Many HIV-Infected Women Do Not Get Pap Tests As Often as Recommended

First published online:

| DOI: https://doi.org/10.1363/4125709

HIV treatment guidelines issued in 1995 recommend that infected women have a yearly Pap test, but findings from a large HIV and AIDS surveillance project suggest that many HIV-positive women do not do so.1 Nearly one-quarter of HIV-infected women interviewed in 18 states in 2000–2004 had not had a Pap test in the preceding year. The older a woman was, the greater her likelihood of having missed a Pap test; women who had a low CD4 cell count, those whose count was unknown and those whose most recent pelvic exam had been performed somewhere other than their usual source of HIV care had relatively high odds of not having had a Pap test in the previous year. Cervical screening is particularly important for HIV-infected women because they have a higher rate of human papillomavirus (HPV) infection than HIV-negative women and are more likely to be infected with a strain of HPV that increases the risk of cervical cancer.

Researchers used data from a convenience sample of women, identified through both facility- and population-based recruitment, who participated in interviews at least one month after receiving their HIV diagnosis. Only women for whom the date of the last Pap test was known or could be calculated were included in the analyses; 2,417 women (95% of those interviewed) met this criterion. The analysts used multivariate logistic regression to identify characteristics associated with women’s not having had a Pap test in the previous year.

Close to one in five women in the sample were younger than 30, seven in 10 were in their 30s or 40s, and the rest were 50 or older. The majority (69%) of the women were black, and most of the rest were white or Hispanic. Fifty-nine percent had finished high school, and 55% reported an annual household income of less than $10,000. Some 46% had a low CD4 cell count (i.e., less than 200 per microliter), and for another 36%, the count was unknown. Four in 10 women had a history of abnormal Pap test findings; in the past year, 18% had had an STD, and 7% had been pregnant. More than half had AIDS. Eighty-three percent of the women had health insurance, 74% went to a community or public health facility for their HIV care and 45% said that they had had their last pelvic exam at a site other than their usual source of HIV care.

Overall, 23% of women had not had a Pap test in the previous year. For every decade of a woman’s age, her odds of not having had a test increased by 30% (odds ratio, 1.3). The odds also were elevated among women whose CD4 cell count was less than 200 (1.6) or unknown (1.4). Women who had ever had an abnormal Pap test result and those who had been pregnant in the last year had reduced odds of not having had a test in the last year (0.6 for each). Recent STD history was significant, but only for women who did not have AIDS; in this group, those who had had an STD during the last year were less likely than others not to have had a Pap test during that time (0.4). Women whose last pelvic exam had occurred at a site other than their usual source of HIV care had elevated odds of not having had a Pap test in the last year, but the increase varied by race or ethnicity: It was much larger for Hispanic women (4.8) than for white women (2.3), black women (1.7) or those of other racial or ethnic backgrounds (2.1).

The researchers acknowledge a number of study limitations, among them the use of a convenience sample of women in only 18 states, the lack of information about whether women had been offered a Pap test during the previous year, the facility-based recruitment strategy and the use of self-reported data on Pap testing. However, partly because of some of the limitations, the researchers suspect that their findings overestimate the proportion of HIV-infected women who get Pap tests with the recommended frequency. They conclude, therefore, that professionals providing HIV care should ensure that infected women receive Pap tests annually. They also stress the need to educate health care providers about the Pap test guidelines for HIV-positive women and to educate women about how often they should be tested. "Finally," they write, "integrating gynecologic care into primary HIV care may be an important tool for increasing adherence to the recommended cervical cancer screening among HIV-infected women.—D. Hollander


1. Oster AM, Sullivan PS and Blair JM, Prevalence of cervical cancer screening of HIV-infected women in the United States, Journal of Acquired Immune Deficiency Syndromes, 2009, 51(4):430–436.