Adherence to the cervical cancer screening program in women living with HIV in Denmark: comparison with the general population

Barriers Associated with Adherence to Cervical Cancer Screening Among Women Living with HIV in Nkhatabay District, Malawi: A Mixed-Methods Study

Background

Cervical cancer (CC) incidence among Women Living with HIV (WLHIV) is high compared to the general population of women. As such, the Malawi National CC guideline recommends yearly screening among WLHIV. However, only 15.9% of WLHIV were screened nationally using Visual Inspection with Acetic Acid (VIA) by 2015 and there is no data regarding adherence and barriers to yearly screening. This study assessed adherence levels and associated barriers to yearly Cervical Cancer screening (CCS) among WLHIV.

Methods

A cross-sectional concurrent mixed-method study was conducted at Nkhatabay District Hospital (NBDH) and Chintheche Rural Hospital (CRH) in Malawi. A sample of 205 WLHIV participated in quantitative strand and in-depth interviews were conducted with 10 health care workers and 10 WLHIV. Quantitative data were analysed using STATA version 16. Pearson's chi-square test and Multivariate logistic regression analysis were performed. P value was set at 0.05. Qualitative data were analysed deductively following six steps of thematic analysis.

Results

Only 5.4% (n=11) of the participants had been screened as required. Women aged ≥45 had 4 times the odds of being screened for CC compared to ≤30 (OR 4.18, 95% CI 0.65-26.8). WLHIV on ART > 10 years had more than 5 times the odds of being screened (OR 5.9, 95% CI 1.08-33.19) compared with those on ART <3 years. Use of male service providers (p =< 0.001), fear of the VIA procedure (p = <0.001) and lack of interest (p = <0.015) were significant barriers to adherence. Qualitative findings revealed a lack of knowledge regarding CCS protocol and the use of male providers.

Conclusion

WLHIV face many challenges in accessing CCS and adherence to yearly CCS is very low. There is urgent need for targeted community awareness, scaling up of HPV tests and incorporation of CCS into routine integrated outreach services.

Cancer screening in people with HIV: Implementation in clinical practice and barriers perceived by medical specialists in Spain

OBJECTIVE

To assess the degree of implementation of cancer screening recommendations in people living with HIV (PLHIV) in Spain.

METHODS

A self-administered questionnaire was designed on the strategies used for early detection of the main types of cancer in PLHIV. The survey was distributed electronically to HIV physicians participating in the Spanish CoRIS cohort.

RESULTS

106 questionnaires were received from 12 different Spanish Autonomous Communities, with an overall response rate among those who accessed the questionnaire of 60.2%. The majority responded that they followed the CPGs recommendations for the early detection of liver (94.3%), cervical (93.2%) and breast (85.8%) cancers. In colorectal and anal cancer, the proportion was 68.9% and 63.2%, and in prostate and lung cancer of 46.2% and 19.8%, respectively. In hospitals with a greater number of beds, a tendency to perform more cancer screening and greater participation of the Infectious Diseases/HIV Services in the screening programmes was observed. Significant differences were observed in the frequency of colorectal and anal cancer screening among the different Autonomous Communities. The most frequent reasons for not performing screening were the scarcity of material and/or human resources and not being aware of what is recommended in the CPGs.

CONCLUSIONS

There are barriers and opportunities to expand cancer screening programmes in PLHIV, especially in colorectal, anal and lung cancers. It is necessary to allocate resources for the early detection of cancer in PLHIV, but also to disseminate CPGs screening recommendations among medical specialists.

Cancer screening in people living with HIV

BACKGROUND

Cancer is the leading cause of mortality in people living with HIV (PWH) and is expected to account for a growing fraction of deaths as PWH age.

METHODS

In this literature review, we have compiled the most recent developments in cancer screening and screening performance in PWH, which are currently primarily implemented in well-resourced settings. This includes an assessment of the associated benefits, harms, and cost-effectiveness. The article also addresses unmet needs and potential strategies for tailored screening in the HIV population.

FINDINGS

Incidence and mortality due to screenable cancer are higher in PWH than in the general population, and diagnosis is frequently made at younger ages and/or at more advanced stages, the latter amenable to improved screening. Adequate evidence on the benefits of screening is lacking for most cancers in the HIV population, in whom standard practice may be suboptimal. While cancer surveillance has helped reduce mortality in the general population, and interest in risk-based strategies is growing, implementation of screening programs in the HIV care settings remains low.

INTERPRETATION

Given the devastating consequences of a late diagnosis, enhancing early detection of cancer is essential for improving patient outcomes. There is an urgent need to extend the investigation in cancer screening performance to PWH, evaluating whether personalized measures according to individual risk could result in higher efficiency and improve patient outcomes.

