Cervical cancer screening intervals and management for women living with HIV: a risk benchmarking approach.
We suggested cervical cancer screening strategies for women living with HIV (WLHIV) by comparing their precancer risks to general population women, and then compared our suggestions with current Centers for Disease Control and Prevention (CDC) guidelines.



We compared risks of biopsy-confirmed cervical high-grade squamous intraepithelial neoplasia or worse (bHSIL+), calculated among WLHIV in the Women's Interagency HIV Study, to 'risk benchmarks' for specific management strategies in the general population.



We applied parametric survival models among 2423 WLHIV with negative or atypical squamous cell of undetermined significance (ASC-US) cytology during 2000-2015. Separately, we synthesized published general population bHSIL+ risks to generate 3-year risk benchmarks for a 3-year return (after negative cytology, i.e. 'rescreening threshold'), a 6-12-month return (after ASC-US), and immediate colposcopy [after low-grade squamous intraepithelial lesion (LSIL)].



Average 3-year bHSIL+ risks among general population women ('risk benchmarks') were 0.69% for a 3-year return (after negative cytology), 8.8% for a 6-12-month return (after ASC-US), and 14.4% for colposcopy (after LSIL). Most CDC guidelines for WLHIV were supported by comparing risks in WLHIV to these benchmarks, including a 3-year return with CD4 greater than 500 cells/μl and after either three negative cytology tests or a negative cytology/oncogenic human papillomavirus cotest (all 3-year risks≤1.3%); a 1-year return after negative cytology with either positive oncogenic human papillomavirus cotest (1-year risk = 1.0%) or CD4 cell count less than 500 cells/μl (1-year risk = 1.1%); and a 6-12-month return after ASC-US (3-year risk = 8.2% if CD4 cell count at least 500 cells/μl; 10.4% if CD4 cell count = 350-499 cells/μl). Other suggestions differed modestly from current guidelines, including colposcopy (vs. 6-12 month return) for WLHIV with ASC-US and CD4 cell count less than 350 cells/μl (3-year risk = 16.4%) and a lengthened 2-year (vs. 1-year) interval after negative cytology with CD4 cell count at least 500 cells/μl (2-year risk = 0.98%).



Current cervical cancer screening guidelines for WLHIV are largely appropriate. CD4 cell count may inform risk-tailored strategies.
aJohns Hopkins Bloomberg School of Public Health, Baltimore, Maryland bAlbert Einstein College of Medicine, Bronx, New York City, New York cWashington University School of Medicine, St. Louis, Missouri dUniversity of California, San Francisco, San Francisco, California eMaimonides Medical Center, Brooklyn, New York City, New York fUniversity of Miami Miller School of Medicine, Miami, Florida gGrady Memorial Hospital and Emory University School of Medicine, Atlanta, Georgia hUniversity of North Carolina School of Medicine, Chapel Hill, North Carolina iUniversity of Southern California, Los Angeles, California jUniversity of Alabama at Birmingham School of Public Health, Birmingham, Alabama kGeorgetown University Medical Center, Washington DC, USA.
Hilary A
HA
Robbins
Howard D
HD
Strickler
L Stewart
LS
Massad
Christopher B
CB
Pierce
Teresa M
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Darragh
Howard
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Minkoff
Marla J
MJ
Keller
Margaret
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Fischl
Joel
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Palefsky
Lisa
L
Flowers
Lisa
L
Rahangdale
Joel
J
Milam
Sadeep
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Shrestha
Christine
C
Colie
Gypsyamber
G
DʼSouza
D000328:Adult; D019985:Benchmarking; D002294:Carcinoma, Squamous Cell / Q000175:diagnosis*; D003584:Cytological Techniques; D019468:Disease Management; D005260:Female; D015658:HIV Infections / Q000150:complications*; D006651:Histocytochemistry; D006801:Humans; D008403:Mass Screening / Q000379:methods*; D008875:Middle Aged; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis*