The newly updated New York State Department of Health Institute of AIDS AIDS Guideline (NYSDOH AI) for screening for cervical dysplasia and cancer in adults with HIV acknowledges that dramatic reductions in HIV-related morbidity and mortality are made possible through widespread implementation of treatment. Effective antiretroviral therapy (ART) has also led to a significant reduction in the incidence of cervical cancer.
Cervical cancer is a disease specific to AIDS and has historically been a leading cause of cancer death among HIV-positive women. Early in the epidemic, women infected with HIV developed cervical cancer at later stages, when treatment was less successful. But over the past 20 years, the risk of women infected with HIV developing cervical cancer has decreased significantly.[2,3] In addition to improving longevity and general health, ART has been found to reduce HPV acquisition, improve regression, and reduce rates of cervical disease progression.[4,5,6,7,8] Studies show that rates of cervical dysplasia in HIV-infected women who are virally suppressed with ART and have a CD4 count ≥ 500 cells/mm3 They are comparable to rates in women without HIV.[9,10,11] The pathogenesis of cervical disease is the same as in virally suppressed HIV-infected women with a CD4 count of 500 cells/mm.3 For women not infected with HIV.[12,13,14,15]
However, the risk of HPV-related cervical disease continues to increase with HIV infection due to the increased prevalence and persistence of HPV in HIV-infected persons.[16,17,18] Vigilance in screening and prompt treatment of high-grade cervical disease remain essential tools in the care of patients living with HIV.
NYSDOH AI guidelines suggest that patients who have been virally suppressed and have demonstrated adherence to primary HIV care and care, who have negative cytology and HPV results, no genital or pelvic complaints, do not use tobacco products, and have no neck Another uterus. Cancer risk factors may benefit from extended screening periods.
In most areas, NYSDOH AI guidelines align with those of the US Department of Health and Human Services; However, the NYSDOH AI guidelines recommend an extended screening interval for patients under 30 years of age. Recognizing that cancer in this population is extremely rare and that HPV is highly prevalent and often regresses in young adults, the guideline recommends starting screening within two years of the first receptive intercourse. If the cytology results are normal, the patient may be examined again in 3 years.
Although the DHHS guidelines describe the issue of anal cancer screening for patients with HIV as unresolved, the NYSDOH AI categorically recommends anal cancer screening for HIV-infected adults aged 35 and over, regardless of gender or sex. More information and evidence-based recommendations can be found in the NYSDOH AI Guidelines for Screening for Anal Dysplasia and Cancer in Adults with HIV.
Physicians should schedule a routine examination of the cervix based on the patient’s medical history, anatomical history, age, and risk profile. The guideline explicitly emphasizes joint decision-making, particularly with regard to prompt treatment of high-quality cervical dysplasia and ongoing screening in patients 65 years of age and older. When addressing the details of treatment plans or issues of extended screening periods or discontinuation of screening based on a lifelong diagnosis, joint patient-centered decision-making is critical. Shared decision-making should consider the patient’s risk of HPV-related disease, screening objectives, cultural and personal values, and the benefits of the screening period based on the patient’s actual risk.
Holistic and culturally sensitive care
In addition to recognizing the shift in cervical cancer risk for HIV-suppressed individuals, the NYSDOH AI guidelines recommend age-based cervical cancer screening for any HIV-positive patient who has or has had cervical cancer. The manual uses gender-neutral language to emphasize the importance of safe and appropriate care for transgender individuals and to avoid assumptions based on the patient’s age, physical appearance, or sexual expression. Holistic, culturally sensitive healthcare includes a safe and welcoming environment that recognizes the needs of transgender, transgender, transgender, and non-binary patients. For more information, see the NYSDOH AI Guidelines: Adopting a Patient-Centered Approach to Sexual Health.
Physicians are encouraged to ask patients to provide details of all sex confirmation and gynecological procedures they have undergone to help inform appropriate screening. On a practical level, clinicians should note the use of testosterone and the presence of amenorrhea in requesting cervical cytology in transgender men to facilitate accurate interpretation of cell morphology.
The guideline stresses that when providing comprehensive primary care to HIV-infected adults, clinicians must ensure that all eligible patients have been vaccinated against HPV. In 2020, the US Food and Drug Administration expanded the age range for approved use of the 9-valent HPV vaccine in the United States to 45 years. Given the increased risk of lifelong HPV infection and the increased prevalence of HPV-related cancers, the guideline supports a standard schedule of 3 doses over 6 months for HIV-infected individuals aged 9 to 45 years, regardless of age. Regardless of CD4 cell count, prior cervical or rectal exam results, HPV test results, HPV-related cytogenetic changes, or other history of HPV-related lesions.
The guideline encourages clinicians to provide education about additional harm reduction measures that may reduce the risk of cervical dysplasia in HIV patients, including quitting tobacco use and sexual exposure prevention strategies such as using barrier protection and reducing the number of sexual partners and linked sexual networks when possible.
Design and Role of the NYSDOH AI Manual
The NYSDOH Artificial Intelligence Clinical Guideline for Screening for Cervical Dysplasia and Cancer in HIV-infected Adults is designed for clinicians in New York State providing primary care and HIV and gynecology for HIV-positive adults at risk of developing cervical dysplasia or infection-related cancer Human papillomavirus.
HIV-positive patients remain at a higher risk of developing cervical disease and cancer than those without HIV. However, successful large-scale implementation of ART has improved longevity and general health and reduced the risk of opportunistic infections, including HPV. The 2022 NYSDOH AI Cervical Cancer Screening Guideline balances the need for vigilance in an at-risk population with the realization that HIV-positive patients who adhere to ARVs and participate in care also reduce the risk of high-grade cervical disease and cancer.