Screening for Cervical Dysplasia and Cancer in HIV

The recently updated New York State Department of Health AIDS Institute (NYSDOH AI) guideline Screening for Cervical Dysplasia and Cancer in Adults With HIV recognizes that the dramatic reductions in HIV-associated morbidity and mortality made possible by the widespread implementation of effective antiretroviral therapy (ART) have also led to significant reductions in rates of cervical cancer.

Cervical cancer is an AIDS-defining illness and has historically been a leading cause of cancer death among women with HIV. Early in the epidemic, women with HIV presented with cervical cancer at later stages, when treatment was less successful.^[1] But over the last 20 years, risk of incident cervical cancer for women with HIV has declined significantly.^[2,3] In addition to improving longevity and overall health, ART has been found to reduce human papillomavirus (HPV) acquisition, improve regression, and decrease rates of cervical disease progression.^[4,5,6,7,8] Studies show that rates of cervical dysplasia in women with HIV who are virally suppressed on ART and have a CD4 count ≥ 500 cells/mm³ are comparable to rates in women without HIV.^[9,10,11] Cervical disease pathogenesis is the same in women with HIV who are virally suppressed and have a CD4 count ≥ 500 cells/mm³ as for women who do not have HIV.^{[12,13,14,15]}

However, the risk of HPV-related cervical disease remains increased with HIV coinfection because of the increased prevalence and persistence of HPV in people with HIV.^[16,17,18] Vigilance in screening and prompt treatment of high-grade cervical disease remain essential tools in the care of patients with HIV.

Age-Based Screening

The NYSDOH AI guideline proposes that patients who are virally suppressed and have demonstrated adherence to HIV care and primary care, who have negative cytology and HPV test results, no genital or pelvic complaints, do not use tobacco products, and do not have any other cervical cancer risk factors may benefit from expanded screening intervals.

In most areas, the NYSDOH AI guideline aligns with US Department of Health and Human Services guidelines^[19]; however, the NYSDOH AI guideline recommends an expanded time interval for screening of patients younger than 30 years. Recognizing that cancer in this population is exceedingly rare and that HPV is highly prevalent and often recedes in young people, the guideline recommends that screening begin within 2 years of first receptive intercourse. If the cytology results are normal, the patient may be screened again in 3 years.

Although the DHHS guidelines describe the question of anal cancer screening for patients with HIV as unresolved, the NYSDOH AI unequivocally recommends anal cancer screening for adults with HIV aged 35 years and older, regardless of sex or gender. More information and evidence-based recommendations can be found in the NYSDOH AI guideline Screening for Anal Dysplasia and Cancer in Adults With HIV.

Clinicians should establish a schedule for routine cervical screening based on a patient’s medical history, anatomical inventory, age, and risk profile. The guideline explicitly emphasizes shared decision-making, particularly regarding expedited treatment of high-grade cervical dysplasia and ongoing screening in patients aged 65 years and older. When addressing the specifics of treatment plans or the issues of extended screening intervals or screening discontinuation based on lifetime prognosis, patient-centered shared decision-making is critical. Shared decision-making should take into account a patient’s lifetime risk of HPV-related disease, screening goals, cultural and personal values, and the benefits of a screening interval based on the patient’s actual risk.

Inclusive and Culturally Sensitive Care

In addition to acknowledging the shift in risk of cervical cancer for virally suppressed individuals, the NYSDOH AI guideline recommends that age-based cervical cancer screening be performed for any patient with HIV who has or has had a cervix. The guideline uses gender-neutral language to underscore the importance of safe and appropriate care for transgender individuals and the avoidance of assumptions based on a patient’s age, physical appearance, or gender expression. Inclusive, culturally sensitive healthcare includes a safe and welcoming environment that acknowledges the needs of transgender, transmasculine, transfeminine, and nonbinary patients. For more information, see NYSDOH AI Guidance: Adopting a Patient-Centered Approach to Sexual Health.

Clinicians are encouraged to ask patients to provide details about all gender-affirming and gynecologic surgical procedures they have undergone to help inform appropriate screening. On a practical level, clinicians should note testosterone use and the presence of amenorrhea in the requisition for cervical cytology in transgender men to best facilitate accurate interpretation of cell morphology.

HPV Vaccination

The guideline stresses that in providing comprehensive primary care for adults with HIV, clinicians should ensure that all eligible patients have been vaccinated against HPV. In 2020, the US Food and Drug Administration expanded the age range for approved use of the 9-valent HPV vaccine in the United States to age 45 years.^[20] Given the increased lifetime risk of persistent HPV infection and increased prevalence of HPV-related cancers, the guideline endorses the standard schedule of 3 doses over a 6-month period for individuals with HIV aged 9 to 45 years, regardless of CD4 cell count, prior cervical or anal screening results, HPV test results, HPV-related cytologic changes, or other history of HPV-related lesions.

Harm Reduction

The guideline encourages clinicians to provide education about additional harm reduction measures that may reduce the risk of cervical dysplasia in patients with HIV, including tobacco use cessation and sexual exposure prevention strategies such as using barrier protection and reducing the number of sex partners and associated sexual networks when possible.

Design and Role of the NYSDOH AI Guideline

The NYSDOH AI clinical guideline Screening for Cervical Dysplasia and Cancer in Adults With HIV is designed for clinicians in NYS who provide primary, HIV, and gynecological care to adults with HIV who are at risk of developing cervical dysplasia or cancer associated with HPV infection.

Patients with HIV remain at higher risk of high-grade cervical disease and cancer than those without HIV. However, the widespread successful implementation of ART has improved longevity and overall health and reduced the risks of opportunistic infections, including HPV. The 2022 NYSDOH AI cervical cancer screening guideline balances the need for vigilance in a vulnerable population with the recognition that patients with HIV who are adherent to ART and engaged in care are also reducing their risk of high-grade cervical disease and cancer.

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