Negative Predictive Value of Pap Testing Implications for Screening Intervals for Women With Human Immunodeficiency Virus
ABSTRACT OBJECTIVE:: To estimate the accuracy of Pap testing for women who are human immunodeficiency virus (HIV)-seropositive, with a focus on negative predictive value. METHODS:: Participants in the Women's Interagency HIV Study were monitored with conventional Pap tests every 6 months. After excluding those with abnormal Pap test results before study, cervical disease, or hysterectomy, women with negative enrollment Pap test results were monitored for development of precancer within 15 or 39 months, defined as a Pap test result read as high-grade squamous intraepithelial lesion, atypical glandular cells favor neoplasia, or adenocarcinoma in situ, or a cervical biopsy read as cervical intraepithelial neoplasia 2 or worse. Correlations between one or more consecutive negative Pap test results and subsequent precancer were assessed using Cox proportional hazards models. RESULTS:: Among 942 HIV-infected women with negative baseline Pap test results, eight (1%) developed precancer within 15 months and 40 (4%) within 39 months. After three consecutive negative Pap test results, precancer was rare, with no cases within 15 months and 10 of 539 (2%) within 39 months. No women developed precancer or cancer within 39 months after 10 consecutive negative Pap test results. Risks for precancer within 15 months after negative Pap test result included current smoking (adjusted hazard ratio [HR] 1.5, 95% confidence interval [CI] 1.2-2.0 compared with nonsmokers), younger age (adjusted HR 1.5, 95% CI 1.1-2.1 for women aged younger than 31 years compared with older than 45 years), and lower CD4 count (adjusted HR 11.8, 95% CI 1.3-2.3 for CD4 200-500/microliter, adjusted HR 2.2, 95% CI 1.6-2.9 for CD4 less than 200/microliter, compared with CD4 more than 500/microliter). CONCLUSION:: Annual Pap testing appears safe for women infected with HIV; for those with serial negative tests, longer intervals are appropriate. LEVEL OF EVIDENCE:: II.
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ABSTRACT: Human papillomavirus (HPV) is a sexually transmitted virus that is associated with increased risk of anogenital cancers in immunosuppressed hosts. The behavior of HPV infection is controlled by the systemic immune system response as well as the local tissue immune system to the HPV virus. Individuals with a depressed immune system, either by viral infection (such as human immunodeficiency virus) or by chronic immunosuppressive agents (such as transplant recipients or patients with autoimmune disease) are at an increased risk of HPV-associated malignancies. This article addresses the data and limitations in developing evidence-driven guidelines for cervical cancer screening in immunocompromised women.Obstetrics and Gynecology Clinics of North America 06/2013; 40(2):339-57. DOI:10.1016/j.ogc.2013.02.005 · 1.40 Impact Factor
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ABSTRACT: BACKGROUND Women who are infected with the human immunodeficiency virus (HIV) are at high risk of human papillomavirus-persistent infections. Invasive cervical cancer is listed among the illnesses associated with the acquired immunodeficiency syndrome. The objective of the current study was to investigate whether, in South Africa, the accuracy of abnormal cytology confirmed by a histological diagnosis using loop electrosurgical excision procedure (LEEP) is affected by knowledge of the woman's HIV serostatus.METHODS Of 7648 biopsy specimens, 941 were LEEPs indicated by a cytology report of low-grade squamous intraepithelial lesion or high-grade squamous intraepithelial lesion. A total of 618 specimens (65.7%) were from HIV-uninfected women and 323 specimens (34.3%) were from HIV-infected women. Those women with an unknown pre-LEEP cytological diagnosis were excluded from the study.RESULTSThe total prevalence of HIV infection among the 7648 patients was 18.6%, reflecting its prevalence in the general population of women aged 15 to 49 years. The rate of HIV infection among 3462 women with invasive cervical cancer was 10.7%. The overall prevalence of preinvasive lesions was 73.9% in HIV-infected women compared with 50.3% in women not infected with HIV (P<.0001). The concordance and discordance rates between cytology and histology were similar in uninfected and infected women (P =.93 and P =.18, respectively). Among HIV-infected women, 79.1% of discordant results were due to cytological overdiagnosis; among HIV-negative women, 86.5% of discordant results were due to underdiagnosis (P<.0001).CONCLUSIONS It appears that the finding of a higher prevalence of preinvasive lesions combined with the knowledge of a patient's HIV-positive serostatus prompts more cytological overdiagnosis, thereby resulting in avoidable LEEP interventions. Cancer (Cancer Cytopathol) 2014. © 2014 American Cancer Society.Cancer Cytopathology 09/2014; 122(12). DOI:10.1002/cncy.21487 · 3.81 Impact Factor
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ABSTRACT: To estimate the impact of HIV infection on the incidence of high grade cervical intraepithelial neoplasia (CIN). HIV seropositive and comparison seronegative women enrolled in a prospective U.S. cohort study were followed with semiannual Pap testing, with colposcopy for any abnormality. Histology results were retrieved to identify CIN3+ (CIN3, adenocarcinoma in situ, and cancer and CIN2+ (CIN2 and CIN3+). Annual detection rates were calculated and risks compared using Cox analysis. Median follow-up (IQR) was 11.0 (5.4-17.2) years for HIV seronegative and 9.9 (2.5-16.0) for HIV seropositive women. CIN3+ was diagnosed in 139 (5%) HIV seropositive and 19 (2%) seronegative women (P < 0.0001), with CIN2+ in 316 (12%) and 34 (4%) (P < 0.0001). The annual CIN3+ detection rate was 0.6/100 person-years in HIV seropositive women and 0.2/100 person years in seronegative women (P < 0.0001). The CIN3+ detection rate fell after the first two years of study, from 0.9/100 person-years among HIV seropositive women to 0.4/100 person-years during subsequent follow-up (P < 0.0001). CIN2+ incidence among these women fell similarly with time, from 2.5/100 person-years during the first two years after enrollment to 0.9/100 person-years subsequently (p < 0.0001). In Cox analyses controlling for age, the hazard ratio for HIV seropositive women with CD4 counts <200/cmm compared to HIV seronegative women was 8.1 (95% C.I. 4.8, 13.8) for CIN3+ and 9.3 (95% C.I. 6.3, 13.7) for CIN2+ (P < 0.0001). Although HIV seropositive women have more CIN3+ than seronegative women, CIN3+ is uncommon and becomes even less frequent after initiation of regular cervical screening. Copyright © 2014 Elsevier Inc. All rights reserved.American Journal of Obstetrics and Gynecology 12/2014; 212(5). DOI:10.1016/j.ajog.2014.12.003 · 3.97 Impact Factor