Hospital in Zambia, attending the routine HIV/AIDS services and cervical cancer screening. 17 mL of first void urine sample collected by each participant was immediately mixed with 3 mL of 0.5 M EDTA preservative solution before cervical sample collection by the clinician. For testing, 2 mL of first void urine and 1 mL of the cervical sample were tested using the GeneXpert platform. An interview-based questionnaire was used to gather data on the acceptability of first void urine sampling. Data was analyzed using Stata version 17.

RESULTS

The mean age of the participants was 42.58 years (95% CI 40.98-44.19; SD 8.01). High-risk HPV prevalence was 34% (95% CI 24%-43.9%) in both cervical and first void urine samples. Sensitivity and specificity were 84.8% (95% CI 68.1%-94.9%) and 92.3% (83%-97.5%), respectively. There was 89.80% agreement between the samples (κ = 0.77; 95% CI 0.64-0.91). First void urine sampling was highly accepted.

CONCLUSION

High-risk HPV DNA can be detected in first void urine samples using the GeneXpert, with a substantial agreement with cervical samples. An affordable preservative such as Ethylenediamine tetraacetic acid can prevent DNA degradation. With optimization, first void urine sampling has the potential to increase screening coverage.

Anal cancer screening among women with HIV: provider experiences and system-level challenges

Women living with HIV (WLWH) are at increased risk of anal cancer compared to women without HIV, often due to persistent human papillomavirus (HPV) infections. This paper describes current practices and challenges conducting anal cancer screening for WLWH at an urban integrated safety-net system and a non-profit community-based HIV clinic. We conducted 25 semi-structured interviews with clinical and administrative stakeholders to assess knowledge, clinic practices and procedures, and experiences with anal cancer screening. Interview transcripts and fieldnotes were thematically analyzed using an iterative deductive and inductive coding scheme. Findings were organized by the Consolidated Framework for Implementation Research (CFIR) domains and constructs. Provider-level barriers to conducting anal cancer screening included limited knowledge of guidelines. System-level barriers included: structural characteristics such as lack of coordination between clinics to discern provider roles and responsibilities; and limitations in available resources such as configuration of electronic health records and infrastructure to manage referrals of abnormal anal Pap results. We conclude that anal cancer screening and follow-up for WLWH requires organization and coordination between multiple care teams, updated clinical information systems to facilitate communication and support anal Pap ordering and result documentation, and infrastructure that includes policies and protocols for management of abnormal results.Trial registration: ClinicalTrials.gov identifier: NCT02135419.

Veteran Women Living With Human Immunodeficiency Virus Have Increased Risk of Human Papillomavirus (HPV)-Associated Genital Tract Cancers

BACKGROUND

Disparities in access to screening often confound observed differences in human papillomavirus (HPV)-associated female genital tract cancer (FGTC) incidence between women living with human immunodeficiency virus (HIV; WLWH) and their HIV-negative counterparts. We aimed to determine if there have been changes in cancer risk among WLWH during the antiretroviral era in a single-payer health system.

METHODS

We retrospectively selected WLWH and HIV-negative controls receiving care between 1999 and 2016 at the US Department of Veterans Affairs (VA) and identified FGTC diagnoses via Cancer Registry and International Classification of Diseases-9/10 codes. We extracted demographic and clinical variables from the VA's Corporate Data Warehouse; evaluated incidence rates (IRs), incidence rate ratios, hazard ratios, and 95% confidence intervals (CIs) for cancer risk; and conducted survival analyses.

RESULTS

We identified 1454 WLWH and compared them with 5816 matched HIV-negative controls. More WLWH developed HPV-associated FGTCs (total n = 28 [2.0%]; cervical = 22, vulvovaginal = 4, and anal/rectal = 2) than HIV-negative women (total n = 32 [0.6%]; cervical = 24, vulvovaginal = 5, and anal/rectal = 5) (log rank P < .0001). Cervical cancer IR was >6-fold higher for WLWH (204.2 per 100 000 person-years [py] [95% CI, 83.8-324.7]) than HIV-negative women (IR = 31.2 per 100 000 py [95% CI, 17.9-44.5]). The IRs for vulvovaginal and anal cancers were also higher in WLWH. Overall, WLWH were more likely to develop HPV-associated FGTCs compared with their HIV-negative counterparts (all log rank P values < .0001).

CONCLUSIONS

Veteran WLWH are more likely to develop HPV-associated FGTCs despite equal access to health care. Even in single-payer health systems, WLWH continue to require special attention to ensure guideline-based high-risk HPV screening for prevention of FGTCs.

