Screening and treatment for pre-cancerous
cells is a particular priority for women with HIV, since SIL can develop so
In the USA the Centers
for Disease Control has recommended that HIV-positive women should be given a
smear test as soon as they are diagnosed with HIV and then six months later, and
every year after that if test results are normal.
Given however that
a possibly much higher proportion of women with HIV who have high-risk HPV
types will progress to SIL and CIN, changes such as including HPV DNA testing are
being considered.8 This is a viral
load-type test that can detect any current HPV infection, not just ones that
produce symptoms, and can determine what type of HPV is present.
In the UK, the BHIVA sexual health
guidelines (published 2008) recommend an initial smear test and colposcopy at HIV
diagnosis followed by a smear test every year.9 They add that “CIN
should be aggressively screened for and treated”. They do not recommend HPV DNA
Dr Fiona Boag
of the Kobler Clinic at the Chelsea and Westminster Hospital
in London says
that there is confusion in the minds of both patients and clinics about how
often to screen HIV-positive women and who should do it.
“Women will be screened on HIV diagnosis
but clinics are only now getting round to offering annual screening, and the
uptake isn’t as good as it should be. We did a survey10 which showed
that about two-thirds of our HIV-positive female patients were aware that they
needed an annual screen, but that only half of them had actually had a screen
in the last year.”
“Patients get confused because they also
get letters from their GPs for three-yearly screening, as well as from us,” she
In England the NHS took the controversial
decision in 2005 only to offer screening to women over 25, but Boag confirms
that HIV-positive women under 25 are also offered annual screening, “though
some clinics still aren’t aware of the BHIVA guidelines”. So it may be
necessary to be proactive to make sure you get your annual screening test.
The screening test for cervical
abnormalities involves inserting a small spatula into the vagina and brushing a
sample of cells from the cervix. This is often still called a ‘smear’ even
though doctors now use a technique called liquid-based cytology (LBC) that
involves putting the sample in a bottle rather than on to a microscope slide.
The test looks for abnormal cells that have
been ‘excited’ by HPV. This is so-called SIL. If this is detected, a colposcopy will be ordered; this involves
a doctor making a visual examination of the cervix (while the woman is in
stirrups) with a binocular microscope. What they will be looking for is cervical
intraepithelial neoplasia (CIN).
If it is left unchecked, then the CIN may develop firstly into a localised ‘pre-cancer’
called CIS (carcinoma in situ), which can still be operated on locally, and
then into invasive cervical cancer needing radical treatment.
It’s important to emphasise that even if
you develop CIN, malignant cervical cancer is not an inevitability. “If I knew
why some women develop cancer and others don’t, I’d be on the plane to Stockholm to get my Nobel
Prize,” says Margaret Stanley. Although about one in six women with HIV and HPV
have either LSIL or HSIL (compared with one in 20 HIV-negative women), only
about one in 400 HIV-positive women (0.24%) would develop invasive cervical
cancer, which can take ten to 15 years to develop, if not treated.