- Cervical Pap test (smear or liquid cytology)
- 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.
- 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.
- Digital rectal examination (DRE)
- Anal Pap test
|No national guidelines for anal cancer screening; consider:
- 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.
- 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.
- 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.
- RPR, VDRL
- 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.