Cervical cancer screening patterns among HIV-positive women in Estonia: a population-based retrospective cohort study

BACKGROUND

The World Health Organisation (WHO) calls for the elimination of cervical cancer (CC) as a public health issue. To achieve elimination, efforts must be aligned and accelerated. Women living with HIV (WLWH) have excess risk for developing, and dying from, CC over the general population. Estimates of cervical cancer screening programme coverage in Eastern European countries that have experienced HIV epidemics since the early 2000's are scarce.

METHOD

This population-based retrospective study uses a healthcare administrative database and follows cohorts of all WLWH in a ratio of 1:3 randomly matched (age, region) HIV negative women from 2009 to 2018. Annual and longitudinal (over the whole study period) coverage for cervical cancer screening (opportunistic, organised, HIV specific) and adjusted odds ratios (AORs) for longitudinal screening coverage predictors were estimated from 2009 to 2018.

RESULTS

Among WLWH and HIV-negative women, the mean annual coverage with opportunistic screening was 61.45 and 65.59%; and organised screening was 20.4 and 28.7%, respectively (both: p < 0.00001). 19.01% (95% CI 18.05-19.97) HIV-negative and 13.9% (95% CI 12.35-15.45) WLWH were longitudinally covered with organised cervical cancer screening. Among WLWH, the mean annual HIV-specific cervical cancer screening coverage was 49.4, and 24.3% were longitudinally covered. Longitudinal coverage with HIV-specific cervical cancer screening was inversely associated with age, hepatitis C virus (HCV) co-infection (AOR 0.754, 95% CI 0.619, 0.916), not having insurance (AOR 0.331, 95% CI 0.264, 0.412), drug abuse (AOR 0.459, 95% CI 0.336, 0.618) and higher among those retained in HIV care (AOR 1.972, 95% CI 1.615, 2.410). Among HIV-negative women, longitudinal coverage with organised cervical cancer screening was inversely associated with residence in the region and higher among older women.

CONCLUSIONS

Our results highlight unacceptably low coverage of cervical cancer screening of WLWH in Estonia. There is need for dedicated cervical cancer screening efforts for WLWH considering the high cancer risk and rate in the study population.

Anal Cancer and Anal Cancer Screening Knowledge, Attitudes, and Perceived Risk Among Women Living With HIV

OBJECTIVES

The aims of the study were (1) to describe anal cancer knowledge, perceived risk, screening barriers, and acceptability of sample self-collection among women living with HIV (WLWH) at an integrated safety-net system and (2) to describe differences in demographic and psychosocial variables among a subsample of WLWH with a history of abnormal cervical cytology results versus those with normal results.

MATERIALS AND METHODS

We conducted telephone surveys with English- and Spanish-speaking WLWH (N = 99) and used electronic health record data to extract insurance type, CD4+ cell count, RNA viral load, and cervical cytology results. We calculated descriptive statistics for participant demographics, HIV laboratory results, and psychosocial variables. Among the subsample of women who completed a recent cervical Pap, we used Fisher exact test to assess differences in demographic variables, CD4+ counts, RNA viral loads, knowledge, awareness, acceptability, and perceived risk by cervical cytology results.

RESULTS

Most participants (70%) reported knowing nothing about anal cancer; 28% correctly responded that HIV increases one's chance of getting anal cancer. Most (68%) never heard of an anal Pap test. Forty percent would get an anal Pap if they could self-collect the sample, whereas 59% were neutral or disagreed. The 2 most commonly cited barriers to obtaining an anal Pap were "I do not know enough about it" (n = 15) and "It might hurt" (n = 9).

CONCLUSIONS

This study highlights a gap in knowledge and awareness among WLWH regarding their heightened risk for anal cancer. It indicates the need for health education and suggests an opportunity for a self-collection intervention.

Prevalence of Cancers Among Patients with HIV Referring to Voluntary Counseling and Testing Center, Tehran, Iran, 2004-2017

