From the Guidelines
Women with HIV should undergo cervical cancer screening with a Pap test upon initiation of care, and this test should be repeated at 6 months and annually thereafter if results are normal. This approach is based on the strong recommendation and moderate quality evidence from the 2014 guidelines for the management of persons infected with HIV 1. The intensified screening is necessary due to the increased risk of cervical cancer in women with HIV, which is attributed to higher rates of HPV infection, persistence, and progression to precancerous lesions due to immunosuppression.
Key considerations for cervical cancer screening in women with HIV include:
- Screening should begin at diagnosis of HIV regardless of age and continue throughout life
- Annual cervical cytology (Pap test) for the first year after HIV diagnosis, with a repeat test at 6 months
- If both results are normal, screening can occur every 3 years, though some experts recommend continuing annual screening
- HPV co-testing (Pap plus HPV test) is also appropriate for women aged 30 and older
- Women with HIV should not follow extended screening intervals (beyond 3 years) even with normal HPV co-testing results
- Abnormal screening results require prompt colposcopy and appropriate follow-up, as recommended by the guidelines 1
It is essential to note that maintaining good HIV control with antiretroviral therapy helps reduce cervical cancer risk but does not eliminate the need for vigilant screening 1. Additionally, HPV vaccination is also recommended for eligible women with HIV to provide additional protection against high-risk HPV types. The guidelines from the US Preventive Services Task Force (USPSTF) in 2015 1 provide general recommendations for cervical cancer screening, but the specific guidelines for women with HIV, as outlined in the 2014 HIV medicine association guidelines 1, should take precedence due to their increased risk and unique considerations.
From the Research
Cervical Cancer Screening for Women with HIV
- Women living with HIV are at increased risk of human papillomavirus (HPV) infection, which can lead to cervical cancer 2, 3, 4, 5, 6
- New guidelines recommend indefinite screening for women living with HIV 2
- A study found that 83% of HIV-infected women received at least one Pap smear in their first year after enrollment, but only 24.5% received the recommended two Pap smears 3
- The same study found that first-year Pap smear rate was significantly associated with type of insurance and Pap smear facility 3
Screening Methods
- Papanicolau (Pap) smear, visual inspection with acetic acid (VIA), and human papillomavirus (HPV) testing are common screening methods for cervical cancer 4
- A study found that Pap smear was the most sensitive screening method, while the combination of Pap and VIA was the most specific 4
- Another study found that primary HPV screening (PHS) had 87% sensitivity for precancer, but a low positive predictive value (PPV) of 9% 6
Management Strategies
- Current Centers for Disease Control and Prevention (CDC) guidelines for cervical cancer screening in women living with HIV are largely appropriate 5
- A study suggested that CD4 cell count may inform risk-tailored strategies for cervical cancer screening in women living with HIV 5
- Another study found that PHS with reflex HPV16/18-genotyping and Pap testing may be a potential alternative to concurrent oncHPV and Pap testing (Co-Testing) in women living with HIV 6
Risk Factors
- Immunosuppression, antiretroviral therapy (ART) duration, and age are risk factors that may affect the accuracy of cervical cancer screening methods in women living with HIV 4, 5, 6
- A study found that CD4⁺ cell count of 350 cells/μl or less was associated with decreased HPV specificity, while ART duration of less than 2 years was associated with decreased HPV and VIA specificity 4