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Screening: Cancer, Osteoporosis, and STDs

for Health Care Providers

Screening: Cancer, Osteoporosis, and STDs

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Cervical cancer screening:
Abbreviations: ASCUS = atypical squamous cells of undetermined significance; CT = Chlamydia trachomatis; GC = Neisseria gonorrhea; HSIL = high-grade squamous intraepithelial lesion; LSIL = low-grade squamous intraepithelial lesion; NAAT = nucleic acid amplification test
  • Cervical Pap test (smear or liquid cytology)
  • Baseline
  • Repeat in 6 months
  • If both Pap results are normal and CD4 count is >200 cells/µL, repeat annually
  • If both Pap results are normal and CD4 count is <200 cells/µL, repeat every 6 months
  • If any Pap smear result is abnormal, additional testing should be done; see Cervical Dysplasia and Management of Abnormal Pap Smear Results, below
  • HIV-infected women are more likely than HIV-uninfected women to be infected with HPV, especially with oncogenic HPV types.
  • Dysplasia may involve the cervix, vulva, vagina, or anus.
  • Abnormalities on cervical colposcopy are seen in 64% of women with CD4 counts of <200 cells/µL and 34% of those with CD4 counts of >400 cells/µL.
  • HIV-infected women have decreased rates of clearance of HPV; as a result, they have an increased risk of disease progression and recurrence.
  • For management of abnormal results, see Cervical Dysplasia and Management of Abnormal Pap Smear Results, below.
Vulvar and vaginal cancer screening:
  • Visual and manual inspection
  • Evaluate at times of cervical Pap test
  • Suspicious lesions: colposcopy; biopsy
  • HIV-infected women have elevated rates of vulvar and vaginal neoplasia.
  • Lesions may be multifocal, extensive, and recurrent, and may have an unusual appearance; sometimes progressing rapidly, especially in women with CD4 counts of <200 cells/µL.
  • Apparent condylomata that are resistant to treatment and unusual vulvar lesions should be referred for biopsy; also check RPR.
Anal cancer screening:
  • Digital rectal examination (DRE)
  • Anal Pap test
No national guidelines for anal cancer screening; consider:
  • Baseline
  • Annual DRE and anal Pap screening if patient is sexually active and baseline result was normal
  • Use polyester swab and liquid cytology method, if available
  • Anal dysplasia and anal cancer rates among HIV-infected women are not fully known but appear to be higher than those for HIV-uninfected women.
  • Anal dysplasia is seen in women with and without a history of receptive anal sex.
  • ART has not been shown to prevent or alter the course of anal dysplasia.
  • ASCUS, LSIL, HSIL: Refer for high-resolution anoscopy with biopsy.
  • Screening was cost-effective in a small study; no large-scale clinical trials on cost-effectiveness have been conducted.
  • See Anal Dysplasia.
Breast cancer screening:
  • Mammogram
  • Age 40-69: every 1-2 years
  • Age ≥70: discuss and take into account estimated life expectancy and presence of comorbid disease
  • HIV-infected women do not appear to have elevated risk of breast cancer.
  • See Cancer Screening.
Osteoporosis/osteopenia screening:
  • Dual-energy X-ray absorptiometry (DEXA) bone densitometry
  • Baseline for patients at risk and all women >65 years of age
  • Also consider for thin female smokers >40 years of age
  • Every 1-2 years for patients with osteoporosis who are treated with bisphosphonates
  • Age and previous fracture are the most significant risk factors.
  • See Osteoporosis, below, for more information and treatment recommendations.
STD screening:
  • Cervical GC and CT (NAAT or culture of first-void urine or cervical specimen)
  • Rectal or pharyngeal testing for GC and CT, based on possible risks or exposures (NAAT or culture of swab)
  • Trichomonas (wet-mount examination or culture of vaginal secretions)
  • HBV, HCV
  • HSV IgG (type specific)
  • Perform at baseline, repeat according to risks or exposures (eg, every 3-6 months for women with new sex partners since previous examination)
  • STDs should be treated to prevent health complications for the patient, and also to prevent perinatal transmission or transmission to sex partners.
  • Inflammatory STDs may increase risk of HIV transmission to uninfected sex partners.
  • See Prevention for Positives.

From Women's Health
Primary Care of Veterans with HIV
Office of Clinical Public Health Programs
Veterans Health Administration, 2009