COMMENTARY

Cervical Cancer Screening in Patients With HIV: Updated Guidelines

Christina D. Norwood, MS, ELS; Gina M. Brown, MD

Disclosures

March 19, 2018

An Updated Guideline on Cervical Screening in Patients With HIV

The New York State Department of Health (NYSDOH) AIDS Institute Medical Care Criteria Committee has updated its guideline, Cervical Screening for Dysplasia and Cancer in Patients With HIV. The guideline presents current, evidence-based recommendations for human papillomavirus (HPV) vaccination, cervical cytologic screening, and follow-up of abnormal test results in people with HIV. The comprehensive guideline also addresses the ongoing need for diligence in early identification and treatment of precancerous and cancerous lesions, when treatment is most successful.

HPV and HIV

Cervical cancer is the leading cause of cancer-related death in women with HIV.[1] In 1993, the Centers for Disease Control and Prevention (CDC) added invasive cervical cancer as an AIDS-defining illness to highlight the increased risk for cervical cancer and the need for comprehensive gynecologic evaluation in women with HIV.[2] Almost all cervical cancers are associated with persistent HPV infections[3,4,5,6] and could be prevented with cervical screening and vaccination against HPV. The nine-valent HPV vaccine protects against nononcogenic HPV types 6 and 11 and high-risk oncogenic HPV types 16, 18, 31, 33, 45, 52, and 58.[7] HPV vaccination and routine screening to identify precancerous lesions, coupled with treatment and follow-up, are essential for reducing the incidence of cervical cancer among women with HIV.[8,9]

The risk for HPV-related cervical disease is strongly associated with HIV infection and low CD4 cell count.[10] Individuals with HIV tend to present with cervical cancer at late stages, when treatment is less successful.[11] All women with HIV, but especially those who are immunosuppressed, have more recurrences[12] and poorer survival rates than women who do not have HIV.[1,13] In one study, nearly 1 in 4 women with HIV did not receive an annual Pap test, with missed Pap tests being more likely among older women and women with low CD4 cell counts.[14] These sobering statistics underscore the need to integrate cervical cancer prevention, screening, and management into primary care for people with HIV.

Prevention

The NYSDOH AIDS Institute guideline includes a recommendation to offer all individuals with HIV, aged 9 to 26 years, the nine-valent HPV vaccine three-dose regimen regardless of previous Pap test results or CD4 cell count. In individuals who have had a previous abnormal Pap test result, the vaccine may protect against infection from HPV types other than those that caused earlier or existing cervical abnormalities. A history of HPV-related cervical cytologic changes should not exclude individuals from being vaccinated. Available data do not support HPV vaccination in all adults older than 26 years, including those with HIV.[15]

Screening

The NYSDOH AIDS Institute guideline specifies that persons eligible for screening include all people with HIV who have a cervix and/or vagina, including cisgender women (individuals assigned female at birth who identify as female), transgender men (individuals assigned female at birth but who identify as male), and nonbinary individuals who were assigned female at birth but who identify as neither male nor female. Vaginal screening is reserved for those who have had a total hysterectomy and have a history of abnormal cervical screening. There are no data on HPV disease in transgender women with a neovagina. Transgender men who have an intact cervix and/or vagina have lower rates of cervical screening than cisgender women, although they remain at risk for HPV infection, vaginal or cervical dysplasia, and cervical or vaginal cancer.[16] The guideline strongly encourages care providers to ask patients about any previous history of cervical abnormalities and about gender-reassignment and gynecologic surgeries to determine whether a patient needs cervical or vaginal screening.

Because the source of most cervical dysplasia is genital HPV, a sexually transmitted infection, the Committee does not recommend Pap tests before sexual debut. No data are available that suggest a decline in risk with age; therefore, Pap testing should be continued for women who are 65 years and older.[17]

Diagnosis

The guideline includes a detailed roadmap to assist clinicians in determining proper follow-up for abnormal cervical Pap test results. The Pap test is useful for identifying patients who need further evaluation, which may include HPV testing, more frequent Pap tests, referral for colposcopy with directed biopsy, and treatment of biopsy-proven histologic abnormalities. HPV co-testing (a cervical cytologic test with a concurrent HPV test) is routinely performed in persons aged 30 years or older. HPV testing in response to an abnormal cervical Pap test result (HPV reflex testing) is performed in persons younger than age 30 years with a Pap test that shows atypical squamous cells (ASCs) of undetermined significance (ASC-US) or above, or a persistent ASC-US Pap, and in persons aged 30 years or older who did not receive an HPV co-test at the time of their cervical Pap test.

A diagnosis of high-risk HPV infection requires follow-up with colposcopy. In addition, colposcopy should be performed in response to the following Pap test results:

  • Persistent ASCs, high-grade squamous intraepithelial lesion (HSIL) cannot be excluded;

  • Low-grade squamous intraepithelial lesion;

  • HSIL; and

  • Any result of atypical glandular cells.

HPV testing as a primary screening test without cytologic screening is not recommended for persons with HIV.

The diagnostic standard for cervical dysplasia is a histologic specimen, which is obtained through colposcopy-directed biopsy. Colposcopy should not be used as a primary screening method. Persons who require colposcopy are identified through the screening Pap test. Random biopsies are not useful for cervical dysplasia diagnosis. Colposcopy should be performed by an experienced clinician.

Treatment

The standard therapeutic approach to treating squamous intraepithelial lesions and cervical cancer is the same regardless of a person's HIV status. However, because the risk for treatment failure and recurrence rates are higher in persons with HIV, close follow-up is essential. Patients who require treatment should be managed by a gynecologic oncologist. The increased risk for treatment failure and high recurrence rate in persons with HIV demand close follow-up even after definitive treatment for cervical cancer.

Role of the Provider

Great emphasis has been placed on treatment with effective antiretrovirals and viral suppression to maintain the health of people with HIV. Aggressive screening and management of preventable conditions, such as cervical cancer, are also crucial. The NYSDOH AIDS Institute guideline, Cervical Screening for Dysplasia and Cancer in Patients With HIV, provides clear, accessible information for primary and HIV care providers so that they can perform appropriate and essential cervical screening and follow-up for their patients with HIV.

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