Lifetime prevalence and adherence rate of cervical cancer screening among women living with HIV: a systematic review and meta-analysis

INTRODUCTION

Women living with HIV (WLWH) are more likely to develop cervical cancer. Screening and available healthcare can effectively reduce its incidence and mortality rates. We aimed to summarize the lifetime prevalence and adherence rate of cervical cancer screening among WLWH across low- and middle-income countries (LMICs), and high-income countries (HICs).

METHODS

We systematically searched PubMed, Web of Science and Embase for studies published between database inception and 2 September 2022, without language or geographical restrictions. Those reporting the lifetime prevalence and/or adherence rate of cervical cancer screening among WLWH were included. Pooled estimates across LMICs and HICs were obtained using DerSimonian-Laird random-effects models. When the number of eligible studies was greater than 10, we further conducted stratified analyses by the World Health Organization (WHO) region, setting (rural vs. urban), investigation year, screening method, type of cervical cancer screening programme, age and education level.

RESULTS

Among the 63 included articles, 26 provided data on lifetime prevalence, 24 on adherence rate and 13 on both. The pooled lifetime prevalence in LMICs was 30.2% (95% confidence interval [CI]: 21.0-41.3), compared to 92.4% in HICs (95% CI: 89.6-94.6). The pooled adherence rate was 20.1% in LMICs (95% CI: 16.4-24.3) and 59.5% in HICs (95% CI: 51.2-67.2).

DISCUSSION

There was a large gap in cervical cancer screening among WLWH between LMICs and HICs. Further analysis found that those in LMICs had higher lifetime prevalence in subgroups with urban settings, with older age and with higher education levels; and those in HICs had higher adherence in subgroups with younger age and with higher education levels.

CONCLUSIONS

Cervical cancer screening among WLWH falls considerably short of the WHO's goal. There should be continuous efforts to further increase screening among these women, especially those residing in the rural areas of LMICs and with lower education levels.

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.

Cervical cancer screening among women living with HIV: a cross-sectional study using the baseline questionnaire data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS)

BACKGROUND

Cisgender women with HIV experience an elevated risk of cervical cancer compared with HIV-negative women, but this cancer can be prevented through regular cervical cancer screening. Our study objective was to measure adherence to current national cervical cancer screening guidelines among women with HIV in 3 Canadian provinces and identify factors associated with delays.

METHODS

We conducted a cross-sectional study using the baseline questionnaire of the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS). Participants were recruited through clinics, peers and community organizations in British Columbia, Ontario and Quebec. Women were eligible for inclusion if they were cisgender female with HIV, aged 21-70 years, and never had cervicectomy/hysterectomy.

RESULTS

Of 1189 eligible participants, 815 (68.5%) had received cervical cancer screening less than 1 year ago (i.e., as recommended), 211 (17.7%) 1-3 years ago (i.e., moderate delay) and 163 (13.7%) at least 3 years ago or never (i.e., long delay). Overall, 309 (26.0%) had never discussed the need for a Papanicolaou smear with a nurse/doctor. Factors associated with a long delay were living in Ontario (adjusted odds ratio [OR] 2.51, 95% confidence interval [CI] 1.29-4.88) or Quebec (adjusted OR 3.70, 95% CI 1.79-7.67) (v. BC), being sexually inactive in the past 6 months (adjusted OR 2.02, 95% CI 1.25-3.25), having unknown or < 200 cells/mm³ CD4 counts (adjusted OR 1.78, 95% CI 1.11-2.85) and having a male HIV care provider (adjusted OR 2.15, 95% CI 1.36-3.42).

INTERPRETATION

Over one-third of women reported cervical cancer screening delays, and one-quarter had never discussed cervical cancer screening recommendations with a health care provider. Additional efforts are needed to improve women's and health care providers' awareness of cervical cancer screening recommendations, particularly among women who are sexually inactive, who are immunosuppressed and who have male HIV care providers.

Human Papillomavirus Infection and Cervical Cancer in HIV+ Women

Human papillomavirus (HPV) is the first identified necessary cause of human cancers and is associated with nearly 100% of all cervical cancers. Compared to the general female populations, HIV+ women have higher prevalence and incidence of cervical HPV infections, higher risks of persistent HPV infections and subsequent cervical intraepithelial lesions, and a higher incidence of cervical cancer. Although the wide use of combined antiretroviral therapy (cART) has improved the immune function and the longevity of HIV+ women, the incidence of cervical cancer in HIV+ women has not declined. For HIV+ women who follow routine cervical cancer screenings, their incidence of cervical cancer is comparable to that in HIV-negative women. Thus, adherence to the recommended cervical cancer screening is still critical for HIV+ women to prevent cervical cancer. Prophylactic HPV vaccines may also benefit HIV+ women, but prospective studies are needed to determine the effectiveness of HPV vaccination on reducing cervical cancer incidence in HIV+ women.

