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Cervical cancer screening among HIV-infected women in an urban, United States safety-net healthcare system

Barnes, Artia; Betts, Andrea C.b,c,e; Borton, Eric K.b; Sanders, Joanne M.b; Pruitt, Sandi L.b,c; Werner, Claudiad,g; Bran, Andresa,g,i; Estelle, Carolee D.a,g; Balasubramanian, Bijal A.c,f; Inrig, Stephen J.b,h; Halm, Ethan A.a,b,c; Skinner, Celette Suggb,c; Tiro, Jasmin A.b,c

doi: 10.1097/QAD.0000000000001881

Objective: Little is known about cervical cancer screening and results patterns among HIV-infected (HIV+) women in real-world healthcare settings. We characterized two periods of screening opportunity.

Design: Retrospective cohort.

Setting: US safety-net healthcare system in Dallas County, Texas.

Participants: We analyzed data from electronic medical records (EMR) of 1490 HIV+ women receiving care 2010–2014.

Main outcome measures: At baseline, we categorized a woman's Pap status 15 months prior to index date as under-screened (vs. screened), and cytology result (normal vs. abnormal). Then, we examined screening completion and results, and colposcopy uptake and results after an abnormal screen, in the subsequent 15-month period.

Results: More than half of women (56%) had no evidence of a Pap test (i.e. under-screened) at baseline. Under-screened women were more likely to be older (50–64 years), have diabetes, and unknown viral load; they were less likely to be Black, Hispanic, have Medicaid, recently pregnant, have a HIV clinic visit, or a CD4+ cell count at least 200 cells/μl. Nearly half of under-screened women (46%, n = 383) remained under-screened in the subsequent 15 months. Among women under-screened at baseline who later completed screening and follow-up during the study period, 21 high-grade dysplasia and three cancers were diagnosed. Overall, 40% of women did not receive colposcopy when needed, with most failures to follow-up occurring in women who were under-screened at baseline.

Conclusion: Most HIV+ women receiving care in a safety-net system did not receive sufficient screening for cervical cancer and remained at exceptionally high risk of developing high-grade dysplasia.

aDepartment of Internal Medicine

bDepartment of Clinical Sciences

cHarold C. Simmons Comprehensive Cancer Center

dDepartment of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas

eDepartment of Health Promotion and Behavioral Sciences

fDepartment of Epidemiology, Human Genetics, and Environmental Sciences, UT Health School of Public Health in Dallas, Texas

gParkland Health and Hospital System

hMount Saint Mary's University, Los Angeles, California

iDivision of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA.

Correspondence to Arti Barnes, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA. Tel: +1 214 648 8268; fax: +1 214 648 2741; e-mail:

Received 18 December, 2017

Revised 23 April, 2018

Accepted 27 April, 2018

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