title: Use of visual inspection with acetic acid, Pap smear, or high-risk human papillomavirus testing in women living with HIV/AIDS for posttreatment cervical cancer screening: same tests, different priorities.
abstract: Few studies have addressed optimal follow-up for HIV-infected women after cervical treatment. This study aimed to compare performance of three available tests to detect posttreatment cervical disease in HIV-infected women in Kenya.
  
  
  
  This is a prospective cohort study.
  
  
  
  At least 6 months following cryotherapy, 517 HIV-infected women were evaluated concurrently with visual inspection with acetic acid (VIA), papanicolaou (Pap) smear, and high-risk human papillomavirus (HR-HPV) testing. Women positive by any test (≥low-grade squamous intraepithelial lesion for Pap) were scheduled for colposcopy and biopsy. Among 248 with histological confirmation [and 174 assumed to be truly negative for cervical intraepithelial neoplasia (CIN)2+ after testing negative by all three tests], the ability of each test alone, or in combination, to detect CIN2+ was calculated to determine their utility in posttreatment follow-up.
  
  
  
  The median age of women was 35 years, 68% were WHO stage 1-2, with a median CD4 cell count of 410 cells/μl, and 87% were on combination antiretroviral therapy. At a median of 6.3 months posttreatment, 64% had an abnormal screen by VIA, Pap, and/or HR-HPV. Among women with histological confirmation, 72 (30%) had persistent/recurrent CIN2+. As single tests, Pap correctly classified the most cases (83%) and had the highest specificity [91% (88 and 95%); sensitivity 44% (35 and 53%)], whereas HR-HPV had the highest sensitivity [85% (75 and 96%); specificity 54% (49 and 58%)]. VIA was not sensitive [27% (18 and 36%)] for the detection of posttreatment CIN2+ [specificity 82% (79 and 86%)].
  
  
  
  With the goal to minimize the number of false negatives (e.g. not miss CIN2+ posttreatment) in this population that is high-risk due to both prior cervical disease and HIV infection, HR-HPV-based algorithms are recommended.
authors.affiliation: aAcademic Model Providing Access to Healthcare (AMPATH) Partnership bDepartment of Reproductive Health, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya cDepartment of Biostatistics, Center for Statistical Science, Brown University School of Public Health, Providence, Rhode Island, USA dDepartment of Obstetrics & Gynaecology, University of Toronto, Toronto, Ontario, Canada eDepartment of Pathology, Brown University, Providence, Rhode Island, USA fDepartment of Pathology, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya gDepartment of Obstetrics and Gynecology, The Miriam Hospital, Brown University, Providence, Rhode Island hDepartment of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
authors.forename: Elkanah
authors.initials: E
authors.lastname: Omenge Orang'o
authors.forename: Tao
authors.initials: T
authors.lastname: Liu
authors.forename: Astrid
authors.initials: A
authors.lastname: Christoffersen-Deb
authors.forename: Peter
authors.initials: P
authors.lastname: Itsura
authors.forename: John
authors.initials: J
authors.lastname: Oguda
authors.forename: Sierra
authors.initials: S
authors.lastname: Washington
authors.forename: David
authors.initials: D
authors.lastname: Chumba
authors.forename: Latha
authors.initials: L
authors.lastname: Pisharodi
authors.forename: Susan
authors.initials: S
authors.lastname: Cu-Uvin
authors.forename: Anne F
authors.initials: AF
authors.lastname: Rositch
mesh_terms: D000293:Adolescent; D000328:Adult; D003127:Colposcopy / Q000706:statistics & numerical data*; D055088:Early Detection of Cancer / Q000379:methods*; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy*; D006801:Humans; D007630:Kenya; D008875:Middle Aged; D025202:Molecular Diagnostic Techniques / Q000706:statistics & numerical data*; D065006:Papanicolaou Test / Q000706:statistics & numerical data*; D030361:Papillomavirus Infections / Q000150:complications / Q000175:diagnosis*; D011446:Prospective Studies; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis*; D055815:Young Adult