Anti-müllerian hormone levels are reduced in women living with human immunodeficiency virus compared to control women: a case-control study from Copenhagen, Denmark

OBJECTIVES

Anti-müllerian hormone (AMH) is a marker of ovarian reserve. The purpose of this study was to compare AMH in women living with HIV with an age-matched control group of HIV-uninfected women, and to identify possible variables associated with decreasing AMH levels in women living with HIV.

METHODS

AMH was measured in frozen EDTA samples from 84 white women living with HIV, aged 20 -40 years, with fully suppressed HIV RNA viral loads for at least 6 months and no hepatitis B or C virus co-infection. All women living with HIV were age-matched with HIV-uninfected control women.

RESULTS

Eighty-four women living with HIV and 252 control women were included. Median age for the women living with HIV was 33.5 years (interquartile range [IQR] 30.6-35.3), and 33.2 years (IQR 30.6-35.5) for the control women. A significant difference (P=0.03) was found in the mean AMH levels for all age groups combined, which was 17.23 pmol/L (95% confidence interval [CI] 14.56-19.89) in the women living with HIV versus 21.65 pmol/L (95% CI 19.50-23.81) in the control women, although levels were within reference limits in both groups.Only increasing age was significantly associated with decreasing AMH levels and not CD4 cell count, AIDS prior to inclusion, antiretroviral treatment/lack of treatment or antiretroviral treatment regimen.

CONCLUSIONS

Well-treated, white women living with HIV in Denmark, have reduced AMH levels compared with age-matched control HIV-uninfected women. The only variable associated with decreasing AMH levels in women living with HIV was increasing age.

Cervical cancer screening uptake among HIV-positive women in Ontario, Canada: A population-based retrospective cohort study

Cervical cancer caused by oncogenic types of the human papillomavirus (HPV) is of concern among HIV-positive women due to impairment of immune responses required to control HPV infection. Our objectives were to describe patterns of cervical cancer screening using Pap cytology testing among HIV-positive women in Ontario, Canada from 2008 to 2013 and to identify factors associated with adequate screening. We conducted a retrospective, population-based cohort study among screen-eligible HIV-positive women using provincial administrative health data. We estimated annual proportions tested and reported these with 95% confidence intervals (CI). Next, using person-years as the unit of analysis, we identified factors associated with annual Pap testing using log-binomial regression. A total of 2271 women were followed over 10,697 person-years. In 2008, 34.0% (95%CI 31.1-37.0%) had a Pap test. By 2013, the proportion of HIV-positive women tested was 25.9% (95%CI 23.6-28.2%). Women who were most likely to undergo testing were younger, were immigrants from countries with generalized HIV epidemics, lived in the highest income neighbourhoods, had a female primary care physician, had two or more encounters per year with an infectious disease or internal medicine specialist, and had greater comorbidity. Nearly three in four HIV-positive women were under-screened despite all having universal insurance for medically-necessary services. Annual Pap testing decreased following the 2011-2013 release of new guidelines for a lengthened screen interval for average risk women and a billing disincentive. Clinic-based intervention such as physician alerts or reminders may be needed to improve screening coverage among HIV-positive women.

Declining prevalence of cytological squamous intraepithelial lesions of the cervix among women living with well-controlled HIV - Most women living with HIV do not need annual PAP smear screening

INTRODUCTION

Cervical screening by means of annual Papanicolaou (PAP) smears has been recommended for all women living with HIV. We analysed the results of our annual PAP smear screening program to identify low-risk subgroups for less rigorous screening.

MATERIAL AND METHODS

The study comprised 369 women followed at the Helsinki University Hospital 2002-2013, with a total of 2033 PAP smear results. We analyzed the temporal changes in PAP smear findings. Logistic regression analysis for binominal dependent variables was used for assessing risk factors for ever having cytological squamous intraepithelial lesions (hereafter referred as SIL) using generalized estimating equations taking into account multiple observations of each patient.