Background: Malignancies, in part, are responsible for high HIV-related morbidity and mortality. While antiretroviral therapy (ART) substantially decreases the risk of developing AIDS-defining cancers, HIV-infected individuals remain at high risk for non-AIDS-defining cancers. Objectives: In Iran, the epidemiology of AIDS and non-AIDS-defining cancers in the HIV-infected population has not been studied; therefore, this study investigated the prevalence of cancers among HIV-infected patients in Iran. Methods: In this cross-sectional study, using convenient sampling, hospital records of 1243 HIV-infected patients from 2004 to 2017 were collected at the Imam Khomeini Hospital in Tehran. The only inclusion criterion was a positive HIV result of ELISA and Western blot tests. The records were investigated for the occurrence of HIV- and non-HIV-defining cancers. To examine the association between relevant factors and cancer, we used a multivariate logistic regression model to calculate the adjusted Odds Ratio (AOR). Results: Thirty-nine out of 1243 HIV-infected patients, including 16 males (41%) and 23 females (59%), were diagnosed with concurrent cancer (3.1%). Twenty-five individuals had AIDS-defining cancers (2%), and 14 had non-AIDS-defining cancers (1.1%). Cervical cancer was detected in 14 patients (1.1%), non-Hodgkin's lymphoma in 7 patients (0.6%), and Kaposi's sarcoma in 4 patients (0.3%). There was a significant association between age group (30-40 years old) and the type of cancer (P = 0.048). Age group (adjusted odds ratio 3.33 for age group ≥ 50 yrs, 95% CI: 0.42-26.60) and gender (adjusted odds ratio 0.36 for men, 95% CI: 0.18–0.70) remained independently associated with cancer (P < 0.05). Conclusions: The prevalence of AIDS-defining cancers was higher than non-AIDS-defining cancers. These results highlighted the importance of promoting cancer screening and early ART initiation among HIV-infected patients.

Prevalence and predictors of HIV screening in invasive cervical cancer: a 10 year cohort study

BACKGROUND

Invasive cervical carcinoma is associated with a human immunodeficiency virus (HIV) prevalence of >0.1%, and screening is recommended and cost-effective for cancer populations exceeding this threshold. HIV status is also prognostic for cancer-specific survival, but compliance with HIV screening is poor in the USA and abroad.

OBJECTIVES

This study aims to describe HIV screening practices in a US comprehensive cancer center. To guide quality improvement, we identify characteristics which may predict compliance with screening.

STUDY DESIGN

Women treated for invasive cervical cancer from January 2007 to December 2017 were identified by local cancer registry and billing data. We assessed age, race, ethnicity, insurance status, histology, stage, pregnancy, drug use, and HIV testing status. Univariate logistical regression was performed to assess predictors of completed HIV screening.

RESULTS

Of 492 eligible women, the cumulative screening rate was 7.6%. Race, ethnicity, histology, and funding source were not predictive of screening. Every 5 year increase in age was associated with a lower chance of screening (OR 0.86, p=0.015), as was earlier stage at diagnosis (OR 0.43, p=0.017). Pregnancy during, or antecedent to, invasive cervical cancer diagnosis was significantly more predictive of screening compliance (OR 10.57, p=0.0007). Only 8/492 (1.6%) women in the cohort were active or former drug users, but within this group HIV screening was performed more frequently (OR 22.7, p<0.0001).

CONCLUSION

Despite US and international recommendations for HIV screening in AIDS-defining cancers, compliance remains low. In our centers, factors including earlier age, advanced stage, active pregnancy at diagnosis, and any drug use history were predictive of greater compliance with screening. These data will inform a tailored intervention to improve compliance with HIV screening in our population.

Impact of healthcare access and HIV testing on utilisation of cervical cancer screening among US women at high risk of HIV infection: cross-sectional analysis of 2016 BRFSS data

OBJECTIVE

Previous studies identified several factors associated with cervical cancer screening. However, many of them used samples from the general population and limited studies focused on women with high-risk health behaviours. We aimed to disentangle the association of cervical cancer screening with healthcare access and HIV testing among women at a high risk of HIV infection.

DESIGN

Nationwide cross-sectional survey in the USA.

SETTING

2016 Behavioral Risk Factor Surveillance System.

PARTICIPANTS

3448 women with a history of high-risk behaviours associated with HIV infection EXPOSURE AND OUTCOME: Clinical check-up, having personal healthcare provider, health coverage and HIV testing history were treated as exposures. Appropriate cervical cancer screening, which was defined according to 2016 US Preventive Services Task Force guideline, was treated as the outcome of interest.

DATA ANALYSIS

Multivariable logistic regression model was performed to evaluate associations of healthcare access and HIV testing with the uptake of cervical cancer screening; adjusted odds ratio (aOR) and 95% CI were reported. We further investigated if educational attainment modified associations identified in the primary multivariable model.

RESULTS

A total of 2911 (84.4%) high-risk women in our sample underwent cervical cancer screening. In the multivariable model, delayed clinical check-up (≥5 years ago vs within the past year: aOR: 0.19, 95% CI: 0.14 to 0.26), having no health insurance (aOR: 0.60, 95% CI: 0.46 to 0.79) and no history of HIV testing (no testing vs testing within the past year: aOR: 0.46, 95% CI: 0.35 to 0.61) were inversely associated with cervical cancer screening utilisation.

CONCLUSION

Factors reflecting healthcare access, specifically clinical check-up and health coverage, as well as history of HIV testing were associated with cervical cancer screening in this population-based study of high-risk women. Targeted interventions are warranted to further increase cervical cancer screening among women at high risk of HIV infection.