Cervical Cancer Screening in People with HIV
Individuals with HIV should begin cervical cancer screening at age 21 years or 1 year after onset of sexual activity (whichever comes first), but no later than age 21 years. 1
Key Screening Initiation Guidelines
For Adolescents with HIV
- Screening must begin 1 year after sexual debut, regardless of age or mode of HIV acquisition (perinatally or sexually acquired), but no later than age 21 years. 1
- This earlier screening approach is warranted because adolescents with HIV demonstrate a high rate of progression of abnormal cytology, unlike immunocompetent adolescents in whom HPV infections typically regress spontaneously. 1
For Adults Newly Diagnosed with HIV
- Sexually active persons should be screened at the time of initial HIV diagnosis, regardless of age. 1, 2
- This immediate screening approach recognizes the substantially elevated risk for HPV persistence and progression to cervical dysplasia in immunocompromised individuals. 3
Critical Distinction from General Population
The standard USPSTF guidelines that recommend starting screening at age 25 years for the general population explicitly exclude immunocompromised patients, including those with HIV. 3, 4 People with HIV require earlier and more intensive screening due to their significantly elevated risk of cervical precancers and cancers. 1, 3
Screening Methodology for HIV-Positive Individuals
- Use conventional or liquid-based cytology (Pap test) as the primary screening method; primary HPV testing alone is NOT recommended in individuals with HIV. 1, 2
- Cotesting (cytology plus HPV test) can be performed in individuals aged ≥30 years with HIV. 1, 2
Ongoing Screening Protocol
- Annual screening is recommended for all persons with HIV infection. 1, 3, 2
- After 3 consecutive years of normal cytology results or normal cotests (normal cytology and negative HPV test), the screening interval can be extended to every 3 years. 1, 2
- Lifelong screening is recommended among persons with HIV infection—there is no age at which to discontinue screening, unlike the general population where screening stops at age 65 years. 1, 3, 2
Evidence Supporting Earlier Screening
Research demonstrates that zero cases of invasive cervical cancer occurred among women with HIV under age 25 years in a large US cohort study, supporting the age 21 cutoff rather than adolescent screening. 5 However, approximately 20% of cervical cancers in HIV-endemic settings occur in women under age 40, emphasizing the importance of not delaying screening initiation. 6
Common Pitfalls to Avoid
- Do not use primary HPV testing alone in people with HIV, as this is not recommended and cytology should be the primary screening method. 1, 2
- Do not apply general population screening guidelines (starting at age 25) to people with HIV, as they require earlier initiation. 3
- Do not discontinue screening at age 65 in people with HIV, as lifelong screening is indicated. 1, 3
- Do not delay screening until age 21 if sexual activity began earlier in adolescents with HIV—screen 1 year after sexual debut. 1