RESULTS

Most women had well-controlled HIV, especially towards the end of the study. PAP smear results improved substantially. At the time of each individual's last PAP smear, 90.0% of the findings displayed normal results. Conversely, the rate of SIL decreased from 16.8% to 4.6% from 2002 to 2013. In multivariate analysis the risk of SIL was significantly lower in women with consecutive normal PAP smear findings during the first two years of follow up [odds ratio (OR) 0.21, 95% confidence interval (CI) 0.10-0.45, p < 0.001] and with CD4 counts >500 cells/μL (OR 0.11, 95% CI 0.05-0.26, p < 0.001).

CONCLUSIONS

Widespread use of combination antiretroviral therapy (cART) and systematic cervical screening has reduced the rate of abnormal PAP smears. It seems feasible to identify low-risk women by combining HIV-related information and PAP smear results. Screening low-risk women living with HIV at three-year intervals similar to HIV-negative women appears justified.

Prevalence and distribution of cervical high-risk human papillomavirus and cytological abnormalities in women living with HIV in Denmark - the SHADE

Background

Women living with HIV (WLWH) are at increased risk of persistent human papillomavirus (HPV) infection, cervical dysplasia and cervical cancer compared with women from the general population (WGP). We assessed the prevalence and distribution of cervical high-risk (hr) HPV infection and cytological abnormalities in WLWH compared with WGP in Denmark. Predictors of HPV and cytological abnormalities were estimated in WLWH.

Methods

WLWH consecutively enrolled in the Study on HIV, cervical Abnormalities and infections in women in Denmark (SHADE) in 2011 and were examined for cervical HPV and cytological abnormalities.

WLWH were matched on age and prior cytological findings with WGP from an earlier study. HIV demographics were retrieved from the nationwide Danish HIV Cohort Study. Logistic regression was used to estimate predictors of hrHPV and cytological abnormalities.

Results

Of 334 included WLWH 26.4 % were positive for hrHPV as opposed to 16.6 % WGP (p < 0.0001). WLWH had a higher number of multiple infections (>1 h genotype present) (38.5 % versus 25.7 %, p = 0.030). Hr genotypes in descending order of frequency were HPV58 (7.1 %), 52 (5.4 %), and 16 (4.8 %) in WLWH versus HPV16 (4.1 %), 52 (2.8 %) and 58 (2.4 %) in WGP. Predictors of hrHPV in WLWH were short duration of HAART (adjusted OR per year 0.90 (95 % CI 0.84-0.96)), AIDS prior to inclusion (adjusted OR 3.61 (95 % CI 1.75-7.46)), ≥5 lifetime sexual partners (adjusted OR 2.20 (95 % CI 1.08-4.49)), sexual debut <16 years of age (adjusted OR 2.05 (95 % CI 1.03-4.10)) and CD4 < 350 cells/μL (adjusted OR 2.53 (95 % CI 1.20-5.40)). Cytological abnormalities were prevalent in 10.4 % vs. 5.2 % (p = 0.0003) of WLWH and WGP. In WLWH with hrHPV, short duration of HAART predicted cervical dysplasia (adjusted OR per year 0.83 (95 % CI 0.71-0.97)).

Conclusions

WLWH presented with more cervical hrHPV infections and cytological abnormalities, and a different distribution of hrHPV genotypes compared with WGP. Cervical hrHPV and cytological abnormalities were predicted by short duration of HAART.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-2881-1) contains supplementary material, which is available to authorized users.

Cause-Specific Mortality in HIV-Positive Patients Who Survived Ten Years after Starting Antiretroviral Therapy

OBJECTIVES

To estimate mortality rates and prognostic factors in HIV-positive patients who started combination antiretroviral therapy between 1996-1999 and survived for more than ten years.

METHODS

We used data from 18 European and North American HIV cohort studies contributing to the Antiretroviral Therapy Cohort Collaboration. We followed up patients from ten years after start of combination antiretroviral therapy. We estimated overall and cause-specific mortality rate ratios for age, sex, transmission through injection drug use, AIDS, CD4 count and HIV-1 RNA.

RESULTS

During 50,593 person years 656/13,011 (5%) patients died. Older age, male sex, injecting drug use transmission, AIDS, and low CD4 count and detectable viral replication ten years after starting combination antiretroviral therapy were associated with higher subsequent mortality. CD4 count at ART start did not predict mortality in models adjusted for patient characteristics ten years after start of antiretroviral therapy. The most frequent causes of death (among 340 classified) were non-AIDS cancer, AIDS, cardiovascular, and liver-related disease. Older age was strongly associated with cardiovascular mortality, injecting drug use transmission with non-AIDS infection and liver-related mortality, and low CD4 and detectable viral replication ten years after starting antiretroviral therapy with AIDS mortality. Five-year mortality risk was <5% in 60% of all patients, and in 30% of those aged over 60 years.

