Roughly one quarter of HIV-positive women in the United States may not be receiving recommended annual cervical Pap smears necessary to prevent cervical cancer, according to a new analysis from the U.S. Centers for Disease Control and Prevention (CDC) reported on Tuesday, February 10, at the 16th Conference on Retroviruses and Opportunistic Infections (CROI) in Montreal. Based on these results, CDC presenters Alexandra Oster, MD, and her colleagues are recommending increased education for providers and women living with HIV, along with integration of HIV and gynecologic care.
According to the CDC, up to 60 percent of women living with HIV—notably those with low CD4 cell counts—have cervical cell abnormalities, ultimately increasing the risk of invasive cervical cancer. To combat this heightened risk, federal treatment guidelines recommend that health care providers conduct Pap smears during an initial evaluation of a woman confirmed to be HIV positive, again during the first year after diagnosis and annually thereafter.
Dr. Oster's group conducted its study to determine whether cervical cancer screening is being performed as recommended. If not, they would mine the gathered information—mostly interview data—to determine the factors associated with not receiving necessary screenings.
Between 2000 and 2004, 2417 women were interviewed by researchers. Of these, 556 (23 percent) did not report a Pap smear during the year leading up to the interview.
Women between 18 and 29 years of age were the least likely to go without a Pap smear—16 percent of the women in this age range reporting going without one. HIV-positive women 50 years of age or older—34 percent of them—were the most likely to have gone without testing during the year before being interviewed.
Those with CD4 counts below 200 were also more likely to go without an annual Pap smear than women with CD4s higher than 200, suggesting to the researchers that competing health issues shift focus from cervical cancer prevention. One hundred-eighteen women, or 26 percent, of those with CD4s below 200 did not receive cervical screening in the year prior to being interviewed.
Of concern, a number of women who were not screened had a history of abnormal Pap smears—a total of 176 women, or 17 percent.
Another key finding was that many women who did not receive an annual cervical screening received a pelvic exam—at which time Pap smears are usually conducted—at a location other than their usual source of HIV care. This was most likely to be the case among Hispanic women interviewed in the study.
Dr. Oster's group offered up a number of key discussion points in its summary of the data. The fact that many HIV-infected women received pelvic exams by a primary care provider or gynecologist who may not normally treat HIV requires additional coordination between the patient and all of the care providers involved in her care. As for the significant drop-off in annual screenings among older women—which may be acceptable among some HIV-negative women above 50 years of age—the CDC study authors reiterated that Pap smears should be continued indefinitely for all HIV-positive women, regardless of age. Finally, with respect to HIV-positive women with fewer than 200 CD4 cells, cervical cancer screening should be a priority.
With its discussion, the CDC also offered up key recommendations—a two-pronged approach to increasing cervical cancer screening. First is the need for education. HIV care providers should be educated about screening all women, including those older than 50, those with low CD4s and those who receive their gynecologic care elsewhere. There is also a need to educate primary care providers and gyncelologists about differences in screening recommendations for HIV-positive women. HIV-positive women themselves also need to be educated about recommendations for annual Pap smears.
The second aspect of the recommended two-pronged approach involves a system change. Despite official screening recommendations, the CDC argues that there is a is a need to integrate HIV and gynecologic care, to prevent HIV-positive women at risk for cervical cancer from falling through the cracks.