Anglian Genitourinary Medicine Audit Group — cervical cytology screening in HIV-positive women

Abstract

Immunosuppressed HIV-infected women are at risk of developing cervical cytological abnormalities and should have routine annual cervical cytology smears performed as recommended by the National Health Services Cervical Screening Programme (NHSCSP). In the Anglian Genitourinary Medicine Audit Group review of practice of cervical cytology smears, only 55.5% of clinics met the NHSCSP standards. The mean age of the 173 women in the cohort was 35.8 ± 8.1, range 16–66 years. Seventy-eight percent of clinics performed cervical cytology screening in women under the age of 25 years. High-grade cervical cytological abnormality (moderate dyskariosis and above) was seen in 9.5% of the cohort and 39.5% had low-grade lesions (borderline and mild dyskariosis). One patient, a 41-year-old black African on highly active antiretroviral therapy with HIV-1 RNA level <50 copies/mL and a CD4 count of 240 cells/mm³ had invasive cervical cancer requiring hysterectomy. The expected mean number of cervical cytology smears for the cohort was 3.29 and the calculated performed mean cervical cytology smear was 1.9 (P = 0.0001), a statistically significant difference. Asylum dispersal among 69.5% black Africans in the cohort contributed to some of the clinics not meeting the NHSCSP standards.

Keywords

Cervical cytology HIV-positive women screening medical audit

INTRODUCTION

Immunosuppression from HIV-infection in women has been recognized to be associated with a high prevalence of abnormal cervical cytology.^1,2 The National Health Services Cervical Screening Programme (NHSCSP)³ recommends that all women newly diagnosed with HIV-infection should have annual cytology performed with an initial colposcopy if resources permit. Subsequent colposcopy for cytological abnormality should follow national guidelines and the age range screened should be the same as for HIV-negative women.

It is against this background that the Anglian Genitourinary Medicine Audit Group (AGAG) agreed to review the clinic policies in place and posit them against case-note reviews.

MATERIALS AND METHODS

There are 10 clinics that make up the AGAG Medicine group. It was agreed in 2007 to review the clinic policies for cervical cytology screening in HIV-infected women by completing an audit proforma circulated to all the participating clinics. Twenty consecutive case-notes were to be retrieved by participating clinics. Data were collected on age, ethnicity, date of documented baseline cervical cytology, date of subsequent cervical smears and outcome, date of last abnormal smear, type of abnormal smear and colposcopy referral date. Dates with details of the most recent CD4 count and viral load was used for benchmarking. Additional data included provision of HIV status on the cervical cytology form. When cervical cytology was performed by the general practitioner (GP), data were collected to enquire if HIV status of the patient was known to the GP. Data were entered and analysed with Epi Info version 3.4 software (Centre for Disease Control Atlanta, USA). Wilcoxon test was used for comparing continuous variables of expected and performed smears. For all statistical analysis, P < 0.05 was considered significant.

RESULTS

In 2007, among the nine clinics which submitted their data 40,002 (new and rebooked) women attended and 886 women were HIV-infected. The details from the individual clinic policies were summarized as shown in Table 1. Only two clinics offered routine colposcopy at the time of baseline cervical smear and one clinic did not perform cervical smears but requested the primary care physicians (GPs) to perform it with results sent back to the clinic. It was not clear if the GP provided the HIV status on the cervical cytology form. Only two clinics performed in-house colposcopy and these were among the clinics that conformed to the NHSCSP recommendation. Three clinics do not routinely perform cervical cytology smears in HIV-infected women under the age of 25.

Table 1

Details of clinical policy review

	Clinic 1	Clinic 2	Clinic 3	Clinic 4	Clinic 5	Clinic 6	Clinic 7	Clinic 8	Clinic 9	Clinic 10
Annual attendance	1867	1518	2280	5509	3616	5900	7605	5189	2009	4509
HIV-infected females	27	15	17	34	109	350	112	67	46	109
Routine screen for HIV	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes
Smear elsewhere		Yes
Baseline smear+colposcopy			Yes				Yes
Baseline smear only	Yes			Yes	Yes	Yes		Yes	Yes	Yes
Annual smears	Yes		Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
All females			Yes	Yes	Yes	Yes	Yes	No	Yes	Yes
Not screen if <25 years	Yes			Yes				Yes
In-house colposcopy			Yes				Yes	No
Colposcopy elsewhere	Yes			Yes	Yes	Yes		Yes		Yes
Audit	No	No	No	No	No	Yes	No	No	No	Yes
Leaflet given	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes
HIV status on form	Yes	N/A	No	Yes	Yes	Yes	Yes	No	Yes
Request for GP results always	No	Yes	No	Yes	Yes	Yes (try to)	Yes (aim to)	No	Yes

The nine clinics provided details of 173 patients, summarized per clinic as shown in Table 2. The mean age of the women was 35.8 ± 8.1, range 16–66 years. Pregnancy occurred in 9.8% of the cohort. The mean age of those pregnant was 28.05 ± 5.67, range 16–41 years.