CONCLUSIONS

Viral replication, lower CD4 count, prior AIDS, and transmission via injecting drug use continue to predict higher all-cause and AIDS-related mortality in patients treated with combination antiretroviral therapy for over a decade. Deaths from AIDS and non-AIDS infection are less frequent than deaths from other non-AIDS causes.

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.

Impact of immunosuppression and region of birth on risk of cervical intraepithelial neoplasia among migrants living with HIV in Sweden

Little is known about the incidence and risk of cervical intraepithelial neoplasia (CIN) grade 3, adenocarcinoma in situ and invasive cervical cancer (CIN3+) among migrants living with HIV in a European setting. We assessed the cumulative incidence (CuI) and hazard ratio (HR) of CIN2+ and CIN3+ in a cohort of women living with HIV (WLWH) (n = 893) identified from the Swedish national HIV register and HIV-negative women (n = 205,842) identified from the Swedish Population Register, matched on region of birth and age. Data was collected between 1993 and 2011 by linking our cohort with the Swedish National Cervical Screening Registry, collecting all cytological and histological results since 1993. The CuI of CIN3+ was 13.1% [95% confidence interval (CI) 8.9-17.2] for WLWH and 2.1% (95% CI 2.0-2.2) for HIV-negative after 18 years of follow-up. WLWH had more than eight times higher, age and region of birth matched, risk of CIN3+ than HIV-negative (HR 8.8: 95% CI 6.9-11.3). WLWH born in the East region, dominated by Thai women, had a two times higher risk of CIN3+ compared with WLWH born in Sweden (HR 2.47: 95% CI 1.2-5.0), which remained after adjusting for immunosuppression. Our results showed a substantially increased risk of CIN3+ among WLWH, which differed depending on birth region. Early HIV diagnosis and attendance to cervical cancer screening, with focus on migrants, is of crucial importance to minimize the incidence of cervical intraepithelial neoplasia.

Immunodeficiency-associated viral oncogenesis

Several viruses with different replication mechanisms contribute to oncogenesis by both direct and indirect mechanisms in immunosuppressed subjects after solid organ transplantation, after allogeneic stem cell transplantation, or with human immunodeficiency virus (HIV) infection. Epstein-Barr virus (EBV), human papillomavirus (HPV), Kaposi sarcoma herpesvirus (KSHV), human T-cell lymphotropic virus type 1 (HTLV-1) and Merkel cell polyoma virus (MCV) are the main viruses associated with the development of cancer in immunosuppressed patients. Besides being a main cause of immunodeficiency, HIV1 has a direct pro-oncogenic effect. In this review, we provide an update on the association between the condition of acquired immunodeficiency and cancer risk, specifically addressing the contributions to oncogenesis of HPV, MCV, KSHV, HTLV-1, and EBV.

Incidence of cervical dysplasia and cervical cancer in women living with HIV in Denmark: comparison with the general population

OBJECTIVES

Women living with HIV (WLWH) are reportedly at increased risk of invasive cervical cancer (ICC). A recent publication found that WLWH in Denmark attend the national ICC screening programme less often than women in the general population. We aimed to estimate the incidence of cervical dysplasia and ICC in WLWH in Denmark compared with that in women in the general population.

METHODS

We studied a nationwide cohort of WLWH and a cohort of 15 age-matched women per WLWH from the general population for the period 1999-2010. Pathology samples were obtained from The Danish Pathology Data Bank, which contains nationwide records of all pathology specimens. The cumulative incidence and hazard ratios (HRs) for time from inclusion to first cervical intraepithelial neoplasia (CIN)/ICC and time from first normal cervical cytology result to first CIN/ICC were estimated. Sensitivity analyses were performed to include prior screening outcome, screening intensity and treatment of CIN/ICC in the interpretation of results.

RESULTS

We followed 1140 WLWH and 17 046 controls with no prior history of ICC or hysterectomy for 9491 and 156 865 person-years, respectively. Compared with controls, the overall incidences of CIN1 or worse (CIN1+), CIN2+ and CIN3+, but not ICC, were higher in WLWH and predicted by young age and a CD4 count < 200 cells/μL. In women with normal baseline cytology, incidences of CIN1+ and CIN2+ were higher in WLWH. However, when we compared subgroups of WLWH and controls where women in both groups were adherent to the national ICC screening programme and had a normal baseline cytology, incidences of CIN and ICC were comparable.

CONCLUSIONS

Overall, WLWH developed more cervical disease than controls. Yet, in WLWH and controls adherent to the national ICC screening programme and with normal baseline cytology, incidences of CIN and ICC were comparable.