Table 2

Characteristics of case-notes

	Clinic 1	Clinic 2	Clinic 3	Clinic 4	Clinic 5	Clinic 6	Clinic 7	Clinic 8	Clinic 9	Clinic 10
Total from clinics	20	N/A	16	20	17	20	20	20	20	20
Ethnicity (%)		N/A
Black Africans	55		43.8	65	70.6	100	60	65	85	75
White British	30		31.3	5	5.9		20	15	15	15
Mean age (years)	33.9	N/A	34.8	31.4	37.8	37.3	40.3	33.4	37.3	36.6
Pregnant (%)	25	N/A	0	40	0	0	5	10	5	0
Negative smears (%)	62.5	N/A	56.3	68.8	56.3	30	70.6	68.4	50	65
Abnormal smears (%)	37.5	N/A	37.4	21.4	31.4	70	29.4*	31.6	50	35
Inadequate smears (%)	0		0	6.3	12.5	0	0	0	0	0
Moderate/severe (%)	6.3		6.3	6.3	6.3	25	10.8	10.5	11.1	0
Colposcopy (%)	20	N/A	40	20	5.9	55	18.8	15	40	30
Expected smears (mean)	4.1	N/A	4.06	1.2	4.52	4.25	3.05	1.65	1.85	4.47
Performed (mean)	1.9	N/A	3.18	1.0	2.34	3.9	1.4	1.55	2.06	1.5
P value (Wilcoxon)	0.04^†		0.05^†	0.001^†	0.35 (NS)	0.01^†	0.008^†	0.002^†	0.002^†	0.06 (NS)
Earliest smear (years)	16		12	2	4	6	8	2	3	16
HAART (%)	75		62.5	60	58.8	75	80	50	55	75
Met standards	No	N/A	Yes	Yes	No	Yes	No	Yes	Yes	No

N/A = not applicable; NS = not statistically significant

*Including cervical cancer requiring hysterectomy in a 41-year-old black African on HAART with undetectable viral load

^†Statistically significant

HAART = highly active antiretroviral Therapy

Ethnic data analysis showed that 69.4% were Black Africans, 15% White British, 5.8% White Other (mostly Portuguese) and 2.9% Black Caribbean. The other groupings were Black British 1.2%, Thai 1.2%, Chinese and other mixed combinations 0.6%.

Abnormal cervical cytology analysis showed that 9.5% of the cohort had high grade dyskariosis (moderate and above) including one case of cervical cancer requiring hysterectomy in a 41-year-old Black African, on highly active antiretroviral therapy (HAART) with HIV-1 RNA level <50 copies/mL and a CD4 count of 240 cells/mm³. Borderline and mild dyskariosis changes were reported in 39.3% of the cohort.

Comparing outcomes

For statistical analysis, patients with normal cervical cytology at baseline and those of whose subsequently documented cervical smears remained normal were selected. Date of the baseline cervical cytology and most recent attendance for CD4 count and viral load assessment were used as measures of the interval for annual cervical cytology screening. Non-parametric analysis of variance (Wilcoxon test) was used for comparing continuous variables of expected and performed smears for the individual clinics and entire cohort.

The expected mean number of cervical cytology smears was 3.29. The calculated performed mean cervical cytology smear was 1.9. The difference of the means of the expected and performed smears was statistically significant (P = 0.0001) and the details of the individual clinics are provided in Table 2.

DISCUSSION

In the recently concluded report⁴ on the sexual health care of people with HIV infection by the National Audit Group of the British Association for Sexual Health and HIV (BASHH) in the UK, only 73% (43–94%) of women eligible for cervical smear had it documented as performed. In this audit, while documentation was variable only 55.5% of clinics in the region met the standards of NHSCSP recommendations of performing annual cervical cytology smears.

Asylum dispersal contributed significantly in some clinics that did not meet the standards as 69.5% were Black Africans in the cohort. However, clinics that incorporated routine in-house audit of cervical cytology as part of their clinic policy met the standards.

It is salutary that 77.7% of clinics performed cervical cytology in women <25 years old in the region. Although not recommended by the NHSCSP, reports in the literature support cervical cytology screening in HIV-infected teenagers, particularly those co-infected with human papilloma virus.⁵ A recent review⁶ urged the NHSCSP to revert the guidelines to include those aged 20–24 years in the screening programme, as delay carries the risk of cervical intraepithelial dysplasia becoming more extensive. The regional consensus was to offer cervical cytology for HIV-infected women aged <25 years old.

There was inadequate documentation in the case-notes, particularly when cervical cytology smear was performed by primary care physicians, who should be informed of the status of the patients to enable annual cervical cytology smears.

Participating clinics

Addenbrookes Hospital, Bedford Hospital, Hinchingbrooke Hospital, Ipswich Hospital, James Paget Hospital, Luton & Dunstable Hospital, Norfolk & Norwich Hospital, Peterborough Hospital, Queen Elizabeth Hospital and West Suffolk Hospital.

DISCLAIMER

The order of listing the clinics above is not representative of the listing in Tables 1 and 2. The listing in the tables has been randomized to preserve the anonymity of the participating clinics.

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